recent journal articles: anesthesiology




Recent Articles in Pain

Tang B, Ji Y, Traub RJ
Estrogen alters spinal NMDA receptor activity via a PKA signaling pathway in a visceral pain model in the rat.
Pain. 2007 Dec 7; .
Pain symptoms in several chronic pain disorders in women, including irritable bowel syndrome, fluctuate with the menstrual cycle suggesting a gonadal hormone component. In female rats, estrogens modulate visceral sensitivity although the underlying mechanism(s) are unknown. In the present study the effects of 17-beta estradiol on N-methyl-d-aspartate (NMDA) receptor signaling of colorectal nociceptive processing in the spinal cord were examined. Estrogen receptor alpha and the NR1 subunit of the NMDA receptor are co-expressed in dorsal horn neurons, supporting a direct action of estradiol on NMDA receptors. Intrathecal administration of the NMDA receptor antagonist d(-)-2-amino-5-phosphonopentanoic acid (APV) dose-dependently attenuated the visceromotor response with greater potency in ovariectomized (OVx) rats compared to OVx with estradiol replacement (E2) rats. Estradiol significantly increased protein expression of NR1 in the lumbosacral spinal cord compared to OVx rats. Colorectal distention significantly increased phosphorylation of NR1ser-897, a PKA phosphorylation site on the NR1 subunit in E2, but not OVx rats. Intrathecal administration of a PKA inhibitor significantly attenuated the visceromotor response, decreased NR1 phosphorylation and increased the potency of APV to attenuate the visceromotor response compared to vehicle-treated E2 rats. These data suggest that estradiol increases spinal processing of visceral nociception by increasing NMDA receptor NR1 subunit expression and increasing site-specific receptor phosphorylation on the NR1 subunit contributing to an increase in NMDA receptor activity. [Abstract]

Zhu H, Yang Y, Zhang H, Han Y, Li Y, Zhang Y, Yin D, He Q, Zhao Z, Blumberg PM, Han J, Wang Y
Interaction between protein kinase D1 and transient receptor potential V1 in primary sensory neurons is involved in heat hypersensitivity.
Pain. 2007 Nov 30;
In previous studies we demonstrated that protein kinase D1 (PKD1/PKCmu) could directly phosphorylate the transient receptor potential V1 (TRPV1) at its N-terminal region and enhance the function of TRPV1 in CHO cells stably transfected with TRPV1. In the current study we assessed the involvement of PKD1 in pain modulation and explored the possible interaction between PKD1 and TRPV1 in rat inflammatory heat hypersensitivity. PKD1 was translocated to cytoplasmic membrane fraction and was trans-phosphorylated only in membrane fraction but not in cytoplasmic fraction of dorsal root ganglia (DRG) at 2 and 6h after Complete Freund's Adjuvant (CFA) treatment. Pre i.t. injection of PKD1 antisense for 4 d or post-i.t. injection for 4 d both alleviated CFA-induced thermal hypersensitivity. Likewise, overexpression of PKD1 in DRG significantly enhanced, while dominant negative PKD1 (DN-PKD1) partly attenuated, heat hypersensitivity. Both PKD1 and TRPV1 were translocated to the cytoplasmic membrane in DRG 6 h after CFA treatment and, at that time, PKD1 interacted with TRPV1 by co-immunoprecipitation in DRG. Electrophysiological measurements indicated that DRG with overexpression of PKD1 were more sensitive to low dose capsaicin than those expressing DN-PKD1. The average magnitude of the peak inward current evoked by capsaicin was greater in the DRG overexpressing PKD1 than in those expressing DN-PKD1. Furthermore, overexpressed PKD1 could up regulate, whereas PKD1 antisense could knock down TRPV1 content in DRG through posttranscriptional regulation manner. We concluded that PKD1 in DRG, through interaction with TRPV1, is involved in developing and maintaining inflammatory heat hypersensitivity. [Abstract]

Miletic G, Miletic V
Loose ligation of the sciatic nerve is associated with TrkB receptor-dependent decreases in KCC2 protein levels in the ipsilateral spinal dorsal horn.
Pain. 2007 Nov 30;
Significant decreases in the protein levels of potassium-chloride co-transporter 2 (KCC2) were detected in the ipsilateral spinal dorsal horn 4h following loose ligation of the sciatic nerve. These decreases were associated with a change in hindlimb weight distribution suggestive of pain behavior. In contrast, no changes in GABA-A receptor subunit alpha-1 levels were detected. The decreases in KCC2 coincided with a significant ipsilateral increase in BDNF protein levels. Both the decreases in KCC2 levels and the early pain behavior were prevented by intrathecal pre-treatment with the BDNF-sequestering TrkB/Fc chimera protein or the tyrosine kinase blocker K252a. The ligation-associated decreases in KCC2 levels were transient. In the ipsilateral spinal dorsal horn of ligated animals exhibiting weight-bearing pain behavior 7 days after the ligation the KCC2 levels were identical to those in control or sham-operated animals. These data suggested that TrkB-dependent reduction in KCC2 protein levels in the spinal dorsal horn was an early consequence of peripheral nerve injury. This decrease in KCC2 may have elicited an early increase in overall dorsal horn neuronal excitability perhaps through a loss of GABA inhibition which is critically dependent on KCC2 activity. The increased neuronal excitability may in turn have caused enhanced and exaggerated communication between primary afferents and dorsal horn neurons to contribute to the early behavioral signs of pain. [Abstract]

Bastuji H, Perchet C, Legrain V, Montes C, Garcia-Larrea L
Laser evoked responses to painful stimulation persist during sleep and predict subsequent arousals.
Pain. 2007 Nov 30;
We studied behavioural responses and 32-channel brain potentials to nociceptive stimuli during all-night sleep in 12 healthy subjects, using sequences of thermal laser pulses delivered over the dorsum of the hand. Laser stimuli less than 20dB over perception threshold had clear awakening properties, in accordance with the intrinsic threatening value of nociceptive signals. Even in cases where nociceptive stimulation did not interrupt sleep, it triggered motor responses in 11% of trials. Only four subjects reported dreams, and on morning questionnaires there was no evidence of incorporation to dreams of nociceptive stimuli. Contrary to previous reports suggesting the absence of cortical nociceptive responses during sleep, we were able to record brain-evoked potentials to laser (LEPs) during all sleep stages. Sleep LEPs were in general attenuated, but their morphology was sleep-stage-dependent: in stage 2, the weakened initial response was often followed by a high-amplitude negative wave with typical features of a K-complex. During paradoxical sleep (PS) LEP morphology was similar to that of waking, but frontal components showed strong attenuation, consistent with the reported frontal metabolic deactivation. A late positive component (450-650ms) was recorded in both stage 2 and PS, the amplitude of which was significantly enhanced in trials that were followed by an arousal. This response appeared functionally related to the P3 wave, which in waking subjects has been associated to conscious perception and memory encoding. [Abstract]

Mitchell K, Yang HY, Tessier PA, Muhly WT, Swaim WD, Szalayova I, Keller JM, Mezey E, Iadarola MJ
Localization of S100A8 and S100A9 expressing neutrophils to spinal cord during peripheral tissue inflammation.
Pain. 2007 Dec 4;
Investigation of hyperalgesia at the spinal transcriptome level indicated that carrageenan-induced inflammation of rat hind paws leads to a rapid but sustained increase in S100A8 and S100A9 expression, two genes implicated in the pathology of numerous inflammatory diseases including rheumatoid arthritis and gout. In situ hybridization revealed that the elevation occurred in neutrophils that migrate to the spinal cord vasculature during peripheral inflammation, not in spinal neurons or glial cells. Immunohistochemical analysis suggests, but does not prove, that these neutrophils abundantly release S100A8 and S100A9. Consistent with this, we detected an increase in ICAM and VCAM, both indicators of endothelial activation, a known trigger for secretion of S100A8 and S100A9. Migration of S100A8- and S100A9-expressing neutrophils to spinal cord is selective, since MCP-1- and CD68-expressing leukocytes do not increase in spinal cord vasculature during hind paw inflammation. Examination of many neutrophil granule mediators in spinal cord indicated that they are not regulated to the same degree as S100A8 and S100A9. Neutrophil migration also occurs in the vasculature of brain and pituitary gland during peripheral inflammation. Together, these findings suggest an interaction between a subpopulation of leukocytes and the CNS during peripheral tissue inflammation, as implied by an apparent release and possible diffusion of S100A8 and S100A9 through the endothelial blood-brain barrier. Although the present findings do not establish the neurophysiological or behavioral relevance of these observations to nociceptive processing, the data raise the possibility that selective populations of leukocytes may communicate the presence of disease or tissue damage from the periphery to cells in the central nervous system. [Abstract]

Crombez G, Eccleston C, De Vlieger P, Van Damme S, De Clercq A
Is it better to have controlled and lost than never to have controlled at all? An experimental investigation of control over pain.
Pain. 2007 Dec 4;
Trying to control pain is a common human goal. But little is know about what happens when one loses control over pain. This paper reports an experiment with 74 healthy volunteers, half of whom were given control over a pain stimulus and subsequently lost control, and half of whom never had control over the pain. This study investigates whether having had control and lost it would result in a more unpleasant pain experience, more fear about impending pain, a heightened vigilance to pain, and greater interference on a secondary task. Participants in the experimental group first learned to avoid a painful stimulus by correctly responding to a card sorting task, but later on lost control over the painful stimulus. In the yoked comparison group, participants had no control over the painful stimulus from the beginning. Results indicated that losing control over pain and, relatedly, attempting to control uncontrollable pain have significant costs such as a higher fear of the impending pain stimulus and retarded performance on a secondary task. When attempts to avoid pain are blocked, individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved. These findings are discussed within the context of a dual process model of coping with uncontrollable adverse events [Brandtstädter J, Renner G. Tenacious goal pursuit and flexible goal adjustment: explication and age-related analysis of assimilative and accommodative strategies of coping. Psychol Aging 1990;5:58-67] and possible mechanisms for perseverance with ineffective solutions. [Abstract]

Crombez G, Eccleston C, Van Hamme G, De Vlieger P
Attempting to solve the problem of pain: A questionnaire study in acute and chronic pain patients.
Pain. 2007 Dec 4;
When faced with the problem of pain one can attempt a solution aimed at relief (assimilation) or a solution aimed at acceptance (accommodation). Using this dual process model of adaptation to pain, this study compares acute and chronic pain patients on their approach to problem solving. Three hundred and sixty-four patients were recruited from clinical settings, 303 with chronic pain and 61 with acute pain, and completed a range of measures of both affect and pain-related behavior, including the Pain Solutions Questionnaire. The effects of overall duration of pain were also investigated. Chronic pain patients reported greater disability and catastrophic thinking about pain than acute pain patients, and assimilative coping was associated with greater disability, greater attention to pain, and more catastrophic thinking about pain, beyond the effects of demographic variables and pain severity. Pain duration did not moderate these associations. Only in the case of catastrophic thinking about pain was it found that the effects of assimilative coping were moderated by pain duration. For chronic pain patients, catastrophic thinking about pain was greater when assimilative coping was higher. These results are discussed within the context of a goal directed motivational model of adaptation to chronic pain. [Abstract]

Buchgreitz L, Lyngberg AC, Bendtsen L, Jensen R
Increased pain sensitivity is not a risk factor but a consequence of frequent headache: A population-based follow-up study.
Pain. 2007 Nov 29;
Altered pain sensitivity is believed to play an important role for chronification of headache. It has however mainly been evaluated in highly selected patients from headache clinics and never in longitudinal studies. The present study is a 12-year follow-up of a population-based study of primary headache disorders and pain perception, combining a diagnostic headache interview with examination of muscle tenderness and measurement of pressure pain thresholds in 1000 subjects drawn randomly from the general population in Denmark. The aim of the study was to explore the cause-effect relationship between the increased pain sensitivity and the development of headache. The pressure pain thresholds were normal at baseline but had decreased at follow-up in subjects who developed chronic tension-type headache over the 12-year period (p=0.025). In subjects who developed frequent episodic tension-type headache the tenderness was normal at baseline but had increased at follow-up (p<0.01) while the pain thresholds were normal both at baseline and at follow-up. The findings demonstrate that increased pain sensitivity is a consequence of frequent tension-type headache, not a risk factor, and support that central sensitization plays an important role for the chronification of tension-type headache. [Abstract]

Gureje O
Treating chronic pain in the context of comorbid depression.
Pain. 2007 Dec 4; [Abstract]

Moseley GL, Zalucki NM, Wiech K
Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain.
Pain. 2007 Dec 1;
Chronic pain is often associated with reduced tactile acuity. A relationship exists between pain intensity, tactile acuity and cortical reorganisation. When pain resolves, tactile function improves and cortical organisation normalises. Tactile acuity can be improved in healthy controls when tactile stimulation is associated with a behavioural objective. We hypothesised that, in patients with chronic limb pain and decreased tactile acuity, discriminating between tactile stimuli would decrease pain and increase tactile acuity, but tactile stimulation alone would not. Thirteen patients with complex regional pain syndrome (CRPS) of one limb underwent a waiting period and then approximately 2 weeks of tactile stimulation under two conditions: stimulation alone or discrimination between stimuli according to their diameter and location. There was no change in pain (100mm VAS) or two-point discrimination (TPD) during a no-treatment waiting period, nor during the stimulation phase (p>0.32 for both). Pain and TPD were lower after the discrimination phase [mean (95% CI) effect size for pain VAS=27mm (14-40mm) and for TPD=5.7mm (2.9-8.5mm), p<0.015 for both]. These gains were maintained at three-month follow-up. We conclude that tactile stimulation can decrease pain and increase tactile acuity when patients are required to discriminate between the type and location of tactile stimuli. [Abstract]

Rainville P
Hypnosis and the analgesic effect of suggestions.
Pain. 2007 Nov 21; [Abstract]

Nieto FR, Entrena JM, Cendán CM, Pozo ED, Vela JM, Baeyens JM
Tetrodotoxin inhibits the development and expression of neuropathic pain induced by paclitaxel in mice.
Pain. 2007 Nov 21;
We evaluated the effect of low doses of systemically administered tetrodotoxin (TTX) on the development and expression of neuropathic pain induced by paclitaxel in mice. Treatment with paclitaxel (2mg/kg, i.p., once daily during 5 days) produced long-lasting (2-4 weeks) heat hyperalgesia (plantar test), mechanical allodynia (electronic Von Frey test) and cold allodynia (acetone drop method), with maximum effects observed on days 7, 10 and 10-14, respectively. Acute subcutaneous treatment with 1 or 3mug/kg of TTX reduced the expression of mechanical allodynia, whereas higher doses (3 or 6mug/kg) were required to reduce the expression of cold allodynia and heat hyperalgesia. In contrast, TTX (3 or 6mug/kg, s.c.) did not affect the response to the same thermal and mechanical stimuli in control animals, which indicates that the antihyperalgesic and antiallodynic effects of TTX were not due to unspecific inhibition of the perception of these stimuli. Administration of TTX (6mug/kg, s.c.) 30min before each of the 5 doses of paclitaxel did not modify the development of heat hyperalgesia produced by the antineoplastic, but abolished the development of mechanical and cold allodynia. Coadministration of a lower dose of TTX (3mug/kg) also prevented the development of mechanical allodynia. No signs of TTX-induced toxicity or motor incoordination were observed. These data suggest that low doses of TTX can be useful to prevent and treat paclitaxel-induced neuropathic pain, and that TTX-sensitive subtypes of sodium channels play a role in the pathogenesis of chemotherapy-induced neuropathic pain. [Abstract]

McIntyre D, Kavussanu M, Ring C
Effects of arterial and cardiopulmonary baroreceptor activation on the upper limb nociceptive flexion reflex and electrocutaneous pain in humans.
Pain. 2007 Nov 21;
Attenuation of the lower limb nociceptive flexion reflex (NFR) during the cardiac cycle has been attributed to inhibition of sensorimotor function by arterial baroreceptor activation. It has been proposed that cardiopulmonary baroreceptors might have similar inhibitory effects. This study examined the effects of arterial and cardiopulmonary baroreceptor stimulation on nociceptive responding in the upper limb by delivering electrocutaneous stimuli to the ulnar nerve at 0, 150, 300, 450, or 600ms after the R-wave of the electrocardiogram while participants lay supine with their legs raised or lowered. Nociceptive responding varied in a quadratic manner with phase of the cardiac cycle; responses were lowest at R+450ms. Nociceptive responding and pain ratings did not differ between postures suggesting no cardiopulmonary effects. This phasic modulation of the upper limb withdrawal response provides further support for arterial baroreceptor-mediated inhibition of nociceptive transmission. [Abstract]

Versloot J, Veerkamp JS, Hoogstraten J
Children's self-reported pain at the dentist.
Pain. 2007 Nov 20;
The aim of the present study is to get an insight into the pain report of children over two sequential dental visits. Furthermore, it was studied whether age, previous dental experience, level of dental anxiety and injection site were of influence on the self-reported pain of children during the first and second treatment session. One hundred and forty-seven children (4-11 years old) were included in the study. After receiving a local anesthesia injection prior to their dental treatment, they were asked how much pain they had felt. The level of dental anxiety was measured once by the parental version of the Dental Subscale of the Children's Fear Survey Schedule. Young children with a low level of dental anxiety show a sensitized reaction trend for self-reported pain over two sequential dental visits. Young children with a high level of dental anxiety reported the most pain on the first treatment session. For the older children, the children having previous dental experience gave the highest pain ratings on the first treatment session. Furthermore, for both young and older children the amount of pain reported for the second injection was best predicted by the amount of pain reported for the first injection, whereby higher scores the first time predict higher scores the second time. In conclusion, the memory of previous experience with dentistry and earlier treatment sessions seems of great influence on the behaviour and the experience of children during subsequent treatment sessions. [Abstract]

Jordan A, Eccleston C, McCracken LM, Connell H, Clinch J
The Bath Adolescent Pain - Parental Impact Questionnaire (BAP-PIQ): Development and preliminary psychometric evaluation of an instrument to assess the impact of parenting an adolescent with chronic pain.
Pain. 2007 Nov 20;
When an adolescent has chronic pain many aspects of a parent's life can be affected, including their emotional and social functioning. The assessment of this multidimensional parental impact is an essential, yet often neglected, clinical task. This study reports on the development and psychometric evaluation of the Bath Adolescent Pain - Parental Impact Questionnaire (BAP-PIQ), an assessment tool comprising multiple scales thought to be relevant for better understanding changes in functioning and behavior associated with parenting an adolescent with chronic pain. A sample of 194 parents of adolescents with chronic pain, recruited from three UK clinics, completed the 94 item draft inventory. Frequency and item correlation analyses resulted in a final inventory of 62 items. Internal consistency of all eight scales was established based on Cronbach's alpha. Convergent validity was undertaken by comparison of individual scales with existing validated measures of parental stress, mood, parenting behavior, marital adjustment, and general functioning. The temporal reliability of each scale was established using a sub-sample of 46 participants over a 14-day period. Psychometric evaluation suggests that the inventory yields a reliable and valid assessment of the multiple impacts of parenting an adolescent with chronic pain. The BAP-PIQ may offer a comprehensive assessment of these impacts in both a research and a clinical setting. Further study of the validity of BAP-PIQ scales and their ability to detect clinically meaningful change would be of use. Additional data from samples comprising fathers of adolescents with chronic pain and parents of adolescents with non-musculoskeletal pain would be of benefit. [Abstract]

Linton SJ, McCracken LM, Vlaeyen JW
Reassurance: Help or hinder in the treatment of pain.
Pain. 2007 Nov 20; [Abstract]

Jensen MP, Mardekian J, Lakshminarayanan M, Boye ME
Validity of 24-h recall ratings of pain severity: Biasing effects of "Peak" and "End" pain.
Pain. 2007 Nov 20;
Despite the frequent use of pain recall ratings in clinical research, there remains doubt about the ability of individuals to accurately recall their pain. In particular, previous research indicates the possibility that the most pain experienced during a recall period and the most recent pain experienced (known as peak and end effects, respectively) might bias recall ratings. The current study used data from a published clinical trial to determine the relative validity of a 24-h recall rating of average post-operative pain and the nature and extent of any biasing influence of peak and end effects on nine separate 24-h recall ratings. The results supported a statistically significant but small biasing influence of both peak and end pain. Also, the influence of peak pain was stronger than that of end pain. However, the biasing impact of both peak and end pain together was very small, suggesting that 24-h recall ratings are adequately valid indicants of average pain for patients participating in post-surgery clinical pain trials. [Abstract]

Edwards L, Inui K, Ring C, Wang X, Kakigi R
Pain-related evoked potentials are modulated across the cardiac cycle.
Pain. 2007 Nov 20;
Evidence suggests that the arterial baroreceptors modulate pain. To examine whether cortical processing of nociception is modulated by natural variations in arterial baroreceptor stimulation during the cardiac cycle, peak-to-peak amplitudes of the N2-P2 pain-related potential and pain ratings were recorded in response to noxious laser stimulation at different times during the cardiac cycle in 10 healthy males. Significant variations in the N2-P2 amplitudes occurred across the cardiac cycle, with smaller amplitudes midcycle, indicating that cortical processing of nociception was attenuated during systole compared to diastole. Pain ratings did not vary across the cardiac cycle. These data support the hypothesis that arterial baroreceptors modulate the processing of nociception during each cardiac cycle. [Abstract]

Sabsovich I, Guo TZ, Wei T, Zhao R, Li X, Clark DJ, Geis C, Sommer C, Kingery WS
TNF signaling contributes to the development of nociceptive sensitization in a tibia fracture model of complex regional pain syndrome type I.
Pain. 2007 Nov 20;
Tibia fracture in rats initiates a cascade of nociceptive, vascular, and bone changes resembling complex regional pain syndrome type I (CRPS I). Previous studies suggest that the pathogenesis of these changes is attributable to an exaggerated regional inflammatory response to injury. We postulated that the pro-inflammatory cytokine tumor necrosis factor alpha (TNF) might mediate the development of CRPS-like changes after fracture. RT-PCR and EIA assays were used to evaluate changes in TNF expression and content in skin, nerve, and bone after fracture. Bilateral hindpaw thickness, temperature, and nociceptive thresholds were determined, and bone microarchitecture was measured using microcomputed tomography. Lumbar spinal cord Fos immunostaining was performed for quantification of Fos positive neurons. After baseline testing, the distal tibia was fractured and the hindlimb casted for 4 weeks. The rats were subcutaneously injected either with a soluble TNF receptor type 1 (sTNF-R1, 5mg/kg/d) or saline every 3 days over 28 days and then were retested at 4 weeks post-fracture. Tibia fracture chronically upregulated TNF expression and protein levels in the hindpaw skin and sciatic nerve. After fracture the rats developed hindpaw mechanical allodynia and unweighting, which were reversed by sTNF-R1 treatment. Consistent with the behavioral data, spinal Fos increased after fracture and this effect was inhibited by sTNF-R1 treatment. Collectively, these data suggest that facilitated TNF signaling in the hindlimb is an important mediator of chronic regional nociceptive sensitization after fracture, but does not contribute to the hindlimb warmth, edema, and bone loss observed in this CRPS I model. [Abstract]

De Pascalis V, Cacace I, Massicolle F
Focused analgesia in waking and hypnosis: Effects on pain, memory, and somatosensory event-related potentials.
Pain. 2007 Nov 17;
Somatosensory event-related potentials (SERPs) to painful electric standard stimuli under an odd-ball paradigm were analyzed in 12 high hypnotizable (HH), 12 medium hypnotizable (MH), and 12 low hypnotizable (LH) subjects during waking, hypnosis, and a cued eyes-open posthypnotic condition. In each of these conditions subjects were suggested to produce an obstructive imagery of stimulus perception as a treatment for pain reduction. A No-Analgesia treatment served as a control in waking and hypnosis conditions. The subjects were required to count the number of delivered target stimuli. HH subjects experienced significant pain and distress reductions during posthypnotic analgesia as compared to hypnotic analgesia and between these two analgesic conditions as compared to the two control conditions. Outside of hypnosis, these subjects remembered less pain and distress levels than they reported during hypnotic and posthypnotic analgesia treatments. In contrast, for waking-analgesia treatment, HH subjects remembered similar pain and distress levels to those they reported concurrently with the stimulation. HH subjects, during hypnotic and posthypnotic analgesia treatments, detected a smaller number of target stimuli and displayed a significant amplitude reduction of the midline frontal and central N140 and P200 SERP components. No significant SERP differences were observed for these subjects between treatments in waking condition and between hypnotic and posthypnotic analgesic treatments. For the MH and LH subjects no significant N140 and P200 amplitude changes were observed among analgesic conditions as compared to control conditions. These amplitude findings are seen as indicating that hypnotic analgesia can affect earlier and later stages of stimulus processing. [Abstract]

Sikes RW, Vogt LJ, Vogt BA
Distribution and properties of visceral nociceptive neurons in rabbit cingulate cortex.
Pain. 2007 Nov 15;
Human imaging localizes most visceral nociceptive responses to anterior cingulate cortex (ACC), however, imaging in conscious subjects cannot completely control anticipatory and reflexive activity or resolve neuron activity. This study overcame these shortcomings by recording individual neuron responses in 12 anesthetized and paralyzed rabbits to define the visceronociceptive response pattern by region and layer. Balloon distension was applied to the colon at innocuous (15mmHg) or noxious (60mmHg) intensities, and innocuous and noxious mechanical, thermal and electrical stimuli were applied to the skin. Simultaneous recording from multiple regions assured differences were not due to anesthesia and neuron responses were resolved by spike sorting using principal components analysis. Of the total 346 neurons, 48% were nociceptive; responding to noxious levels of visceral or cutaneous stimulation, or both. Visceronociceptive neurons were most frequent in ACC (39%) and midcingulate cortex (MCC, 36%) and infrequent in retrosplenial cortex (RSC, 12%). In contrast, cutaneous nociceptive units were higher in MCC (MCC, 43%; ACC, 32%; RSC, 23%). Visceral-specific neurons were proportionately more frequent in ACC (37%), while cutaneous-specific units predominated in RSC (62.5%). Visceral nociceptive response durations were longer than those for cutaneous responses. Postmortem analysis of electrode tracks confirmed regional designations, and laminar analysis found inhibitory responses mainly in superficial layers and excitatory in deep layers. Thus, cingulate visceral nociception extends beyond ACC, this is the first report of nociceptive activity in RSC including nociceptive cutaneous responses, and these regional differences require a new model of cingulate nociceptive processing. [Abstract]

Gündel H, Valet M, Sorg C, Huber D, Zimmer C, Sprenger T, Tölle TR
Altered cerebral response to noxious heat stimulation in patients with somatoform pain disorder.
Pain. 2007 Nov 15;
Idiopathic chronic pain conditions with a mismatch between anatomical abnormalities and symptoms can be categorized as somatoform pain disorder according to the DSM-IV criteria. A dysfunction of pain processing circuits has been suggested as one underlying pathophysiological factor. There is accumulating evidence for a crucial role of affect regulating brain structures such as the medial frontal cortex in this context. We investigated the cerebral processing of noxious heat stimuli as objective marker for pain sensation in 12 right handed women with somatoform pain disorder fulfilling DSM-IV criteria and 13 age-matched healthy volunteers using functional MRI. The average ratings for experimentally induced pain were not significantly different between controls and patients concerning pain intensity and pain unpleasantness. Comparing patients with controls a pain related hypoactive state of the ventromedial prefrontal/orbitofrontal cortex (BA 10/11) and a hyperactive state of the parahippocampal gyrus, amygdala and anterior insula were found in the patient group. Our findings of an altered cerebral processing of experimentally induced pain in patients with somatoform pain disorder support the hypothesis of dysfunctional pain processing, especially in affect regulating regions. [Abstract]

Kroenke K, Shen J, Oxman TE, Williams JW, Dietrich AJ
Impact of pain on the outcomes of depression treatment: Results from the RESPECT trial.
Pain. 2007 Nov 15;
Objective: Pain is prevalent in patients with depression. The purpose of this study was to determine the impact of pain on depression treatment outcomes. Methods: Data was analyzed from a randomized controlled trial comparing a collaborative care intervention to usual care for the treatment of depression in 60 primary care practices. A total of 405 patients with either current major depressive disorder or dysthymia were enrolled, and assessed at baseline, 3, and 6months. Main measures included the 20-item Hopkins Symptom Check List (HSCL-20) depression score, and the SF-36 pain interference score. Results: Pain severe enough to produce at least moderate interference with daily activities was present in 42% of depressed patients at baseline. Pain outcomes did not differ between intervention and control groups but improved similarly in both over time. However, pain was still at least moderately severe in 32% of patients at 6months. Both baseline pain and the amount of pain improvement over time were associated with depression remission and response rates. In a multivariate model controlling for age, gender, and medical co-morbidity, depression severity increased with higher pain interference and decreased with the passage of time (p<.0001 for both). There was also a significant pain by time by treatment group interaction (p=.027). The beneficial effects of collaborative care on depression outcome persisted (p=.049) even after controlling for pain interference, time, covariates, and interaction effects. Conclusions: Pain has a strong negative impact on the response of depression to treatment. Recognizing and optimizing the management of comorbid pain that commonly coexists with depression may be important in enhancing depression response and remission rates. [Abstract]

Gottschling S, Meyer S, Gribova I, Distler L, Berrang J, Gortner L, Graf N, Shamdeen MG
Laser acupuncture in children with headache: A double-blind, randomized, bicenter, placebo-controlled trial.
Pain. 2007 Nov 15;
To investigate whether laser acupuncture is efficacious in children with headache and if active laser treatment is superior to placebo laser treatment in a prospective, randomized, double-blind, placebo-controlled trial of low level laser acupuncture in 43 children (mean age (SD) 12.3 (+/-2.6) years) with headache (either migraine (22 patients) or tension type headache (21 patients)). Patients were randomized to receive a course of 4 treatments over 4 weeks with either active or placebo laser. The treatment was highly individualised based on criteria of Traditional Chinese medicine (TCM). The primary outcome measure was a difference in numbers of headache days between baseline and the 4 months after randomization. Secondary outcome measures included a change in headache severity using a 10cm Visual Analogue Scale (VAS) for pain and a change in monthly hours with headache. Measurements were taken during 4 weeks before randomization (baseline), at weeks 1-4, 5-8, 9-12 and 13-16 from baseline. The mean number of headaches per month decreased significantly by 6.4 days in the treated group (p<0.001) and by 1.0 days in the placebo group (p=0.22). Secondary outcome measures headache severity and monthly hours with headache decreased as well significantly at all time points compared to baseline (p<0.001) and were as well significantly lower than those of the placebo group at all time points (p<0.001). We conclude that laser acupuncture can provide a significant benefit for children with headache with active laser treatment being clearly more effective than placebo laser treatment. [Abstract]

Williams AC, Amris K
Pain from torture.
Pain. 2007 Dec 15;133(1-3): [Abstract]

Nurmikko TJ, Serpell MG, Hoggart B, Toomey PJ, Morlion BJ, Haines D
Sativex successfully treats neuropathic pain characterised by allodynia: a randomised, double-blind, placebo-controlled clinical trial.
Pain. 2007 Dec 15;133(1-3):
Cannabinoids are known to have analgesic properties. We evaluated the effect of oro-mucosal sativex, (THC: CBD), an endocannabinoid system modulator, on pain and allodynia, in 125 patients with neuropathic pain of peripheral origin in a five-week, randomised, double-blind, placebo-controlled, parallel design trial. Patients remained on their existing stable analgesia. A self-titrating regimen was used to optimise drug administration. Sixty-three patients were randomised to receive sativex and 62 placebo. The mean reduction in pain intensity scores (primary outcome measure) was greater in patients receiving sativex than placebo (mean adjusted scores -1.48 points vs. -0.52 points on a 0-10 Numerical Rating Scale (p=0.004; 95% CI: -1.59, -0.32). Improvements in Neuropathic Pain Scale composite score (p=0.007), sleep NRS (p=0.001), dynamic allodynia (p=0.042), punctate allodynia (p=0.021), Pain Disability Index (p=0.003) and Patient's Global Impression of Change (p<0.001) were similarly greater on sativex vs. placebo. Sedative and gastrointestinal side effects were reported more commonly by patients on active medication. Of all participants, 18% on sativex and 3% on placebo withdrew during the study. An open-label extension study showed that the initial pain relief was maintained without dose escalation or toxicity for 52 weeks. [Abstract]

Coste J, Voisin DL, Miraucourt LS, Dallel R, Luccarini P
Dorsal horn NK1-expressing neurons control windup of downstream trigeminal nociceptive neurons.
Pain. 2007 Oct 29;
Windup is a progressive, frequency-dependent increase in the excitability of trigeminal and spinal dorsal horn wide dynamic range (WDR) nociceptive neurons to repetitive stimulation of primary afferent nociceptive C-fibers. Superficial dorsal horn neurokinin 1 receptor (NK1R)-expressing neurons were recently shown to regulate sensitization of WDR nociceptive neurons through activation of a defined spino-bulbo-spinal loop. However, the windup of WDR nociceptive neurons was not regulated through this loop. In the present study, we sought to identify the alternative circuit activated by dorsal horn NK1Rs that mediates WDR neuron windup. As a model we used the rat spinal trigeminal nucleus, in which the subnucleus oralis (Sp5O) contains a pool of WDR neurons that receive their nociceptive C-input indirectly via interneurons located in the medullary dorsal horn (MDH). First, we found that intravenous injection of NK1R antagonists (SR140333 and RP67580) produced a reversible inhibition of Sp5O WDR neuron windup. Second, we anatomically identified in the MDH lamina III a subpopulation of NK1R-expressing local interneurons that relay nociceptive information from the MDH to downstream Sp5O neurons. Third, using microinjections of NK1R antagonists during in vivo electrophysiological recordings from Sp5O WDR neurons, we showed that WDR neuron windup depends on activation of NK1Rs located in the MDH laminae I-III. We conclude that, in contrast to central sensitization that is controlled by a spino-bulbo-spinal loop, Sp5O WDR neuron windup is regulated through a local circuit activated by MDH lamina III NK1Rs. [Abstract]

Petersen KL, Meadoff T, Press S, Peters MM, Lecomte MD, Rowbotham MC
Changes in morphine analgesia and side effects during daily subcutaneous administration in healthy volunteers.
Pain. 2007 Oct 29;
Tolerance to the anti-nociceptive effects of opioids develops rapidly in animals. In contrast, humans with chronic pain show little or no loss of pain relief in prospective opioid trials of 4-8 weeks duration. Employing the Brief Thermal Sensitization model to induce transient cutaneous secondary hyperalgesia, we tested the hypothesis that opioid analgesic tolerance would develop rapidly. In this outpatient randomized placebo-controlled study, subjects in the MMMMP group received two injections of subcutaneous morphine 6mg (150min apart) on Monday-Thursday (total 48mg over 4 days) and matching saline placebo on Friday. Subjects in the PPPPM group received placebo on Monday-Thursday and morphine (total 12mg) on Friday. Sixty-one healthy volunteers were enrolled; morphine side effects accounted for all nine non-completions. Compared to the first placebo day, the reduction in the area of secondary hyperalgesia on the first morphine day was significant and robust in both groups. Morphine suppression of the painfulness of skin heating and elevation of the heat pain detection threshold were also significant. During 4 days of twice-daily injections, the decline in anti-hyperalgesic effects of morphine did not reach statistical significance (p=0.06) compared to placebo. Morphine side effects did not correlate with anti-hyperalgesic effects and withdrawal symptoms did not emerge. As 4 days is the threshold for demonstrating analgesic tolerance to twice-daily morphine in animal models, a longer period of opioid exposure in healthy volunteers might be needed to detect analgesic tolerance. [Abstract]

Sutherland R, Morley S
Self-pain enmeshment: Future possible selves, sociotropy, autonomy and adjustment to chronic pain.
Pain. 2007 Oct 29;
The aims of this study were to replicate and extend previous observations on the relationship between enmeshment of the self and pain and measures of adjustment [Morley et al., Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance, Pain 2005;115:84-94], and to test the hypothesis that individual variation in motivational preferences interacts with enmeshment. 82 chronic pain patients completed standardized self-report measures of depression, anxiety, acceptance and the possible selves interview which generated measures of their hoped-for (own and other perspectives) and feared-for selves. They made judgments about the conditionality of each self on the continuing presence of pain as a measure of self-pain enmeshment. A series of hierarchical regression analyses, that adjusted for demographics, pain characteristics and disability, confirmed the relationship between self enmeshment and depression and acceptance. When anxiety was considered, there was no main effect for any of the self aspects but there were specific interactions between the hoped-for (own) and (other) selves and two motivational preferences - autonomy and sociotropy. [Abstract]

Aasvang EK, Brandsborg B, Christensen B, Jensen TS, Kehlet H
Neurophysiological characterization of postherniotomy pain.
Pain. 2007 Oct 30;
Inguinal herniotomy is one of the most frequent surgical procedures and chronic pain affecting everyday activities is reported in approximately 10% of patients. However, the neurophysiological changes and underlying pathophysiological mechanisms of postherniotomy pain are not known in detail, thereby precluding advances in treatment strategies and prophylaxis. Therefore, we examined forty-six patients reporting moderate to severe postherniotomy pain affecting daily activities for more than a year postoperatively, and compared them with a control group of patients without pain 1yr postoperatively. A quantitative sensory testing protocol was used, assessing sensory dysfunction type, location and severity. We assessed the protocol test-retest variability using data from healthy control subjects. All patients (pain and pain-free) had signs of nerve damage, seen as sensory dysfunction. Detection thresholds for tactile and warmth stimulation were significantly increased while cold detection and pressure pain detection thresholds were significantly decreased in pain patients compared to controls. Repetitive punctuate and brush stimulation resulted in significantly more frequent and intense pain on the painful side than on the unaffected side in pain patients, and was not observed in controls. Our findings showed large and small fiber dysfunction in both pain and pain-free patients but more profound in pain patients and with signs of central sensitization (abnormal temporal summation). The specific finding of reduced pain detection threshold over the external inguinal annulus is consistent with damage to the cutaneous innervation territory of nervous structures in the inguinal region. The correspondence between pain location and sensory disturbance suggests that the pain is neuropathic in nature. Whether the underlying pathophysiological mechanisms are related to direct intraoperative nerve injury or nerve injury due to an inflammatory mesh response remains to be determined. [Abstract]

Recent Articles in Anesthesiology

Instructions for Obtaining Journal CME Credit.
Anesthesiology. 2007 Dec;107(6):1045-1046. [Abstract]

Nominations Sought for: Award for Excellence in Research.
Anesthesiology. 2007 Dec;107(6):1044. [Abstract]

Petterson MT
Misleading Behavior of Masimo Pulse Oximeter Tone during Profound Bradycardia.
Anesthesiology. 2007 Dec;107(6):1039-1040. [Abstract]

St Jean B
Potential Hazard Associated with a Laryngoscope Blade.
Anesthesiology. 2007 Dec;107(6):1038. [Abstract]

Forde RE, DeBros FM, Guimaraes EL, Sandberg WS
Misleading behavior of Masimo pulse oximeter tone during profound bradycardia.
Anesthesiology. 2007 Dec;107(6):1038-9; discussion 1039-40. [Abstract]

Luginbuehl I, Matthews K
Potential hazard associated with a laryngoscope blade.
Anesthesiology. 2007 Dec;107(6):1037-8; discussion 1038. [Abstract]

Altose MD, León-Ruiz E
Etomidate Unlikely to Have Induced Pacemaker-mediated Tachycardia.
Anesthesiology. 2007 Dec;107(6):1037. [Abstract]

Rozner MA
Etomidate unlikely to have induced pacemaker-mediated tachycardia.
Anesthesiology. 2007 Dec;107(6):1036; author reply 1037. [Abstract]

Scott DA, Cameron CM, Davies MJ, McDonald WM
Epidural Complications across the Globe.
Anesthesiology. 2007 Dec;107(6):1035. [Abstract]

McCabe SE, Christie IW
Epidural complications across the globe.
Anesthesiology. 2007 Dec;107(6):1034-5; author reply 1035. [Abstract]

Heitmiller E, Martinez E, Pronovost PJ
Medication Error: A Leading Cause of Anesthesia-related Morbidity and Mortality.
Anesthesiology. 2007 Dec;107(6):1034. [Abstract]

Hove LD, Steinmetz J
Medication Error: A Leading Cause of Anesthesia-related Morbidity and Mortality.
Anesthesiology. 2007 Dec;107(6):1034. [Abstract]

Meyer R, Orser BA, Byrick R
Medication error: a leading cause of anesthesia-related morbidity and mortality.
Anesthesiology. 2007 Dec;107(6):1033; author reply 1034. [Abstract]

Augoustides JG
Perioperative central venous cannulation: it is time for action.
Anesthesiology. 2007 Dec;107(6):1032-3; author reply 1034. [Abstract]

Gupta DK, Manyam SC, Johnson KB, Egan TD
Can 1% Sevoflurane with 5 ng/ml Remifentanil Prevent Implicit Memory?
Anesthesiology. 2007 Dec;107(6):1031. [Abstract]

Richman JM
Does combined epidural-general anesthesia increase risk over either technique used alone?
Anesthesiology. 2007 Dec;107(6):1031-2; author reply 1034. [Abstract]

Hagihira S, Takashina M, Mori T, Mashimo T
Can 1% sevoflurane with 5 ng/ml remifentanil prevent implicit memory?
Anesthesiology. 2007 Dec;107(6):1030; author reply 1031. [Abstract]

Preece A
Clarifying equipment specifications and performance characteristics.
Anesthesiology. 2007 Dec;107(6):1029; author reply 1029-30. [Abstract]

Jaber S, Tassaux D, Sebbane M, Pouzeratte Y, Battasti A, Capdevila X, Eledjam JJ, Jolliet P
Clarifying Equipment Specifications and Performance Characteristics.
Anesthesiology. 2007 Dec;107(6):1029-1030. [Abstract]

Lavi R, Lavi S, Daghini E, Lerman LO
New frontiers in the evaluation of cardiac patients for noncardiac surgery.
Anesthesiology. 2007 Dec;107(6):1018-28. [Abstract]

Rittner HL, Lux C, Labuz D, Mousa SA, Schäfer M, Stein C, Brack A
Neurokinin-1 receptor antagonists inhibit the recruitment of opioid-containing leukocytes and impair peripheral antinociception.
Anesthesiology. 2007 Dec;107(6):1009-17.
BACKGROUND: Neurokinins (e.g., substance P) contribute to pain transmission in the central nervous system, peripheral neurogenic inflammation, and leukocyte recruitment in inflammation. Leukocyte recruitment involves (1) up-regulation of adhesion molecule expression through neurokinin-1 (NK1) receptors on endothelial cells, (2) augmented chemokine production, or (3) chemotaxis through NK1 receptors on leukocytes. In inflammation, leukocytes can trigger endogenous antinociception through release of opioid peptides and activation of opioid receptors on peripheral sensory neurons. The authors hypothesized that NK1 receptor antagonists impair recruitment of opioid-containing leukocytes and stress-induced antinociception. METHODS: Rats were treated intraperitoneally and intrathecally with peripherally restricted (SR140333) or blood-brain barrier-penetrating (L-733,060) NK1 receptor antagonists and were evaluated for paw pressure thresholds, numbers of infiltrating opioid-containing leukocytes and leukocyte subpopulations, expression of adhesion molecules, NK1 receptors, and chemokines 24-48 h after complete Freund adjuvant-induced hind paw inflammation. RESULTS: Systemic and peripherally selective, but not intrathecal, NK1 receptor blockade reduced stress-induced antinociception (control: 177 +/- 9 g, L-733,060: 117 +/- 8 g, and control: 166 +/- 30 g, SR140333: 89 +/- 3 g; both P < 0.05, t test) without affecting baseline hyperalgesia. In parallel, local recruitment of opioid-containing leukocytes was decreased (L-733,060 and SR140333: 56.0 +/- 4.3 and 59.1 +/- 7.9% of control; both P < 0.05, t test). NK1 receptors were expressed on peripheral neurons, infiltrating leukocytes and endothelial cells. Peripheral NK1 receptor blockade did not alter endothelial expression of intercellular adhesion molecule-1 or local chemokine and cytokine production, but decreased polymorphonuclear cell and macrophage recruitment. CONCLUSIONS: Endogenous inhibition of inflammatory pain is dependent on NK1 receptor-mediated recruitment of opioid-containing leukocytes. [Abstract]

White RL, Cohen SP
Return-to-duty rates among coalition forces treated in a forward-deployed pain treatment center: a prospective observational study.
Anesthesiology. 2007 Dec;107(6):1003-8.
BACKGROUND: Non-battle-related injuries and the recurrence of chronic pain are major causes of medical evacuation in wartime. Because a pain medicine specialist may or may not be assigned to a forward-deployed medical unit, the treatment of pain from non-battle-related injuries in war zones is a serendipitous endeavor. Previous studies have demonstrated that the return-to-unit rate for soldiers evacuated to a tertiary care facility for pain management is abysmally low. METHODS: This is a prospective, observational study measuring return-to-duty rates in the first forward-deployed pain treatment center. RESULTS: Over a 6-month period, 132 patients were treated, the large majority (n = 113) of whom were coalition forces. In descending order, the four most common diagnoses among coalition forces were lumbar radiculopathy (n = 63), thoracic pain (n = 13), cervical radiculopathy (n = 8), and groin pain (n = 8). Epidural steroid injections (n = 125) were by far the most frequently performed procedure, followed by trigger point injections (n = 21), lumbar facet blocks (n = 16), and groin blocks (n = 9). Nonsteroidal antiinflammatory drugs were prescribed to 70% of patients, and 24% were referred to physical therapy. The return-to-duty rate for coalition forces was 94.7%. The primary complaint of all 7 patients who required medical evacuation outside the theaters of operation was groin pain. CONCLUSIONS: These results demonstrate the feasibility of obtaining high return-to-duty rates when aggressive pain management strategies are used in forward-deployed areas. [Abstract]

Yasui Y, Masaki E, Kato F
Sevoflurane directly excites locus coeruleus neurons of rats.
Anesthesiology. 2007 Dec;107(6):992-1002.
BACKGROUND: Sevoflurane, an anesthetic showing high incidence of emergence agitation in human patients, especially in children, increases noradrenaline release in the preoptic area in the rat brain. The clinically observed frequency of emergence agitation with sevoflurane is significantly reduced by drugs activating alpha2 adrenoceptors. The locus coeruleus (LC) is a source nucleus of widely spreading noradrenergic projections in the central nervous system and is also known as one of the principal targets of some alpha2-adrenoceptor agonists, such as dexmedetomidine. The authors analyzed the effects of sevoflurane and other anesthetics on the membrane current of the LC neurons to study the mechanism of the paradoxical "excitatory" effects of the anesthetics. METHODS: Effects of volatile and nonvolatile anesthetics on the membrane potential and currents of LC neurons in pontine slices of the rat were evaluated. Action potential-dependent transmission was suppressed with tetrodotoxin. RESULTS: Sevoflurane at 5% (measured concentration in the recording chamber, 0.5 mm) induced an early-phase inward current in most of LC neurons in a robust manner, which significantly increased the firing frequency in the absence of tetrodotoxin under current clamp recording. Preadministration of dexmedetomidine (1-3 nm) occluded this increase in firing frequency with sevoflurane. This inward current was inhibited by a gap junction inhibitor carbenoxolone and was not observed with nonvolatile general anesthetics and in non-LC neurons examined. CONCLUSIONS: The excitatory current activated by sevoflurane in LC neurons, likely to be mediated by gap junction-related mechanisms, might be one of the potential cellular mechanisms underlying paradoxical excitatory effect of sevoflurane. [Abstract]

Hudetz AG, Imas OA
Burst activation of the cerebral cortex by flash stimuli during isoflurane anesthesia in rats.
Anesthesiology. 2007 Dec;107(6):983-91.
BACKGROUND: The degree of suppression of sensory functions during general anesthesia is controversial. Here, the authors investigated whether discrete flash stimuli induced cortical field potential responses at an isoflurane concentration producing burst suppression and compared the spatiotemporal properties and frequency spectra of flash-induced burst responses with those occurring spontaneously. METHODS: Rats were equipped with multiple epidural and intracortical electrodes to record cortical field potentials in the right hemisphere at several locations along the anterior-posterior axis. At isoflurane concentrations of 1.1, 1.4, and 1.8%, discrete light flashes were delivered to the left eye while cortical field potentials were continuously recorded. RESULTS: Isoflurane at 1.4-1.8% produced burst suppression. Each flash produced a visual evoked potential in the primary visual cortex followed by secondary bursting activity in more anterior regions. The average latency and duration of these bursts were 220 and 810 ms, respectively. The spontaneous and flash-induced bursts were similar in frequency, duration, and spatial distribution. They had maximum power in the frontal (primary motor) cortex with a dominant frequency of 10 Hz. CONCLUSIONS: The results suggest that discrete flash stimuli activate the motor regions of the cerebral cortex during isoflurane anesthesia and that these activations are analogous with those that occur spontaneously during burst suppression. Electrocortical suppression of the cortex during anesthesia does not prevent its response to visual stimuli. [Abstract]

Metz LB, Dasgupta N, Liu C, Hunt SJ, Crowder CM
An evolutionarily conserved presynaptic protein is required for isoflurane sensitivity in Caenorhabditis elegans.
Anesthesiology. 2007 Dec;107(6):971-82.
BACKGROUND: Volatile general anesthetics inhibit neurotransmitter release by an unknown mechanism. A mutation in the presynaptic soluble NSF attachment protein receptor (SNARE) protein syntaxin 1A was previously shown to antagonize the anesthetic isoflurane in Caenorhabditis elegans. The mechanism underlying this antagonism may identify presynaptic anesthetic targets relevant to human anesthesia. METHODS: Sensitivity to isoflurane concentrations in the human clinical range was measured in locomotion assays on adult C. elegans. Sensitivity to the acetylcholinesterase inhibitor aldicarb was used as an assay for the global level of C. elegans neurotransmitter release. Comparisons of isoflurane sensitivity (measured by the EC50) were made by simultaneous curve fitting and F test as described by Waud. RESULTS: Expression of a truncated syntaxin fragment (residues 1-106) antagonized isoflurane sensitivity in C. elegans. This portion of syntaxin interacts with the presynaptic protein UNC-13, suggesting the hypothesis that truncated syntaxin binds to UNC-13 and antagonizes an inhibitory effect of isoflurane on UNC-13 function. Consistent with this hypothesis, overexpression of UNC-13 suppressed the isoflurane resistance of the truncated syntaxins, and unc-13 loss-of-function mutants were highly isoflurane resistant. Normal anesthetic sensitivity was restored by full-length UNC-13, by a shortened form of UNC-13 lacking a C2 domain, but not by a membrane-targeted UNC-13 that might bypass isoflurane inhibition of membrane translocation of UNC-13. Isoflurane was found to inhibit synaptic localization of UNC-13. CONCLUSIONS: These data show that UNC-13, an evolutionarily conserved protein that promotes neurotransmitter release, is necessary for isoflurane sensitivity in C. elegans and suggest that its vertebrate homologs may be a component of the general anesthetic mechanism. [Abstract]

Zhao P, Peng L, Li L, Xu X, Zuo Z
Isoflurane preconditioning improves long-term neurologic outcome after hypoxic-ischemic brain injury in neonatal rats.
Anesthesiology. 2007 Dec;107(6):963-70.
BACKGROUND: Preconditioning the brain with relatively safe drugs seems to be a viable option to reduce ischemic brain injury. The authors and others have shown that the volatile anesthetic isoflurane can precondition the brain against ischemia. Here, the authors determine whether isoflurane preconditioning improves long-term neurologic outcome after brain ischemia. METHODS: Six-day-old rats were exposed to 1.5% isoflurane for 30 min at 24 h before the brain hypoxia-ischemia that was induced by left common carotid arterial ligation and then exposure to 8% oxygen for 2 h. The neuropathology, motor coordination, and learning and memory functions were assayed 1 month after the brain ischemia. Western analysis was performed to quantify the expression of the heat shock protein 70, Bcl-2, and survivin 24 h after isoflurane exposure. RESULTS: The mortality was 45% after brain hypoxia-ischemia. Isoflurane preconditioning did not affect this mortality. However, isoflurane preconditioning attenuated ischemia-induced loss of neurons and brain tissues, such as cerebral cortex and hippocampus in the survivors. Isoflurane also improved the motor coordination of rats at 1 month after ischemia. The learning and memory functions as measured by performance of Y-maze and social recognition tasks in the survivors were not affected by the brain hypoxia-ischemia or isoflurane preconditioning. The expression of Bcl-2, a well-known antiapoptotic protein, in the hippocampus is increased after isoflurane exposure. This increase was reduced by the inhibitors of inducible nitric oxide synthase. Inducible nitric oxide synthase inhibition also abolished isoflurane preconditioning-induced neuroprotection. CONCLUSIONS: Isoflurane preconditioning improved the long-term neurologic outcome after brain ischemia. Inducible nitric oxide synthase may be involved in this neuroprotection. [Abstract]

Heerdt PM, Lane P, Pan BY, Schaefer U, Crabtree M, Hong R, Singer AA, Levi R, Park BJ
Nitrosative stress and myocardial sarcoplasmic endoreticular calcium adenosine triphosphatase subtype 2a activity after lung resection in swine.
Anesthesiology. 2007 Dec;107(6):954-62.
BACKGROUND: Chronic, disease-associated oxidative stress induces myocardial peroxynitrite formation that may lead to nitrosative inhibition of the calcium cycling protein sarcoplasmic endoreticular calcium adenosine triphosphatase subtype 2a (SERCA2a). The current study was designed to test the hypothesis that the acute oxidative stress associated with lung resection also induces myocardial nitrosative stress and alters SERCA2a activity. METHODS: Ventricular myocardium from 16 swine was studied; 11 animals had undergone left upper lobectomy (n = 7) or sham thoracotomy (n = 4) 3 days before harvest, and 5 were nonoperated controls. Tissue peroxynitrite was assessed by measurement of 3-nitrotyrosine incorporation into proteins. SERCA2a activity was determined from indo-1 uptake by isolated sarcoplasmic reticular membranes. Expression of SERCA2a and its regulatory protein phospholamban were determined by Western blotting, as was the phospholamban phosphorylation state (when dephosporylated, phospholamban inhibits SERCA2a). Mechanical significance of changes in SERCA2a activity was assessed from the force-frequency relation of isometric myocardial trabeculae. RESULTS: Relative to both the control and sham groups, lobectomy animals exhibited a greater than twofold higher myocardial 3-nitrotyrosine incorporation and an approximately 50% lower SERCA2a activity, but no difference in SERCA2a or phospholamban expression or phospholamban phosphorylation. Concomitantly, whereas the trabecular force-frequency relation of control animals was positive, that of lobectomy animals was negative, consistent with impaired calcium cycling. CONCLUSIONS: These data indicate that oxidative/nitrosative stress associated with lung resection influences SERCA2a activity independent of any influence on protein expression or phospholamban phosphorylation. The findings link an acute event with a subcellular process primarily described for chronic illness and suggest a biochemical basis for perioperative changes in myocardial mechanical reserve. [Abstract]

Breschan C, Platzer M, Jost R, Schaumberger F, Stettner H, Likar R
Comparison of catheter-related infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates.
Anesthesiology. 2007 Dec;107(6):946-53.
BACKGROUND: The primary aim of this study was to compare catheter-associated infections and tip contaminations between percutaneously placed central venous catheters in the internal jugular and subclavian veins in surgical neonates undergoing major noncardiac surgery. METHODS: The prospectively computerized protocols of 295 procedures were analyzed retrospectively. RESULTS: One hundred twenty-nine internal jugular venous (group I) and 107 subclavian venous catheters (group S) were included. The median postconceptual age was 37 weeks in group I and 38 in group S. The weight ranged from 580 g to 4.5 kg in group I and from 820 g to 4.5 kg in group S at the time of insertion. Significantly more catheter-associated infections were observed in group I (15.5 vs. 4.7%; chi-square analysis: P < 0.01). The internal jugular venous catheters were also associated with a significantly increased probability of an earlier onset of a catheter-associated infection compared with the subclavian venous catheters (log rank test: P < 0.01; Cox model: P < 0.01). This probability was only slightly increased by a lower weight (Cox model: P = 0.075), and it was not increased by a lower age (Cox model: P = 0.93). Significantly more catheter tips were contaminated by pathogens in group I (55.8 vs. 33.6%; chi-square analysis: P < 0.01). CONCLUSION: The internal jugular venous catheters were associated with a higher infection rate as well as earlier onset of catheter-associated infection compared with the subclavian venous catheters. [Abstract]

Bauer A, Kofler S, Thiel M, Eifert S, Christ F
Monitoring of the sublingual microcirculation in cardiac surgery using orthogonal polarization spectral imaging: preliminary results.
Anesthesiology. 2007 Dec;107(6):939-45.
BACKGROUND: The recent introduction of orthogonal polarization spectral imaging enables the direct visualization of the microcirculation of man without imaging enhancing dyes. The authors studied the changes in microvascular perfusion of sublingual mucosa during cardiac surgery with the use of cardiopulmonary bypass (CPB) using this optical method. METHOD: Orthogonal polarization spectral images were recorded in 47 patients after skin incision (T1), after the start of CPB (T2), in the late phase of CPB (T3), and 1 h after the discontinuation of CPB (T4). The images were analyzed for microvascular diameter, erythrocyte velocity, and functional capillary density using an established analysis routine for intravital microscopy studies. In a subpopulation (n = 8), the expression of the adhesion molecules CD18 on circulation leukocytes was compared with the number of visualized rolling leukocytes. RESULTS: Preoperatively, no significant changes of the microvascular diameter and erythrocyte velocity were seen. The functional capillary density was significantly reduced at T3 to 90% of the values observed before CPB but recovered at T4 and showed a weak but significant correlation with body temperature (r = 0.38, P < 0.01) and hemoglobin concentration (r = 0.20, P < 0.05). Expression of CD18 was significantly increased in the late phase of CPB (T3) only, whereas the numbers of rolling leukocytes increased during CPB and revealed a significant threefold increase 1 h after termination of CPB. CONCLUSIONS: Orthogonal polarization spectral imaging revealed no major changes of microvascular perfusion during uncomplicated hypothermic CPB. The slightly reduced functional capillary density during CPB may be caused by several factors all present during CPB, including hypothermia, the artificial extracorporeal perfusion, surgical trauma, hemodilution, and inflammatory reaction. The current data do not allow differentiation between the effects of those possible causes. [Abstract]

Särkelä MO, Ermes MJ, van Gils MJ, Yli-Hankala AM, Jäntti VH, Vakkuri AP
Quantification of epileptiform electroencephalographic activity during sevoflurane mask induction.
Anesthesiology. 2007 Dec;107(6):928-38.
BACKGROUND: Sevoflurane may induce epileptiform electroencephalographic activity leading to unstable Bispectral Index numbers, underestimating the hypnotic depth of anesthesia. The authors developed a method for the quantification of epileptiform electroencephalographic activity during sevoflurane anesthesia. METHODS: Electroencephalographic data from 60 patients under sevoflurane mask induction were used in the analysis. Electroencephalographic data were visually classified. A novel electroencephalogram-derived quantity, wavelet subband entropy (WSE), was developed. WSE variables were calculated from different frequency bands. Performance of the WSE in detection and quantification of epileptiform electroencephalographic activity and the ability of the WSE to recognize misleading Bispectral Index readings caused by epileptiform activity were evaluated. RESULTS: Two WSE variables were found to be sufficient for the quantification of epileptiform activity: WSE from the frequency bands 4-16 and 16-32 Hz. The lower frequency band was used for monophasic pattern monitoring, and the higher frequency band was used for spike activity monitoring. WSE values of the lower and higher bands followed the time evolution of epileptiform activity with prediction probabilities of 0.809 (SE, 0.007) and 0.804 (SE, 0.007), respectively. In deep anesthesia with epileptiform activity, WSE detected electroencephalographic patterns causing Bispectral Index readings greater than 60, with event sensitivity of 97.1%. CONCLUSIONS: The developed method proved useful in detection and quantification of epileptiform electroencephalographic activity during sevoflurane anesthesia. In the future, it may improve the understanding of electroencephalogram-derived information by assisting in recognizing misleading readings of depth-of-anesthesia monitors. The method also may assist in minimizing the occurrence of epileptiform activity and seizures during sevoflurane anesthesia. [Abstract]

Recent Articles in Anaesthesia

Gum J
How I became an anaesthetist.
Anaesthesia. 2007 Dec;62 Suppl 1118-9. [Abstract]

Henderson K
Lessons from working overseas.
Anaesthesia. 2007 Dec;62 Suppl 1113-7.
To spend time in a developing country may not appear an obvious choice in a UK-based anaesthetic career. However, dealing with challenging situations and meeting people who spend their working lives in this environment can be an unforgettable experience. Reliance on personal clinical skills and basic techniques teaches us an enormous amount about the ability within us as physicians. There are benefits to us as individuals, the country involved, the people, and also the NHS in the long term. This article gathers personal experiences that are representative of commonly expressed opinions. [Abstract]

Morris S, Clyburn P, Harries S, Rees L, Sewell J, Hall J
Mothers of Africa--an anaesthesia charity.
Anaesthesia. 2007 Dec;62 Suppl 1108-12.
An anaesthetic charity 'Mothers of Africa' has been established as a link between the academic departments of anaesthesia in Togo and Benin and the University Hospital of Wales. Visits by UK consultant anaesthetists have identified a number of clinical areas where collaborative working in both classroom and theatre has the potential to improve outcomes in maternal mortality and morbidity. [Abstract]

Stevenson C
Educational resources: website and book review.
Anaesthesia. 2007 Dec;62 Suppl 1103-7.
Good quality educational material for anaesthesia providers in the developing world is limited in both quantity and availability. Traditionally, textbooks have been the main source of information but these are frequently expensive, easily damaged and rapidly become outdated. Many first world texts concentrate on the use of expensive drugs for an increasingly complex range of patients and procedures, making them less suitable for practitioners in resource-poor locations. Improved access to broadband internet connections will increasingly be a major portal for the delivery of up to date educational material. [Abstract]

Dobson M
Training the trainers.
Anaesthesia. 2007 Dec;62 Suppl 196-102.
Our understanding of how adults learn has undergone many advances in the last few years. This information needs to be used to build more effective training in anaesthesia throughout the world, especially in those countries where the need to train large numbers is critical to the development of effective medical services. Training a new generation of teachers is a key part of this. [Abstract]

Gatrad AR, Gatrad S, Gatrad A
Equipment donation to developing countries.
Anaesthesia. 2007 Dec;62 Suppl 190-5.
Equipment donations to colleagues working in developing countries may be a very effective form of aid, provided that the items supplied follow international guidelines and are practical for the receiving unit. A number of predictable difficulties may arise during the process and this article demonstrates what can be achieved by a few enthusiastic volunteers. [Abstract]

Wright IG, Walker IA, Yacoub MH
Specialist surgery in the developing world: luxury or necessity?
Anaesthesia. 2007 Dec;62 Suppl 184-9.
Patients suffering from conditions requiring specialist intervention cannot obtain treatment when facilities do not exist locally. Specialist visiting teams in a number of surgical disciplines have attempted to address these issues in collaboration with local clinicians. These interventions require careful planning and communication to achieve optimum results. Several teams have been successful in building long-term relationships that have lead to important clinical developments in the local country. [Abstract]

Frossard J, Bojarska A
Employment opportunities with international agencies, mission organisations and government hospitals.
Anaesthesia. 2007 Dec;62 Suppl 178-83.
This article describes work with aid agencies in different developing countries. In addition to providing anaesthesia, the aim should be to increase resources and sustainability of local practice, irrespective of the duration of the visit. This article describes the background to some of the international aid agencies and our experience working with the International Committee of the Red Cross, Médecins Sans Frontières, and Response International, as well as various other mission organisations. [Abstract]

Thoms GM, McHugh GA, O'Sullivan E
The Global Oximetry initiative.
Anaesthesia. 2007 Dec;62 Suppl 175-7.
Global Oximetry (GO) is an initiative launched recently in Uganda, India, the Philippines and Vietnam. The overall aims are to promote oximetry utilisation and reduce oximetry costs in lower income countries. Research objectives include studying the feasibility of cost reduction; overcoming non-cost barriers to global oximetry including issues of prioritization; education and guidelines; servicing and access to parts. Promotional objectives include creating new policy, influencing oximetry design, and setting new global standards for safer monitoring. [Abstract]

Aitken H, O'Sullivan E
The International Relations Committee of the Association of Anaesthetists of Great Britain and Ireland.
Anaesthesia. 2007 Dec;62 Suppl 172-4.
The International Relations Committee of the Association of Anaesthetists of Great Britain and Ireland was established over 30 years ago to assist anaesthetists working in developing countries. The committee has attempted to make an impact through distribution of educational materials, supporting training courses and investing in a number of small equipment projects. In 2005, the Overseas Anaesthesia Fund was set up to allow members to donate directly to support our work. [Abstract]

Enright A, Wilson IH, Moyers JR
The World Federation of Societies of Anaesthesiologists: supporting education in the developing world.
Anaesthesia. 2007 Dec;62 Suppl 167-71.
The World Federation of Societies of Anaesthesiologists (WFSA) was formed in 1955 and is currently composed of 120 national societies. The aims of WFSA are to improve the standards of anaesthesia worldwide, with a particular emphasis in developing countries. This article details the structure of the WFSA, the various activities carried out by the different committees, and our achievements in education and training. [Abstract]

Cherian MN, Merry AF, Wilson IH
The World Health Organization and anaesthesia.
Anaesthesia. 2007 Dec;62 Suppl 165-6.
The World Health Organization has been involved in a wide range of global healthcare initiatives for many years. Recently an initiative 'Safe Surgery Saves Lives' has been launched to improve the safety of surgery throughout the world. Safe anaesthesia is a key component to achieving this aim. [Abstract]

Wilkinson D, McDougall R
Primary trauma care.
Anaesthesia. 2007 Dec;62 Suppl 161-4.
The Primary Trauma Care programme is a course designed to train anaesthetists, surgeons and others in the systematic review and management of severe trauma victims at the District Hospital. Over the last 10 years, many individuals have been involved in training, empowering and supporting doctors and nurses in a number of countries. Local programmes and training courses are increasingly co-ordinated by regional offices in South America, India, China, Indonesia, the South Pacific and Africa. The Primary Trauma Care Foundation continues to support these regional offices in their need for qualified instructors, fund-raising, and for updating educational material. With anaesthetic support, the Primary Trauma Care Foundation will continue to empower anaesthetists worldwide as they work with their surgical colleagues to treat severely injured patients in areas where, previously, due to inadequate resources and training, comprehensive treatment was not available. [Abstract]

McCormick BA, Eltringham RJ
Anaesthesia equipment for resource-poor environments.
Anaesthesia. 2007 Dec;62 Suppl 154-60.
The design of anaesthesia equipment for use in hospitals in the developing world must take into account the local conditions, particularly whether reliable supplies of compressed oxygen and electricity are available. Designs should ensure that maintenance is feasible locally. International standards should encourage the design of suitable equipment to ensure safe anaesthesia for patients worldwide. [Abstract]

Craven R
Anaesthesia. 2007 Dec;62 Suppl 148-53.
Ketamine is a very versatile inexpensive drug and plays an invaluable role in the developing world. In regions where access and funding for a wider range of drugs is problematic, its broad range of clinical applications is ideal. Its good safety profile and ease of storage makes it ideal for use in areas where refrigerators, complex monitoring, electricity and oxygen may all be in short supply or unreliable. Ketamine is also finding increasing use in both the acute and chronic pain settings and research is still ongoing into a potential neuroprotective effect for ketamine in brain injury. [Abstract]

Schnittger T
Regional anaesthesia in developing countries.
Anaesthesia. 2007 Dec;62 Suppl 144-7.
In modern anaesthesia practice, regional techniques are preferred to general anaesthesia for many types of surgery, particularly in obstetric care. Improved outcomes have been recorded in UK practice, but the techniques remain underutilised in many parts of the world. With encouragement, training and a regular supply of appropriate needles and local anaesthetic agents, the advantages of regional techniques in the developing world could be realised. [Abstract]

Size M, Soyannwo OA, Justins DM
Pain management in developing countries.
Anaesthesia. 2007 Dec;62 Suppl 138-43.
Access to pain relief is an integral part of peri-operative care jointly managed by clinicians and nursing staff. Simple regimens, relying on inexpensive drugs, are often not followed due to inadequate healthcare systems. This article describes some of the common challenges, and suggests practical approaches to overcoming them. [Abstract]

Towey RM, Ojara S
Intensive care in the developing world.
Anaesthesia. 2007 Dec;62 Suppl 132-7.
Appropriate and sustainable intensive care practice is possible even in the resource-limited locations of sub-Saharan Africa. Data from seven sub-Saharan African countries indicates that the majority of patients served are surgical. Comparison between intensive care units is difficult due to lack of laboratory support, which precludes the severity sickness scores used internationally. Hospital mortality can be reduced by increasing nurse/patient ratios, adequate monitoring and initiating postoperative intermittent positive pressure ventilation when required. Equipment should include appropriate technology, for instance using oxygen concentrators and a ventilator not dependent on compressed gases or disposable circuits. The clinical officer anaesthetist has a major role to play in the intensive care team. [Abstract]

Hodges SC, Walker IA, Bösenberg AT
Paediatric anaesthesia in developing countries.
Anaesthesia. 2007 Dec;62 Suppl 126-31.
Each year millions of children undergo surgery in the developing world with inadequate facilities, equipment and drugs. In many hospitals, anaesthesia is largely dependent on the availability of ketamine. Application of well-established clinical techniques, particularly for postoperative pain control, would relieve unnecessary suffering in children. Improvements in peri-operative care are required by investment in health systems and training. [Abstract]

Clyburn P, Morris S, Hall J
Anaesthesia and safe motherhood.
Anaesthesia. 2007 Dec;62 Suppl 121-5.
The challenges of obstetric care in the developing world are enormous. Many fit young mothers die or suffer disabling birth injuries from preventable complications of pregnancy that are easily treated with basic facilities. Maternal mortality rates in excess of 1% have been recorded in a number of countries. Access to Caesarean section is a particular problem, with rates lower than 1% being commonplace. The provision of appropriate anaesthesia services is of international concern. [Abstract]

Parry EH, Percy DB
Anaesthesia and hospital links: strengthening healthcare through South-North hospital partnerships.
Anaesthesia. 2007 Dec;62 Suppl 115-20.
Health services can respond to the needs of the poorest people in developing countries if those who work in the front line of health care are supported and motivated and if development needs in services and training programmes can be filled. This can be achieved when a Health Link between a southern hospital and/or training school and its northern counterpart is designed to build a disciplined and long-term programme of staff development including the needs of anaesthetic services, which meets the needs identified by the southern partner. Development of anaesthetic practice is best carried out in the context of an institution-wide Health Link where not only the staff and systems involved in anaesthesia but all the essential 'back office' or support services are also supported and developed. [Abstract]

Tyson S, Gordon M
United Kingdom government aid.
Anaesthesia. 2007 Dec;62 Suppl 111-4.
The Department for International Development (DFID) is the UK government department with responsibility for managing Britain's aid to poor countries, with an overall budget of pound 5.3 billion in 2007-8. Our health strategy is to strengthen healthcare systems by working in partnership with governments and other stakeholders in public health in assisted countries. DFID also supports a substantial research programme, principally in health and education. [Abstract]

Nambiar B, Lewycka S, Mwansambo C, Costello A
Planning health care in developing countries.
Anaesthesia. 2007 Dec;62 Suppl 15-10.
The major challenge for health care planners lies in integrating health promotion and disease prevention on the one hand and treatment of acute illness and chronic care on the other. This has to be done at all levels of the health system with the aim of delivering quality services equitably and efficiently to the whole population. This is a particular problem as many governments spend less than US $10 per person per year on health. Acute sector healthcare, including anaesthesia, is often deficient under these circumstances. [Abstract]

Tumwebaze J
Lamula's story.
Anaesthesia. 2007 Dec;62 Suppl 14. [Abstract]

Walker I, Wilson I, Bogod D
Anaesthesia in developing countries.
Anaesthesia. 2007 Dec;62 Suppl 12-3. [Abstract]

Isherwood P, Edwards M
A novel technique to aid the teaching and supervision of aseptic procedures.
Anaesthesia. 2007 Dec;62(12):1302. [Abstract]

Flatt NW
Bribery in the anaesthetic room.
Anaesthesia. 2007 Dec;62(12):1301. [Abstract]

Millar K, Asbury AJ, Bowman AW, Hosey MT, Martin K, Musiello T, Welbury RR
A randomised placebo-controlled trial of the effects of midazolam premedication on children's postoperative cognition.
Anaesthesia. 2007 Sep;62(9):923-30.
This randomised, placebo-controlled study assessed the effects of midazolam premedication on children's postoperative cognition and physical morbidity. In all, 179 children aged 5-10 years were randomly assigned to receive buccal midazolam (0.2 mg x kg(-1)) or placebo before sevoflurane-nitrous oxide anaesthesia for multiple dental extractions. They performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), before discharge and at 48 h. The reaction time of both groups was significantly slower before discharge compared to baseline, with the midazolam group being significantly slower than placebo. Psychomotor co-ordination was also significantly impaired postoperatively after midazolam. Performance on both tests had recovered to baseline by 48 h. Midazolam was also associated with significant anterograde amnesia, both postoperatively and at 48 h, for information presented in the interval between premedication and surgery. The results show significant short-term impairment of children's cognitive function and amnesia enduring for 48 h after low-dose midazolam premedication. [Abstract]

Clifford MJ, Berry P
A self-powered laryngoscope for remote communities.
Anaesthesia. 2007 Dec;62(12):1300. [Abstract]

Madamombe TD, Hollis JN
Wrong-route drug error.
Anaesthesia. 2007 Dec;62(12):1300-1. [Abstract]

Recent Articles in British Journal of Anaesthesia

Acknowledgement of Assessors.
Br J Anaesth. 2008 Jan;100(1):147-149. [Abstract]

Br J Anaesth. 2008 Jan;100(1):146. [Abstract]

Liu EH, Poon KH, Ng BS, Goh EY, Goy RW
The Airway Scope, a new video laryngoscope: its use in three patients with cervical spine problems.
Br J Anaesth. 2008 Jan;100(1):142-3. [Abstract]

Appukutty J
Post-intubation cricoarytenoid joint dysfunction.
Br J Anaesth. 2008 Jan;100(1):141; author reply 141. [Abstract]

Saxena KN, Nischal H, Bhardwaj M, Gaba P, Shastry BV
Right molar approach to tracheal intubation in a child with Pierre Robin syndrome, cleft palate, and tongue tie.
Br J Anaesth. 2008 Jan;100(1):141-2. [Abstract]

Alderson LM, Montgomery J
Day case surgery and obesity: a changing perspective.
Br J Anaesth. 2008 Jan;100(1):140; author reply 140. [Abstract]

Parker RJ, Rechner IJ, Parke TJ
Tracheo-oesophageal fistula and upper airway leak in the intensive care unit.
Br J Anaesth. 2008 Jan;100(1):139-40. [Abstract]

Kotze CW, Kong RS, Hutchinson NP, Harper CM, Yusuf SW
Coronary artery stents and non-cardiac surgery.
Br J Anaesth. 2008 Jan;100(1):138; author reply 138-9. [Abstract]

Bhatia A, Nicholls H
Coronary artery stents and non-cardiac surgery.
Br J Anaesth. 2008 Jan;100(1):137; author reply 137-8. [Abstract]

Maruyama K, Yamada T, Kawakami R, Kamata T, Yokochi M, Hara K
Upper cervical spine movement during intubation: fluoroscopic comparison of the AirWay Scope, McCoy laryngoscope, and Macintosh laryngoscope.
Br J Anaesth. 2008 Jan;100(1):120-4.
BACKGROUND: The AirWay Scope (AWS) is a new fibreoptic intubation device, which allows visualization of the glottic structures without alignment of the oral, pharyngeal, and tracheal axes, and thus may be useful in patients with limited cervical spine (C-spine) movement. We fluoroscopically evaluated upper C-spine movement during intubation with the AWS or Macintosh or McCoy laryngoscope. METHODS: Forty-five patients, with normal C-spine, scheduled for elective surgery were randomly assigned to one of the three intubation devices. Movement of the upper C-spine was examined by measuring angles formed by adjacent vertebrae during intubation. Time to intubation was also recorded. RESULTS: Median cumulative upper C-spine movement was 22.3 degrees, 32.3 degrees, and 36.5 degrees with the AWS, Macintosh laryngoscope, and McCoy laryngoscope, respectively (P<0.001, AWS vs, Macintosh and McCoy). The AWS reduced maximum movement of the C-spine at C1/C2 in comparison with the Macintosh or McCoy laryngoscope (P=0.012), and at C3/C4 in comparison with the McCoy laryngoscope (P=0.019). Intubation time was significantly longer in the AWS group than in the Macintosh group (P=0.03). CONCLUSIONS: Compared with the Macintosh or McCoy laryngoscope, the AWS produced less movement of upper C-spine for intubation in patients with a normal C-spine. [Abstract]

Dijkstra T, Reesink JA, Verdouw BC, Van der Pol WS, Feberwee T, Vulto AG
Spinal anaesthesia with articaine 5% vs bupivacaine 0.5% for day-case lower limb surgery: a double-blind randomized clinical trial.
Br J Anaesth. 2008 Jan;100(1):104-8.
BACKGROUND: A local anaesthetic with fast onset and short reliable duration of anaesthesia may be preferable for out-patient lower limb surgery. Articaine is believed to act faster and to have a shorter duration of action than bupivacaine, but there are no conclusive data available. The purpose of this study was to compare articaine and bupivacaine for day-case lower limb surgery. METHODS: Eighty patients planned for day-case lower limb surgery enrolled in this study. Patients were randomized to receive hyperbaric articaine 80 mg or plain bupivacaine 15 mg intrathecally. Primary outcome variable was recovery time from motor block. Secondary outcomes were: onset of sensory and motor block, maximum spread of sensory block, time to micturition, discharge from the hospital, and complications. RESULTS: The groups were comparable for the medians and the range of the maximum blocks after 30 min. Median time to complete regression of motor block was 101 min (range 80-129) for articaine compared with 307 min (range 225-350) for bupivacaine (P<0.0005). First spontaneous micturition occurred after 257 min (210-293) in the articaine group and after 350 min (304-370) in the bupivacaine group (P<0.0005). In the articaine and bupivacaine groups, patients were discharged after 300 min (273-347) and 380 min (332-431), respectively (P<0.0005). There was no significant difference in the occurrence of complications between the groups. CONCLUSIONS: Spinal anaesthesia with 80 mg of hyperbaric articaine has a shorter duration than a spinal anaesthesia with 15 mg of plain bupivacaine in lower limb surgery of approximately 1 h duration. [Abstract]

Tirel O, Wodey E, Harris R, Bansard JY, Ecoffey C, Senhadji L
Variation of bispectral index under TIVA with propofol in a paediatric population.
Br J Anaesth. 2008 Jan;100(1):82-7.
BACKGROUND: In this prospective observational study, we aim to explore the relationship between age and bispectral index (BIS) values at different plasma concentrations of propofol. METHODS: Fifty children aged from 3 to 15 yr were included. Anaesthesia was induced using a target-controlled infusion of propofol with the Kataria pharmacokinetic model together with a bolus of remifentanil followed by a continuous infusion rate at 0.2 microg kg(-1) min(-1). Target plasma propofol concentration was initially stabilized to 6 microg ml(-1) and continued for 6 min. The target was then decreased and stabilized to 4 microg ml(-1) and then to 2 microg ml(-1). BIS values, plasma propofol concentration, and EEG were continuously recorded. In order to explore the relationship between variations in propofol concentration and the EEG bispectrum, we used a multiple correspondence analysis (MCA). Results are shown in median (range). RESULTS: We found no statistical difference between BIS values with propofol 6 microg ml(-1) [23 (12-40)] and 4 microg ml(-1) [28 (9-67)]. At 2 microg ml(-1), BIS was significantly different [52 (24-71)], but a significant correlation between the age of children and BIS values was found (r2=0.66; P<0.01). There was little change in children's position between 6 and 4 microg ml(-1) in the structure model of the MCA. From 4 to 2 microg ml(-1), the position of children moved only on axis 2. CONCLUSIONS: These results showed the difficulty to interpret BIS values because of the absence of significant change for higher plasma propofol concentration variation or because of the link with age for the lower plasma concentration. [Abstract]

Cooper GM, McClure JH
Anaesthesia chapter from Saving mothers' lives; reviewing maternal deaths to make pregnancy safer.
Br J Anaesth. 2008 Jan;100(1):17-22.
This chapter concerning maternal mortality due to anaesthesia, reprinted with permission from Saving Mothers' Lives, is the 18th in a series of reports within the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. In the years 2003-05 there were six women who died from problems directly related to anaesthesia, which is the same as the 2000-02 triennium. Obesity was a factor in four of these women who died. Two of these deaths were in women in early pregnancy, who received general anaesthesia for gynaecological surgery by inexperienced anaesthetists who failed to manage the airway and ventilation adequately. When trainee anaesthetists are relatively inexperienced their consultants must know the limits of their competence and when close supervision and help may be needed. One death was due to bupivacaine toxicity due to a drug administration error when a bag of dilute local anaesthetic was thought to be intravenous fluid. In a further 31 cases poor perioperative management may have contributed to death. Obesity was again a relevant factor. Other cases could be categorized into poor recognition of women being sick and poor clinical management of haemorrhage, sepsis and of pre-eclampsia. Early warning scores of vital signs may help identify the mother who is seriously ill. Learning points are highlighted in relation to the clinical management of these obstetric complications. [Abstract]

Höhener D, Blumenthal S, Borgeat A
Sedation and regional anaesthesia in the adult patient.
Br J Anaesth. 2008 Jan;100(1):8-16.
This review discusses sedation for regional anaesthesia in the adult population. The first section deals with general aspects of sedation and shows that the majority of patients receiving sedation for regional anaesthesia are satisfied and would choose it again. Methods of assessing the level of sedation are discussed with emphasis on clinical measures. The pharmacology of the drugs involved in sedation is discussed, with propofol and remifentanil appearing to be the combination of choice for sedation in regional anaesthesia. The techniques for administering sedation are discussed and replacement of the traditional repeated boluses or continuous infusion with pharmacokinetic and patient-controlled systems is supported. Patient satisfaction studies suggest that patient-controlled systems are preferred. [Abstract]

Reilly CS
Volume 100.
Br J Anaesth. 2008 Jan;100(1):6-7. [Abstract]

Hemmerling TM, Carli F, Noiseux N
Thoracic epidural anaesthesia for cardiac surgery: are we missing the point?
Br J Anaesth. 2008 Jan;100(1):3-5. [Abstract]

Heidegger T, Nuebling M, Saal D, Kreienbühl G
Patient-centred outcomes in clinical research: does it really matter?
Br J Anaesth. 2008 Jan;100(1):1-3. [Abstract]

Gottschalk A, Freitag M, Steinacker E, Kreissl S, Rempf C, Staude HJ, Strate T, Standl T
Pre-incisional epidural ropivacaine, sufentanil, clonidine, and (S)+-ketamine does not provide pre-emptive analgesia in patients undergoing major pancreatic surgery.
Br J Anaesth. 2008 Jan;100(1):36-41.
BACKGROUND: The concept of pre-emptive analgesia remains controversial. This prospective, randomized, and double-blind study compared epidural administration of ropivacaine 2 mg ml(-1), sufentanil 0.5 microg ml(-1), clonidine 3 microg ml(-1), and S(+)-ketamine 0.25 mg ml(-1) (study solution) given before incision with the same combination started at the end of the operation. METHODS: After testing the stability of the solution using high performance liquid chromatography (HPLC) and examining 12 patients for possible side-effects in comparison with the epidural infusion of ropivacaine 2 mg ml(-1) and sufentanil 0.5 microg ml(-1), 30 patients undergoing major pancreatic surgery were recruited into the study. Before induction of anaesthesia, an epidural catheter was inserted (TH6-8). Patients in Group 1 received a bolus of 8 ml followed by a continuous infusion (8 ml h(-1)) of the study solution before induction of anaesthesia. In Group 2, patients received the same volume of saline before operation, the study solution was started at the end of surgery. After operation, the infusion was maintained for at least 96 h using a patient-controlled epidural analgesia (PCEA) pump in both groups. Patients were evaluated up to the seventh postoperative day for pain and side-effects. RESULTS: Visual analogue scale (VAS) values at rest were as follows: G1 vs G2: 24 h, 19 (sd 23) vs 6 (13); 48 h, 4 (10) vs 11 (21); and 72 h, 12 (22) vs 13 (21). VAS values during coughing and mobilization were also comparable. Total volume of epidural infusion was 904 (114) ml in G1 vs 892 (154) ml in G2. The incidence of side-effects (nausea, vomiting, and motor block) was low and not different between the groups. CONCLUSIONS: Pre-incisional epidural analgesic infusion did not provide pre-emptive analgesia compared with administration started at the end of surgery, but both groups had low pain scores. [Abstract]

Chai YF, Yang J, Liu J, Song HB, Yang JW, Liu SL, Zhang WS, Wang QW
Epidural anaesthetic effect of the 8% emulsified isoflurane: a study in rabbits.
Br J Anaesth. 2008 Jan;100(1):109-15.
BACKGROUND: Studies have shown that local use of volatile anaesthetics produce local anaesthetic effects such as local infiltration anaesthesia (in rats and humans) and spinal anaesthesia (in dogs). However, there is still no report on the epidural anaesthetic effect of volatile anaesthetics. The aim of the present study was to evaluate the epidural anaesthetic effect of the 8% emulsified isoflurane in rabbits. METHODS: Forty rabbits chronically instrumented with an epidural catheter were randomly divided into four groups of 10 rabbits each. According to group assignment, rabbits received epidural administration of 8% emulsified isoflurane (v/v) 1 ml in the E-isoflurane group, 1% lidocaine 1 ml in the Lidocaine group, 30% lipid emulsion 1 ml in the Itralipid group, or normal saline 1 ml in the NS group. The sensory and motor functions and the state of consciousness were assessed at baseline and at predetermined regular intervals. Then, the rabbits were continuously observed for 2 weeks to examine the possible long-term neurological complications. RESULTS: The sensory blockade onset time, motor blockade onset time, and motor blockade duration in the E-isoflurane group [1.4 (0.7), 1.6 (0.7), and 34 (10) min, respectively] were similar to those in the Lidocaine group [1.3 (0.5), 1.7 (0.8), and 38 (8), min, respectively]. The sensory blockade duration in the E-isoflurane group was longer than that in the Lidocaine group [68 (13) vs 49 (13) min, P<0.01]. No epidural anaesthetic effects occurred in the NS group and the Intralipid group. None of the rabbits showed an abnormal consciousness after the epidural drug administration. None of the rabbits showed any long-term neurological deficits during a 2 week observation. CONCLUSIONS: The present study demonstrates that epidural administration of the 8% emulsified isoflurane produces completely a reversible epidural anaesthetic effect that does not affect the level of consciousness in rabbits. [Abstract]

Ozturk T, Kaya H, Aran G, Aksun M, Savaci S
Postoperative beneficial effects of esmolol in treated hypertensive patients undergoing laparoscopic cholecystectomy.
Br J Anaesth. 2007 Nov 23;
BACKGROUND: /st> In an attempt to decrease haemodynamic instability and early postoperative complications such as nausea, vomiting, and pain, esmolol was added to the routine alfentanil infusion of patients with treated hypertension undergoing laparoscopic cholecystectomy. METHODS: /st> Forty consecutive ASA class II patients with controlled hypertension about to undergo laparoscopic cholecystectomy were randomized into two groups: an esmolol group (Group E, n=20) was given a 1 mg kg(-1) bolus of esmolol and a placebo group (Group P, n=20) was given an identical volume of Ringer's lactate. The rate of esmolol infusion was adjusted to keep the heart rate between 65 and 75 beats min(-1) and was 5-10 microg kg(-1) min(-1) throughout the procedure. After operation, patients reported their nausea using a four-point scale. RESULTS: /st> Esmolol had an opioid-sparing effect intraoperatively (P=0.001). Postoperative requirements for antiemetics were significantly less in the esmolol group, with no antiemetics given to eight patients. In the placebo group, however, all patients required at least one dose of antiemetic (P=0.007). The frequency of PONV did not correlate to the amounts of alfentanil, propofol, postoperative antiemetics consumed, or to female gender, non-smoking status, and history of PONV or motion sickness. Postoperative analgesic consumption in Group E was significantly lower than in Group P (P=0.012). CONCLUSIONS: /st> Esmolol had an opioid-sparing effect in the intraoperative and immediate postoperative period in hypertensive patients undergoing laparoscopy. When combined with alfentanil, it was more effective than placebo in decreasing early PONV. [Abstract]

Reinstrup P, Ryding E, Ohlsson T, Sandell A, Erlandsson K, Ljunggren K, Salford LG, Strand S, Uski T
Regional cerebral metabolic rate (positron emission tomography) during inhalation of nitrous oxide 50% in humans.
Br J Anaesth. 2008 Jan;100(1):66-71.
BACKGROUND: Recent studies in man have shown that cerebral blood flow increases during inhalation of nitrous oxide (N2O), a finding which is believed to be a result of an increased cerebral metabolic rate (CMR). However, this has not previously been evaluated in man. METHODS: Regional CMR(glu) (rCMR(glu)) was measured three dimensionally with positron emission tomography (PET) after injection of 2-(18F)fluoro-2-deoxy-D-glucose in 10 spontaneously breathing men (mean age 31 yr) inhaling either N2O 50% in O2 30% or O2 30% in N2. RESULTS: Global CMR(glu) in young men was 27 (3) micromol 100 g(-1) min(-1) [mean (SD)]. Inhalation of N2O 50% did not change global CMR(glu) [30 (5) micromol 100 g(-1) min(-1)] significantly, but it changed the distribution of the metabolism in the brain (P<0.0001 analysis of variance). Compared with inhalation of O2 30% in N2, N2O 50% inhalation increased the metabolism in the basal ganglia [14 (17)%, P<0.05] and thalamus [22 (23) %, P<0.05]. There was a prolonged metabolic effect of N2O inhalation seen on a succeeding PET scan with oxygen-enriched air (P<0.0001) performed 1 h after the N2O administration. CONCLUSIONS: Inhalation of N2O 50% did not change global CMR(glu), but the metabolism increased in central brain structures, an effect that was still present 1 h after discontinuation of N2O. [Abstract]

Gögenur I, Wildschiøtz G, Rosenberg J
Circadian distribution of sleep phases after major abdominal surgery.
Br J Anaesth. 2008 Jan;100(1):45-9.
BACKGROUND: It is believed that the severely disturbed night-time sleep architecture after surgery is associated with increased cardiovascular morbidity with rebound of rapid eye movement (REM). The daytime sleep pattern of patients after major general surgery has not been investigated before. We decided to study the circadian distribution of sleep phases before and after surgery. METHODS: Eleven patients undergoing elective major abdominal surgery were included in the study. Continuous ambulatory polysomnographic monitoring was made 24 h before surgery and 36 h after surgery, thus including two nights after operation. Sleep was scored independently by two blinded observers and the recordings were reported as awake, light sleep (LS, stages I and II), slow wave sleep (SWS, stages III and IV), and REM sleep. RESULTS: There was significantly increased REM sleep (P=0.046), LS (P=0.020), and reduced time awake (P=0.016) in the postoperative daytime period compared with the preoperative daytime period. Five patients had REM sleep during the daytime after surgery. Three of these patients did not have REM sleep during the preceding postoperative night. There was significantly reduced night-time REM sleep for two nights after surgery compared with before surgery (P=0.001). CONCLUSIONS: Patients have significantly increased REM sleep, LS, and reduced time awake during the daytime period after surgery compared with before surgery. Disturbances in the circadian regulation of the sleep-wake cycle may be involved in the development of postoperative sleep disturbances. [Abstract]

Rai MR, Parry TM, Dombrovskis A, Warner OJ
Remifentanil target-controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial.
Br J Anaesth. 2008 Jan;100(1):125-30.
BACKGROUND: Awake fibreoptic intubation (AFOI) is a technique used in patients with difficult airways. This study compares the suitability of remifentanil target-controlled infusion (TCI) to propofol TCI for conscious sedation during AFOI in patients with bona fide difficult airways. METHODS: We recruited 24, ASA I-III patients, who were undergoing sedation for elective AFOI. Patients were randomized to one of the two groups, Group P (n=10) received propofol TCI and Group R (n=14) received remifentanil TCI. Primary outcome measures were conditions achieved at endoscopy, intubation, and post-intubation, which were graded using scoring systems. Other parameters measured were the endoscopy time, intubation time, and number of attempts at intubation. A postoperative interview was conducted to determine recall of events and level of patient satisfaction. RESULTS: Endoscopy scores (0-5) and intubation scores (0-5) were significantly different [Group P 3 (1-4) vs Group R 1 (0-3) P<0.0001, Group P 3 (2-4) vs Group R 1 (0-3) P<0.0001, respectively]; with much better conditions in Group R, endoscopy times and intubation times were also significantly different, being shorter in Group R (P<0.007 and P<0.023, respectively). Patient tolerance of the procedure, judged by the discomfort scores (P<0.004) and the post-intubation scores (P<0.08), was significantly better in Group R. The level of recall for events was higher in Group R. However, there were no significant differences in the patient satisfaction scores. CONCLUSIONS: Remifentanil TCI appears to provide better conditions for AFOI when compared with propofol TCI. The disadvantage of remifentanil in this setting may be a higher incidence of recall. [Abstract]

Hirabayashi G, Uchino H, Joko T, Kaneko H, Ishii N
Effects of carbon dioxide absorbent cooling and temperature gradient reduction on water condensation in the anaesthesia circuit.
Br J Anaesth. 2008 Jan;100(1):131-6.
BACKGROUND: Large quantities of water condensation occur in the anaesthesia circuit during low-flow anaesthesia. We hypothesized that cooling of the CO2 absorbent would prevent water condensation. METHODS: To cool CO2 absorbent efficiently, we constructed a novel temperature gradient reduction (TGR) canister, which was cooled by a blower. Experiments were divided into three groups: the conventional canister group (control group, n=6), the TGR canister without cooling group (TGR group, n=6), and the TGR canister with cooling group (TGR cooling group, n=6). One kilogramme of CO2 absorbent was placed into the canister. The anaesthetic ventilator was connected to a 3 litre bag and 300 ml min(-1) of CO2 was introduced. About 500 ml min(-1) of oxygen was used as fresh gas. The anaesthetic ventilator was set at a ventilatory frequency of 12 bpm, and tidal volume was adjusted to 700 ml. RESULTS: The longevity of the CO2 absorbent was 437 (sd 7.8) min in the control group, 564 (13.8) min in the TGR group (P<0.001 vs control), and 501 (5.8) min in the TGR cooling group (P<0.001 vs control, TGR). Total water condensation in the anaesthesia circuit was 215 (9.4) mg min(-1) in the control group, 223 (9.7) mg min(-1) in the TGR group, and 47.7 (5.7) mg min(-1) in the TGR cooling group (P<0.001 vs control, TGR). CONCLUSIONS: TGR of CO2 absorbent with cooling is a useful and simple method to reduce water condensation in the anaesthesia circuit in low-flow anaesthesia, with a little increase in the longevity of the CO2 absorbent. [Abstract]

Biccard BM, Sear JW, Foëx P
Meta-analysis of the effect of heart rate achieved by perioperative beta-adrenergic blockade on cardiovascular outcomes.
Br J Anaesth. 2008 Jan;100(1):23-8.
BACKGROUND: Acute perioperative beta-adrenergic blockade may be cardioprotective in the high-risk cardiac patient for major non-cardiac surgery. We have investigated the association between the heart rate achieved with perioperative beta-blockade and the incidence of perioperative cardiac complications. METHODS: We identified eight randomized studies (1931 patients) reporting acute perioperative beta-blockade and major perioperative cardiovascular outcomes after non-cardiac surgery. The mean heart rates within the first 72 h after operation were analysed. A meta-analysis of means was conducted using a random effects model. A bivariate correlation analysis was conducted using Spearman's correlation coefficient to assess for an association between the mean postoperative heart rate and the 30 day cardiac outcomes. RESULTS: Acute perioperative beta-blockade did not significantly reduce 30 day cardiac death [odds ratio (OR) 0.35, 95% confidence interval (CI) 0.08-1.52] or non-fatal myocardial infarction (OR 0.90, 95% CI 0.52-1.56) in the studies with adequate methodology. The mean (95% CI) heart rate was 73 (71-74) beats min(-1) in the beta-blockade group, which was significantly lower than the placebo group (mean heart rate 82, P=0.0001). There was no correlation between heart rate and 30 day cardiac complications (P=0.848). The reduction in heart rate was associated with increased drug-associated adverse events (OR 2.53, 95% CI 2.05-3.13, P<0.0001). A major limitation of this analysis may be that postoperative heart rate was not a primary outcome in any of the studies identified and the mean postoperative heart rate achieved may be too high to realize optimal cardioprotection. CONCLUSION: This meta-analysis cannot confirm that heart rate control with beta-adrenergic blockade is cardioprotective. A randomized controlled trial examining the effect of tight perioperative heart rate control with beta-adrenergic blockade on clinically important outcomes and adverse events is warranted. [Abstract]

Carles M, Dellamonica J, Roux J, Lena D, Levraut J, Pittet JF, Boileau P, Raucoules-Aime M
Sevoflurane but not propofol increases interstitial glycolysis metabolites availability during tourniquet-induced ischaemia-reperfusion.
Br J Anaesth. 2008 Jan;100(1):29-35.
BACKGROUND: Ischaemia/reperfusion (I/R) is one of the main pathophysiological phenomena involved in the anaesthetic practice. The authors hypothesized that anaesthetic regimens can influence skeletal muscle tolerance to tourniquet-induced I/R that should be reflected by the interstitial metabolite levels of anaerobic glycolysis. METHODS: Microdialysis probes were implanted in three groups of 10 patients each receiving either sevoflurane (SEVO), propofol (PRO), or spinal (SA) anaesthesia (for induction and maintenance). SA group was considered as a control group. Interstitial fluid was obtained during tourniquet-induced I/R and was analysed for interstitial glucose, lactate, pyruvate, and glycerol. RESULTS: The microdialysis flow rate was 0.5 microl min(-1). Compared with the control group, the SEVO group had a higher level of both lactate and pyruvate and an increase in glucose during ischaemia. In contrast, the PRO group had a lower level of pyruvate, resulting in a significant higher increase (eight times from baseline) of the lactate pyruvate ratio. Glucose level remained low in this group. During reperfusion, lactate, pyruvate, and glucose remained at a significantly higher level in the SEVO group. In the PRO group, there was no difference in lactate, pyruvate, and glucose levels compared with the control group. The interstitial level of glycerol exhibits only few and comparable changes during I/R between the groups. CONCLUSIONS: Our results indicate that there is a better availability of interstitial glycolysis metabolites (glucose, lactate, and pyruvate) in the skeletal muscle during ischaemia and reperfusion after sevoflurane exposure than after propofol, suggesting a potential preconditioning effect of sevoflurane on tourniquet-induced skeletal muscle I/R. [Abstract]

Sumathi PA, Shenoy T, Ambareesha M, Krishna HM
Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice.
Br J Anaesth. 2007 Nov 16;
BACKGROUND: /st> Postoperative sore throat, cough, and hoarseness of voice though minor sequelae after general tracheal anaesthesia can be distressing to the patient. METHODS: /st> This prospective, randomized, double blind, controlled study compares the incidence of postoperative sore throat, cough, and hoarseness of voice after general tracheal anaesthesia when applying betamethasone gel (betamethasone group) or lidocaine jelly (lidocaine group) on the tracheal tube. One hundred and fifty ASA class I and II patients undergoing elective surgeries under general orotracheal anaesthesia were randomized into three groups: betamethasone gel, lidocaine jelly, and control groups. In the post-anaesthesia care unit, a blinded anaesthesiologist interviewed all patients on postoperative sore throat, cough, and hoarseness of voice at 1, 6, 12, and 24 h after operation. RESULTS: /st> In the first 24 h after surgery, the incidence of postoperative sore throat was 40, 100, and 100%; cough was 6, 40, and 28%; and hoarseness of voice was 4.1, 32.9, and 50%, for the betamethasone, lidocaine and control groups, respectively. The incidence of postoperative sore throat, cough, and hoarseness of voice was significantly lower in the betamethasone group compared with the other two groups (P<0.05). CONCLUSIONS: /st> A wide spread application of betamethasone gel on the tracheal tube decreases the incidence and severity of postoperative sore throat, cough, and hoarseness of voice. [Abstract]

Norozi K, Beck C, Osthaus WA, Wille I, Wessel A, Bertram H
Electrical velocimetry for measuring cardiac output in children with congenital heart disease.
Br J Anaesth. 2008 Jan;100(1):88-94.
BACKGROUND: The purpose of this study was to evaluate the agreement of cardiac output measurements obtained by electrical velocimetry (CO(EV)) and those that derived from the direct Fick-oxygen principle (CO(F)) in infants and children with congenital heart defects. METHODS: Simultaneous measurements of CO(EV) and CO(F) were compared in 32 paediatric patients, aged 11 days to 17.8 yr, undergoing diagnostic right and left heart catheterization. For non-invasive measurements of cardiac output by electrical velocimetry, which is a variation of impedance cardiography, standard surface electrodes were applied to the left side of the neck and the left side of the thorax at the level of the xiphoid process. Cardiac output determined using direct Fick-oxygen principle was calculated by direct measurement of oxygen consumption (VO2) and invasive determination of the arterio-venous oxygen content difference. RESULTS: An excellent correlation (r=0.97) was found between CO(EV) and CO(F) (P<0.001). The slope of the regression equation [0.96 (SD 0.04)] was not significantly different from the line of identity. The bias between the two methods (CO(EV)-CO(F)) was 0.01 litre min(-1) and the limits of agreement, defined as the bias (2 SD), were -0.47 and +0.45 litre min(-1). CONCLUSIONS: CO(EV) demonstrates acceptable agreement with data derived from CO(F) in infants and children with congenital heart disease. The new technique is simple, completely non-invasive, and provides beat-to-beat estimation of CO. [Abstract]

Freo U, Carron M, Micaglio M, Ori C
ProSeal laryngeal mask airway for laparoscopic gastric banding in a myasthenic, morbidly obese patient.
Br J Anaesth. 2007 Dec;99(6):921-2. [Abstract]

Xue FS, Yang QY, Liao X
Topical anaesthesia of the airway using Trachlight and MADgic atomizer in patients with predicted difficult tracheal intubation.
Br J Anaesth. 2007 Dec;99(6):920-1. [Abstract]

Recent Articles in The Clinical Journal of Pain

Lee A, Chan S, Chen PP, Gin T, Lau AS
Economic evaluations of acute pain service programs: a systematic review.
Clin J Pain. 2007 Oct;23(8):726-33.
OBJECTIVE: The purpose was to review the literature on the economic benefits associated with Acute Pain Service (APS) programs systematically. APSs have received widespread acceptance and formal support from institutions and organizations, but little is known about its economic benefits. METHODS: MEDLINE and other databases were searched for economic evaluations of APSs. The study characteristics and methodological quality was assessed using standardized tools. All costs were adjusted to 2005 US dollars. RESULTS: Ten economic evaluations (involving 14,774 patients) were identified that met eligibility criteria. There were wide variations in study designs, methodological quality, and outcome measures. There was insufficient data to identify which APSs model (anesthesiologist-based/nursing support or nurse-based/anesthesiologist supervised) was more cost-effective. The cost of APSs for surgical patients from direct and indirect effects (improved pain management from education in patients not receiving APS) varied from $2.28 to $5.08/patient/d. The level of evidence to support the cost-savings associated with APSs (shorter duration of intensive care unit and hospital stays) were limited to partial economic analyses. There was insufficient evidence to draw conclusions about the cost-effectiveness and cost-benefit of APSs as the quality of life and patient's willingness to pay for an APS intervention were not measured, respectively. The overall quality of published economic evaluations of APSs was poor. CONCLUSIONS: There is a lack of high-quality economic studies to support the cost-effectiveness and cost-benefits of APSs. [Abstract]

Coudeyre E, Tubach F, Rannou F, Baron G, Coriat F, Brin S, Revel M, Poiraudeau S
Fear-avoidance beliefs about back pain in patients with acute LBP.
Clin J Pain. 2007 Oct;23(8):720-5.
OBJECTIVE: We aimed to assess fear-avoidance beliefs in patients with acute low back pain (LBP) and to identify features of patients and general practitioners (GPs) associated with patients' fear-avoidance beliefs. METHODS: A cross-sectional study conducted in primary care practice in France. A total of 709 GPs completed a self-administered questionnaire assessing fear-avoidance beliefs [the Fear-Avoidance Beliefs Questionnaire (FABQ)] and 2,727 patients with acute LBP completed a self-administered questionnaire assessing pain, perceived handicap and disability (on the Quebec Back Pain Disability Scale) and fear-avoidance beliefs (on the FABQ). RESULTS: Patients' FABQ mean scores were 16.8+/-5.0 for physical activities (FABQ Physical) and 19.5+/-10.9 for occupational activities (FABQ Work). From multivariate analysis, the following factors were associated with patients' FABQ Phys and Work scores: having a GP with a high rating on the FABQ Phys (P=0.0001 and 0.02 for FABQ Phys and Work, respectively), no sport practice (vs. occasional: P=0.0003 and 0.03; vs. usual/competition: P=0.0001 and 0.004), disability score (Quebec) (P=0.0001 for both FABQ scores), and pain intensity (P=0.0012 and 0.0013). CONCLUSIONS: High levels of fear-avoidance beliefs occur early in LBP patients, and key messages on this topic should probably be delivered at a very early stage of the disease. [Abstract]

White P, Lewith G, Prescott P
Should we recruit patients or healthy volunteers for acupuncture studies of chronic pain?
Clin J Pain. 2007 Oct;23(8):714-9.
OBJECTIVE: The aim of this study was to compare the results of healthy volunteers with patients in chronic pain, in terms of acupuncture needle sensation. The search for a credible mechanism that underpins the effect of acupuncture in pain has recently involved the use of brain imaging techniques in an attempt to identify the neural correlates involved in pain control. Such studies have usually enrolled healthy participants rather than patients. This practice might be inappropriate as we are unsure if we can generalize from healthy volunteers to patients in chronic pain. METHOD: This paper describes a comparison of data obtained from 2 small randomized controlled studies, 1 involving patients with chronic pain and the other which recruited healthy volunteers. Both studies used real acupuncture and a nonpenetrating "placebo" needle in a crossover design. The outcome studied in this paper was a comprehensive needling sensation questionnaire. RESULTS: There was a difference in the sensations experienced by patients as compared with healthy volunteers. Patients tended to feel much stronger sensation. Neither group differed in distinguishing between real and placebo needling. However, patients were more likely to state that both needles were real, whereas healthy participants were more likely to suggest that neither were real. DISCUSSION: It is concluded that if the nature of the sensation felt is of importance, then it might be inappropriate to recruit healthy volunteers in lieu of patients and a larger study is required to clarify this. [Abstract]

Pells J, Edwards CL, McDougald CS, Wood M, Barksdale C, Jonassaint J, Leach-Beale B, Byrd G, Mathis M, Harrison MO, Feliu M, Edwards LY, Whitfield KE, Rogers L
Fear of movement (kinesiophobia), pain, and psychopathology in patients with sickle cell disease.
Clin J Pain. 2007 Oct;23(8):707-13.
OBJECTIVES: Fear of movement (ie, kinesiophobia) has emerged as a significant predictor of pain-related outcomes including disability and psychologic distress across various types of pain (eg, back pain, headache, fibromyalgia, complex regional pain syndrome). However, no research has examined the prevalence of kinesiophobia in adults with sickle cell disease (SCD). The purpose of this study was to assess the degree of kinesiophobia reported by African American men and women with SCD and to determine whether kinesiophobia is related to pain and psychologic distress in this population. METHODS: Sixty-seven men and women with SCD recruited from a comprehensive sickle cell treatment program in a large academic medical center completed questionnaires that assess fear of movement, pain and pain interference, and psychologic distress. RESULTS: Participants reported levels of kinesiophobia (M=30.48, SD=7.55) that were comparable to those obtained for patients with low back pain and fibromyalgia. Although pain levels did not differ by sex, men reported greater kinesiophobia than women (P=0.02). As hypothesized, higher levels of kinesiophobia were associated with greater psychologic distress, particularly Phobic Anxiety (r=0.35), Psychoticism (r=0.29), Somatization (r=0.45), Anxiety (r=0.35), Obsessive-compulsive (r=0.34), Interpersonal Sensitivity (r=0.25), Depression (r=0.29), and all 3 summary indices of the SCL-90-R (all Ps<0.05). DISCUSSION: Although and historically, pain associated with SCD has not been considered in the context of fear of movement, findings suggest that both kinesiophobia and sex are relevant constructs for consideration in understanding pain-related outcomes in SCD. Though our results require replication, this study suggests that greater kinesiophobia is associated with greater pain and psychologic distress. [Abstract]

Carroll I, Gaeta R, Mackey S
Multivariate analysis of chronic pain patients undergoing lidocaine infusions: increasing pain severity and advancing age predict likelihood of clinically meaningful analgesia.
Clin J Pain. 2007 Oct;23(8):702-6.
OBJECTIVES: The proportion of chronic pain patients with suspected neuropathic pain who will have clinically meaningful pain relief with intravenous (IV) lidocaine and the clinical characteristics that identify these patients have not been described previously. METHODS: We conducted a cohort study of 99 patients who underwent IV lidocaine infusions for suspected neuropathic pain. An 11-point Numerical Rating Score (NRS) of pain intensity was recorded at the beginning and end of each infusion. A predefined literature-based criteria for "clinically meaningful" reductions in pain score was used to classify patients as responders or nonresponders. Multivariate logistic regression was used to determine clinical variables that predicted an increased likelihood of being a lidocaine responder. RESULTS: The mean reduction in NRS during lidocaine infusions was 2.34 (95% confidence interval 2.83-1.85, P<0.001). Forty-two percent of patients (95% confidence interval 32.5%-52.8%) had NRS reductions of 30% or greater and met the predefined criteria as lidocaine responders. Univariate and multivariate analyses indicated that advancing age and pain severity significantly increased the odds of being a lidocaine responder. Controlled for all other factors, each decade of advancing age increased the odds of being a lidocaine responder by 36%. Each 1-point increase, on an 11-point scale of baseline pain severity, increased the odds of being a lidocaine responder by 29%. DISCUSSION: IV lidocaine effectively reduces pain in a minority of patients suspected of having neuropathic pain. Pain severity and patient age can be used to target therapy to those most likely to respond. [Abstract]

Offenbächer M, Cieza A, Brockow T, Amann E, Kollerits B, Stucki G
Are the contents of treatment outcomes in fibromyalgia trials represented in the International Classification Of Functioning, Disability, and Health?
Clin J Pain. 2007 Oct;23(8):691-701.
OBJECTIVES: To identify the concepts contained in treatment outcomes of randomized controlled trials (RCTs) for interventions in patients with fibromyalgia (FM) using the International Classification of Functioning, Disability, and Health (ICF) as external reference. METHODS: RCTs between 1992 and 2001 were located in MEDLINE and selected according to predefined eligibility criteria. The outcome measures were extracted and the concepts within the outcome measures were identified and linked to the ICF using a content-analytical approach. RESULTS: Forty-two trials on FM were included. Twenty-seven different questionnaires were extracted. Of all, 79.2% (N=236) of the clinical and physiologic outcomes could be linked to 31 different ICF categories and 84.7% (N=964) of the concepts contained in the health-status questionnaire to 113 ICF categories. CONCLUSIONS: The ICF provides a useful external reference to identify the concepts contained in outcome measures used in RCTs in FM. [Abstract]

Hill JC, Lewis M, Sim J, Hay EM, Dziedzic K
Predictors of poor outcome in patients with neck pain treated by physical therapy.
Clin J Pain. 2007 Oct;23(8):683-90.
OBJECTIVES: This study evaluated predictors of poor outcome in patients with neck pain treated by physical therapy, and sought to compare the findings of empirical data with physical therapy practitioners' subjective perceptions about predictors of outcome. METHODS: This study was a secondary analysis of data from a randomized controlled trial assessing physical therapy treatments for neck pain (n=346). A baseline questionnaire provided data on a number of potential risk factors of poor outcome at follow-up. Follow-up was conducted at 6 weeks and 6 months by postal questionnaire with outcome defined separately by perceived (global) change and minimal clinically important differences in the Northwick Park Neck Pain Questionnaire (MCID-NPQ). Therapists' perceptions of predictors for treatment outcome were captured using a separate questionnaire, and the ratings compared with ranks derived from the 6-month trial data. RESULTS: Baseline characteristics accounted for a much greater proportion of explained variance for global change compared with MCID-NPQ at 6 months. Independent biopsychosocial characteristics included manual social class, catastrophizing, anxiety and depression, low treatment expectations, severity of baseline neck pain/disability, presence of comorbid back pain, and older age. Physical therapist ranks correlated highly with those derived from the trial data. CONCLUSIONS: Significant predictors of outcome were identified, particularly at 6 months, including psychosocial, functional, and demographic indicators. Our findings suggest that physical therapists are collectively aware of the relative importance of physical and psychosocial factors in predicting clinical outcome. However, a significant amount of variability in outcomes in our prognostic models remained largely unexplained, indicating that we need to explore further underlying factors to inform clinical decision-making. [Abstract]

Landers MR, Cheung W, Miller D, Summons T, Wallmann HW, McWhorter JW, Druse T
Workers' compensation and litigation status influence the functional outcome of patients with neck pain.
Clin J Pain. 2007 Oct;23(8):676-82.
OBJECTIVES: The purpose of this study was to determine if workers' compensation (WC) and litigation status were associated with long-term functional limitation in patients with neck pain. Understanding what physical and psychologic variables are related to long-term functional limitation is an important aspect of clinical decision-making and understanding illness behavior in patients with neck pain. METHODS: Seventy-nine patients reporting neck pain participated in this study. Of these, 27 had either a WC case or had injury-related litigation (WC=9, motor vehicle accident litigant=14, and personal injury litigant=4). Upon initial presentation to physical therapy and 12 weeks later, the patient's functional status was evaluated using the Neck Disability Index (NDI). An NDI score of 15 or more at 12-weeks was operationally defined as long-term functional limitation. RESULTS: Mean NDI scores at initial presentation and at 12-weeks were significantly higher for those with WC/litigation involvement (mean=18.9, SD=9.7) than for those without (mean=9.4, SD=7.3). Those with WC/litigation involvement also had a higher percentage of long-term functional limitation than those who did not have WC/litigation involvement, 70.4% and 19.2%, respectively. The odds for developing long-term functional limitation were 9.5 times greater for those with WC/litigation involvement than for those without. DISCUSSION: Results from this study suggest that patients with WC/litigation involvement exhibit more long-term functional limitation than patients who do not have WC/litigation involvement. These results underscore a need for future research in this area. [Abstract]

Piguet V, Cedraschi C, Dumont P, Desmeules J, Allaz AF, Dayer P
Patients' representations of antidepressants: a clue to nonadherence?
Clin J Pain. 2007 Oct;23(8):669-75.
OBJECTIVES: Antidepressants are prescribed frequently to chronic pain patients due to their pain relief effects. This medication raises major adherence issues. Despite the adverse effects, little is known about the factors that may jeopardize adherence in chronic pain patients. We carried out a qualitative study to investigate chronic pain patients' representations of antidepressants as compared with pain-free controls. METHODS: One hundred thirteen chronic pain patients recruited in a multidisciplinary pain clinic and 62 matched controls were questioned with standardized semistructured interviews. The interviews were submitted to content analysis. RESULTS: Ambivalence emerged as an important aspect of "patients" and controls' views about antidepressants. Antidepressants were described as potent chemicals acting in the brain, possibly causing effects on cognition, emotions, and personality, and inducing dependence and loss of control. Positive effects were mentioned, but when respondents related their own views and experiences, the statements became less favorable. Another key point was that neither the representations of the patients and nor those of the controls comprised the analgesic properties of antidepressants. DISCUSSION: Chronic pain patients' representations differed only little from those of controls. Antidepressants were not considered as addressing somatic problems. Thus, the prescription of antidepressants for chronic pain may be mistaken for a denial of the "reality" of pain. Although this study did not assess medication adherence, it is possible that patient representations have a bearing on adherence. Clinically, this suggests that these representations should be elicited and addressed, taking into account the patients' own models of pain. [Abstract]

Kettenmann B, Wille C, Lurie-Luke E, Walter D, Kobal G
Impact of continuous low level heatwrap therapy in acute low back pain patients: subjective and objective measurements.
Clin J Pain. 2007 Oct;23(8):663-8.
OBJECTIVES: Muscular pain is usually associated with increased muscle tension resulting in a vicious tension-pain-cycle, leading to increased alertness and stress. However, this has not been broadly evaluated using objective methods, for example, looking at neurophysiologic changes. The focus of this study was, therefore, to combine objective [spontaneous electroencephalogram (EEG) as a surrogate of alertness and stress] with subjective parameters (self-assessed pain affected variables) to investigate the effect of continuous low-level heat therapy in low back pain (LBP)-patients. METHODS: This investigation was a randomized, active controlled, parallel-designed study. Thirty patients were randomly assigned to one of 2 groups: the control group, in which patients were provided with oral analgesics (nonsteroidal anti-inflammatory drug) and instructed to use it if needed, and the treatment group, in which patients in addition to oral analgesics as rescue medication were provided with a heatwrap therapy. The objective parameters were assessed by measuring the power of frequency bands in the spontaneous EEG. The subjective parameters (sleep pattern, well-being, pain intensity, etc.) were assessed by a Pain, Sleep, and Stress Questionnaire. RESULTS: In the EEG-recordings, the heatwrap therapy group showed decreased power in Beta-1 and Beta-2 frequency bands compared with the control group, indicating a reduction in arousal. Also, in comparison to the control group, the heatwrap therapy group reported significantly reduced LBP, everyday situations being less stressful, a better night's sleep, and a decreased number of daytime naps. DISCUSSION: In addition to classic psychophysical assessment of pain-related parameters and sleep quality, performance in daily life, we were able to obtain objective measures (EEG) that suggest an acute therapeutic relaxation on the basis of the central nervous system effects accompanying the reported significant pain relief. We believe that this was due to a reduced nociceptive information load in LBP-patients after the use of the heatwrap therapy. [Abstract]

Gagnon AM, Kahan M, Srivastava A
Opioid use and abuse: is there a problem?
Clin J Pain. 2007 Oct;23(8):661-2. [Abstract]

Katz NP, Adams EH, Chilcoat H, Colucci RD, Comer SD, Goliber P, Grudzinskas C, Jasinski D, Lande SD, Passik SD, Schnoll SH, Sellers E, Travers D, Weiss R
Challenges in the development of prescription opioid abuse-deterrent formulations.
Clin J Pain. 2007 Oct;23(8):648-60.
Opioid analgesics remain the cornerstone of effective management for moderate-to-severe pain. In the face of persistent lack of access to opioids by patients with legitimate pain problems, the rate of prescription opioid abuse in the United States has escalated over the past 15 years. Abuse-deterrent opioid products can play a central role in optimizing the risk-benefit ratio of opioid analgesics--if these products can be developed cost-effectively without compromising efficacy or creating new safety issues for the target treatment population. The development of scientific methods for assessing prescription opioid abuse potential remains a critical and challenging step in determining whether a claim of abuse deterrence for a new opioid product is indeed valid and will thus be accepted by the medical, regulatory, and reimbursement communities. To explore this and other potential impediments to the development of prescription opioid abuse-deterrent formulations, a panel of experts on opioid abuse and diversion from academia, industry, and governmental agencies participated in a Tufts Health Care Institute-supported symposium held on October 27 and 28, 2005, in Boston, MA. This manuscript captures the main consensus opinions of those experts, and also information gleaned from a review of the relevant published literature, to identify major impediments to the development of opioid abuse-deterrent formulations and offer strategies that may accelerate their commercialization. [Abstract]

Van Dillen LR, McDonnell MK, Susco TM, Sahrmann SA
The immediate effect of passive scapular elevation on symptoms with active neck rotation in patients with neck pain.
Clin J Pain. 2007 Oct;23(8):641-7.
OBJECTIVE: To examine the effect of elevating the scapulae on symptoms during neck rotation. METHODS: A retrospective analysis of clinical records was conducted. One physical therapist examined 46 patients with neck pain (30 women, 16 men; mean age 45.89+14.39 y) using a standardized examination. Patients had a long-standing history of neck pain with a moderate level of symptoms and disability. Reports of symptoms were obtained in 2 scapulae position conditions: a patient-preferred scapulae position and a passively elevated scapulae position. RESULTS: In the patient-preferred positions, 29 (63%) of the 46 patients reported an increase in symptoms with neck rotation in at least one direction. In the scapulae elevated position, a significant percentage of patients reported a decrease in symptoms with neck rotation, right (82%) and left (76%) (both comparisons, P<or=0.01). CONCLUSIONS: Passive elevation of the scapulae resulted in a decrease in symptoms with right and left neck rotation in the majority of patients. These findings are important because they indicate that neck symptoms can be immediately improved within the context of the examination. Such information potentially can be used to assist in directing intervention. [Abstract]

Sprenger T, Tölle TR
Pain relief by electrostimulation of myofascial trigger points: peripheral or central mechanisms?
Clin J Pain. 2007 Sep;23(7):638-9. [Abstract]

Niddam DM, Chan RC, Lee SH, Yeh TC, Hsieh JC
Central modulation of pain evoked from myofascial trigger point.
Clin J Pain. 2007 Jun;23(5):440-8.
OBJECTIVES: Low-intensity low-frequency electrostimulation delivered within a myofascial trigger point (MTP) has been used as intervention to deactivate MTPs. The therapeutic effect has been suggested to be due to peripheral mechanisms. However, nonpainful stimuli are also known to reduce simultaneous pain through central effects. The primary objective of the present study was to assess if central pain modulation occurs after intervention with low-intensity electrostimulation within an MTP. We hypothesized that intervention induces pain inhibition via the periaqueductal gray (PAG). METHODS: Twenty-four patients with myofascial pain syndrome participated in the study. During functional magnetic resonance scanning, painful (high-intensity) intramuscular electrostimulation was delivered at random intervals (mean interstimulus interval=10.2 s) within an MTP of the upper left trapezius muscle. In-between scanning sessions, intervention (intramuscular electrostimulation, low-intensity, interstimulus interval=0.5 s) was applied to the same area. Patients were divided into responders and nonresponders according to their change in pressure pain thresholds relative to intervention. In addition to a whole brain search, a region of interest approach was also implemented to test the effect of intervention on PAG signal change. RESULTS: The main findings were: (1) intervention modulated PAG activity to painful stimuli more in responders than in nonresponders, (2) change in PAG activity from the whole patient population correlated with change in pressure pain threshold, and (3) a network known to regulate affective qualities of the pain experience was (subsignificantly) engaged more in responders than in nonresponders. DISCUSSION: The applied intervention most likely involves supraspinal pain control mechanisms related to both antinociception and regulation of pain affect. [Abstract]

Garcia-Eroles X, Mayoral V, Montero A, Serra J, Porta J
Celiac plexus block: a new technique using the left lateral approach.
Clin J Pain. 2007 Sep;23(7):635-7.
We describe a new celiac plexus block approach in a patient with cholangiocarcinoma who was referred to the Pain Clinic due to uncontrollable abdominal pain. The patient was initially programmed for a neurolytic celiac plexus block using the anterior approach with helical computerized tomography (CT) guidance. The CT scan revealed interposition of the transverse colon in the anterior approach territory, which made the anterior approach technique difficult, and also difficulty to practice the posterior approach without injuring the kidneys. We decided to attempt a left lateral atypical approach because the CT revealed the possibility of using a left lateral window to arrive to the celiac area. The left lateral access allowed us to carry out the neurolytic block using 50% alcohol without injuring any viscera. The patient tolerated the technique and was discharged without pain. No complications regarding either the punction or the block were observed. [Abstract]

Wessels T, Ewert T, Limm H, Rackwitz B, Stucki G
Change factors explaining reductions of "interference" in a multidisciplinary and an exercise prevention program for low back pain.
Clin J Pain. 2007 Sep;23(7):629-34.
OBJECTIVES: To identify relevant changes in process variables that are associated with outcome following an exercise and a multidisciplinary secondary prevention program for low back pain. METHODS: Data from a randomized controlled clinical trial to examine the effectiveness of an exercise and a multidisciplinary prevention program were analyzed using multiple regression analyses. The specific goal was to examine the amount of variance in changes in "interference" postintervention that could be explained by prechanges to postchanges in physical and psychologic parameters, and to determine if there are interactions between physical/psychologic parameters and the program type. RESULTS: One hundred sixty-two (89%) participants were included in the regression analyses. Reductions of interference at postmeasurement were explained best by reductions of pain intensity and catastrophizing in the multidisciplinary and the exercise prevention program. No significant interaction between the changes in process variables and the program type was found. The final model could explain 68.7% of variance. CONCLUSIONS: Owing to methodologic limitations, strong conclusions cannot be drawn from this study. The findings suggest that treatment success in exercise and multidisciplinary interventions might be influenced by the same change factors, namely changes in pain and psychologic factors. The results raise the question of whether the mechanism through which exercise works, is improve in physical variables, or rather a change in psychologic attributes, in that people correct their irrational cognitions by making experiences that differ from their expectations. If these findings can be confirmed in longitudinal studies with more measurement points, they would have implications for treatment refinement. [Abstract]

Butler SF, Venuti SW, Benoit C, Beaulaurier RL, Houle B, Katz N
Internet surveillance: content analysis and monitoring of product-specific internet prescription opioid abuse-related postings.
Clin J Pain. 2007 Sep;23(7):619-28.
OBJECTIVES: This study describes the development of a systematic approach to the analysis of Internet chatter as a means of monitoring potentially abusable opioid analgesics. METHODS: Message boards dedicated to drug abuse were selected using specific inclusion criteria. Threaded discussions containing 48,293 posts were captured. A coding system was created to compare content of posts related to 3 opioid analgesics: Kadian, Vicodin, and OxyContin. RESULTS: The number of posts containing mentions of the target drugs were significantly different [OxyContin (1813)>Vicodin (940)>Kadian (27), P<0.001]. Analyses revealed that these differences were not simply a reflection of the availability of each product (ie, number of prescriptions written). Reliability tests indicated that the content coding system achieved good interrater reliability coefficients (average kappa across all categories=0.76, range=0.52 to 1.0). Content analysis of a sample of 234 randomly selected posts indicated that the proportion of Internet posts endorsing abuse of Kadian was statistically significantly less than OxyContin (45.5% vs. 68.4%, P=0.036, not adjusted for multiple comparisons). DISCUSSION: These results suggest that a systematic approach to postmarketing surveillance of Internet chatter related to pharmaceutical products is feasible and yields reliable information about the quantity of discussion of specific products and qualitative information regarding the nature of the discussions. Kadian was associated with fewer Internet mentions than either OxyContin or Vicodin. This investigation stands as a first attempt to establish systematic methods for conducting Internet surveillance. [Abstract]

Bucerius J, Wallny T, Brackmann HH, Joe AY, Roedel R, Biersack HJ, Palmedo H
Rhenium-186 hydroxyethylidenediphosphonate (186Re HEDP) for the treatment of hemophilic arthropathy: first results.
Clin J Pain. 2007 Sep;23(7):612-8.
OBJECTIVES: The aim of this study was to evaluate the efficacy of a systemic application of rhenium-186 hydroxyethylidenediphosphonate (Re HEDP) for pain treatment in patients with hemophilic arthropathies. METHODS: Twelve patients with hemophilic arthropathy with at least 3 involved joints with persistent pain were included in this prospective study. A single dose of 15 mCi (555 MBq) Re HEDP was administered intravenously. Before and 12 weeks after treatment, pain assessment was performed using the visual analog scale (VAS). The pain status assessment included the general status, pain of all joints affected, and pain of the 3 mostly involved joints. Furthermore, quality of life was assessed. RESULTS: With regard to the 3 most involved joints, an improvement of the pain symptoms in 25 of 36 (69.4%) joints was observed. With regard to all involved joints a median of 3 joints per patient improved after Re HEDP therapy. General pain status after treatment was 2.0 VAS points lower as compared with pretreatment. The total number of involved joints remained unchanged in 7 patients, increased in 1 patient, and decreased in the remaining 4 patients. CONCLUSIONS: The results of this study show an improvement of the pain symptoms of the involved joints 12 weeks after therapy with Re HEDP in patients with hemophilic arthropathy. The only moderate success regarding a reduction of the total number of involved joints is by the fact that despite this improvement most affected joints remained still painful on a lower level after the therapy or due to newly affected joints not painful before initiation of the radionuclide therapy. [Abstract]

Schmidt S, Bethge C, Förster MH, Schäfer M
Enhanced postoperative sensitivity to painful pressure stimulation after intraoperative high dose remifentanil in patients without significant surgical site pain.
Clin J Pain. 2007 Sep;23(7):605-11.
OBJECTIVES: This clinical study tested the hypothesis whether intraoperative high versus low dose of intravenous remifentanil resulted in postoperatively increased pain sensitivity to painful cold or pressure stimulation in eye surgery patients without significant postoperative pain. METHODS: Forty-two minor eye surgery patients were randomized to receive intraoperative high (0.4 microg/kg/min) or low (0.1 microg/kg/min) dose of intravenous remifentanil plus isoflurane over an average period of 70 minutes. Pain assessment at the surgical site, postoperative versus preoperative baseline measurements by the cold as well as the pressor test, sedation score, and withdrawal signs were evaluated 30 and 90 minutes after stop of remifentanil infusion. Patients with pain at the surgical site were excluded. RESULTS: Pressure pain tolerance thresholds at the palmar carpus of the right hand were significantly decreased in these patients after cessation of intraoperative high but not low dose of IV remifentanil. However, withdrawal latencies to cold stimulation were not significantly altered. Isoflurane concentrations were slightly higher in patients receiving the low dose of remifentanil, however, there were no significant differences in length of anesthesia and postoperative sedation. Signs of withdrawal were not observed. DISCUSSION: After high dose intravenous remifentanil our results show signs of a reduced tolerance to painful pressure but not cold stimuli distant to the surgical field. Although clinically relevant surgical pain was not reported in these patients, the demonstrated induction of hyperalgesia to painful pressure stimuli suggests a general effect in the central nervous system. [Abstract]

Bohm-Starke N, Brodda-Jansen G, Linder J, Danielsson I
The result of treatment on vestibular and general pain thresholds in women with provoked vestibulodynia.
Clin J Pain. 2007 Sep;23(7):598-604.
OBJECTIVE: To correlate changes in vestibular pain thresholds to general pain thresholds in a subgroup of women with provoked vestibulodynia taking part in a treatment study. METHODS: Thirty-five women with provoked vestibulodynia were randomized to 4 months' treatment with either electromyographic biofeedback (n=17) or topical lidocaine (n=18). Vestibular and general pressure pain thresholds (PPTs) were measured and the health survey Short Form-36 (SF-36) was filled out before treatment and at a 6-month follow-up. Subjective treatment outcome and bodily pain were analyzed. Thirty healthy women of the same age served as controls for general PPTs and SF-36. RESULTS: No differences in outcome measures were observed between the 2 treatments. Vestibular pain thresholds increased from median 30 g before to 70 g after treatment in the anterior vestibule (P<0.001) and from median 20 to 30 g in the posterior vestibule (P<0.001). PPTs on the leg and arm were lower in the patients as compared with controls both before and at the 6-month follow-up. Patients reporting total cure were 3/35; 25/35 were improved. The number of patients who frequently reported of other bodily pain was reduced after the treatment. The patients had lower scores for SF-36 (General Health, Vitality) before treatment, which was restored at the 6-month follow-up. DISCUSSION: Treating provoked vestibulodynia by either topical lidocaine or electromyographic biofeedback increased vestibular pain thresholds, reduced dyspareunia, and improved bodily pain. The patients showed a general hypersensitivity to pressure pain compared with controls and in this study the hypersensitivity did not seem to be affected by treating the superficial dyspareunia. [Abstract]

Holm LW, Carroll LJ, David Cassidy J, Ahlbom A
Factors influencing neck pain intensity in whiplash-associated disorders in Sweden.
Clin J Pain. 2007 Sep;23(7):591-7.
OBJECTIVES: To investigate if sociodemographic and economic factors, preinjury health status, and collision factors are associated with initial neck pain intensity in whiplash-associated disorders (WAD) in Sweden. The factors of interest were demographic and socioeconomic factors, prior health, and collision factors. METHODS: A cohort study of car occupants, insured by either of 2 Swedish traffic insurers, age 18 to 74 years, who filed an injury claim and reported WAD after a motor vehicle collision (n=1187) were approached with mailed questionnaires. These contained questions about prior health, details about the collision, and symptoms after the collision. Neck pain intensity was measured on a visual analog scale and categorized into mild pain (0 to 30 mm), moderate pain (31 to 54 mm), and severe pain (55 to 100 mm). RESULTS: Low educational level [odds ratio (OR) 2.8; 95% confidence interval (CI) 1.8-4.5], being sole adult in the family (OR 1.6; 95%CI 1.1-2.2), prior neck pain (OR 2.9; 95%CI 1.4-6.2), prior headache (OR 2.2; 95%CI 0.7-6.9), prior poor general health (OR 2.6; 95%CI 1.4-4.8), and exposure to rollover collision (OR 1.9; 95%CI 1.0-3.8) were all associated with severe initial neck pain intensity. Most of these factors were also associated with moderate pain intensity. DISCUSSION: This study confirms results from a previous study that sociodemographic and economic status, preinjury health status, and collision-related factors are associated with participants' rating of initial neck pain intensity in WAD. The findings are of importance for interpreting and understanding the underlying factors of pain rating. [Abstract]

Shiau JM, Hung KC, Chen HH, Chen WH, Wu YH, Tseng CC
Combination of topical EMLA with local injection of lidocaine: superior pain relief after Ferguson hemorrhoidectomy.
Clin J Pain. 2007 Sep;23(7):586-90.
OBJECTIVE: To determine whether a combination of topical anesthetic (EMLA) and local injection with lidocaine is better than lidocaine alone for pain relief after Ferguson hemorrhoidectomy. METHODS: Sixty patients scheduled for hemorrhoidectomy were randomized into 2 groups: (1) control group (CG, n=30) received neomycin ointment (5 g), and (2) EMLA group (EG, n=30) received EMLA (5 g), both agents applied topically after surgery. Before the surgical incision was made, lidocaine (10 mL of a 1% solution) was locally injected into all 60 patients. After surgery, analgesics were provided when necessary. The visual analog scale score was recorded at 4 time points: (1) upon arrival in the postanesthesia room, (2) 2 hours after arriving in the postanesthesia room, (3) between 9 and 10 PM on the first postoperative evening, and (4) on the first postoperative morning. The frequency of meperidine requests, 1-time catheterizations for urinary retention, and patient satisfaction with postoperative pain management, were also recorded. RESULTS: The median visual analog scale scores and cumulative dosages of meperidine were significantly lower in the EG than the CG (P<0.05). Patient satisfaction with postoperative pain control was also significantly higher in the EG than the CG (P<0.01). No systemic complications occurred. DISCUSSION: EMLA is considered a breakthrough in cutaneous analgesia, capable of reducing pain in many cutaneous procedures. Because Ferguson hemorrhoidectomy has been performed for years with ongoing concerns over postoperative pain, we felt that using EMLA could lower postoperative pain intensity and the number of requests for additional medication. [Abstract]

Desmoulin GT, Yasin NI, Chen DW
Spinal mechanisms of pain control.
Clin J Pain. 2007 Sep;23(7):576-85.
OBJECTIVES: To demonstrate initial results using Khan Kinetic Treatment (KKT) as a chronic neck pain treatment and to present pain control mechanistic theory on which the treatment is based. METHODS: A self-reported functional assessment, neck pain questionnaire, and pain medication dose were used as outcome measures for 44 matched patients randomly split into 2 groups ("treatment" and "control"). The treatment group underwent a treatment period consisting of several individual KKT treatments, whereas the control group continued conventional therapy. RESULTS: Compared with a control group, the treatment group lowered both their self-recorded neck pain scores (P=0.012) and pain medication dose (P=0.048), although current functional assessment questionnaires (range of motion, overall activity, and recreation/work activities) did not detect changes (P=0.233, 0.311, and 0.472, respectively). DISCUSSION: We address the theory of the pain control mechanisms of the device in detail. Although we await randomized placebo controlled trials and additional results from ongoing mechanistic studies, initial results show that KKT is potentially an effective treatment for chronic neck pain and may contribute to the reduction of pain relieving medication. [Abstract]

Kapural L, Mekhail N, Bena J, McLain R, Tetzlaff J, Kapural M, Mekhail M, Polk S
Value of the magnetic resonance imaging in patients with painful lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid injections.
Clin J Pain. 2007 Sep;23(7):571-5.
OBJECTIVES: Purpose of this study is to examine the relationship between the magnetic resonance imaging (MRI) findings, pain scores, and opiates use in patients with lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid (LES) injections by retrospective review of 719 patients' electronic medical records. METHODS: Reviewed were Visual Analog Scale (VAS) pain scores and opioid use before and 8 to 12 weeks after series of LES injections. The stenosis pain index (SPI) was produced by adding an assigned numerical value of severity (1=mild, 2=moderate, 3=severe) to the number of lumbar vertebral levels affected by LSS on MRI (lateral or central). RESULTS: The average age of patients was 68.4 years. There was no relationship between the pretreatment age, sex, or number of vertebral levels affected on MRI with pretreatment VAS pain scores or opioid use. The degree of LSS present on MRI, categorized as a mild, moderate, or severe, correlated clearly with initial VAS pain scores (P=0.017). The improvement in VAS pain scores after LES injections correlated well with number of levels affected (P=0.003) and the severity of stenosis (P=0.12). Positive correlation was observed between change in VAS pain score 8 to 12 weeks after the series of LES injections and the SPI (P=0.001). There were no differences found in opioid use. DISCUSSION: The improvement in VAS pain scores after LES injections correlated well with the changes in the SPI except in those patients classified on MRI as severe LSS and more than 3 lumbar levels affected. That patient group is unlikely to benefit from LES injections. [Abstract]

Binning A
Nimesulide in the treatment of postoperative pain: a double-blind, comparative study in patients undergoing arthroscopic knee surgery.
Clin J Pain. 2007 Sep;23(7):565-70.
OBJECTIVE: To evaluate the efficacy and tolerability of nimesulide in the relief of postoperative pain after orthopedic surgery compared with naproxen and placebo. METHODS: In this multicenter, double-blind, double-dummy, randomized, parallel group study, 94 patients with at least moderate postoperative pain after arthroscopy and meniscectomy were randomized to receive nimesulide 100 mg b.i.d., naproxen 500 mg b.i.d., or placebo for a maximum of 3 days. RESULTS: Nimesulide was significantly more effective than placebo for the treatment of postoperative pain, as measured by the primary efficacy variable of summed pain intensity difference within 6 hours after first treatment (10.91 vs. 6.29). Furthermore, nimesulide also provided significantly better pain relief than naproxen on this parameter. Overall, nimesulide demonstrated superior analgesic activity compared with naproxen and placebo for the majority of secondary efficacy variables. All 3 treatments were well tolerated, with a lower number of patients reporting adverse events in the nimesulide group. Nimesulide recipients reported no gastrointestinal disorders. CONCLUSIONS: This study demonstrates that nimesulide is an effective, fast-acting and well-tolerated oral anti-inflammatory drug with a distinct analgesic activity after out-patient orthopedic surgery. [Abstract]

Moss-Morris R, Humphrey K, Johnson MH, Petrie KJ
Patients' perceptions of their pain condition across a multidisciplinary pain management program: do they change and if so does it matter?
Clin J Pain. 2007 Sep;23(7):558-64.
OBJECTIVES: The primary aim of this study was to determine whether changes in cognitive processes are related to improved functional outcomes across a multidisciplinary pain management program. METHODS: A longitudinal design was employed where patients completed 6 versions of the same questionnaire at the beginning, middle, and end of the 4-week treatment program and at 1, 3, and 6 months follow-up. Seventy-six patients consented to participate in this study. Outcome was assessed using the physical and mental component scores of the Short Form Health Questionnaire. Measures of cognitive processes included the Illness Perceptions Questionnaire Revised, the Pain Catastrophizing Scale, and the Pain Vigilance and Awareness Questionnaire. Fifty-eight patients (76%) completed all 6 questionnaires. RESULTS: We found reductions in catastrophizing and beliefs about the serious consequences of pain were most strongly associated with improved physical functioning, whereas reductions in pain vigilance, emotional representations of pain, and sense of coherence about pain were the best predictors of improved mental functioning. Overall, change in cognitive processes accounted for 26% of the variance in improved physical functioning and 23% of the variance in mental functioning. DISCUSSION: These findings suggest that interventions that specifically target cognitive processes may enhance treatment effects for patients with chronic pain. [Abstract]

Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F, Paladini A, Mojoli F
Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion.
Clin J Pain. 2007 Sep;23(7):551-7.
BACKGROUND: Efficacy of epidural local anesthetics plus steroids for the treatment of cervicobrachial pain is uncertain. METHODS: A prospective study randomized 160 patients with cervicobrachial pain resistant to conventional therapy. Patients were divided into 4 groups on the basis of the time between pain onset and treatment initiation: group A, 40 patients with pain onset 15 to 30 days; group B, 40 patients with pain from 31 to 60 days; group C, 40 patients, 61 to 180 days; and group D, 40 patients with pain >180 days. Patients of each group were randomized to receive an epidural block with bupivacaine and methylprednisolone at intervals of 4 to 5 days (Single injection) or continuous epidural bupivacaine every 6, 12, or 24 hours plus methylprednisolone every 4 to 5 days (Continuos epidural). The maximum duration of treatment (9 blocks in Single injection, and 30 days in Continuos epidural) was dependent on achieving Pain Control (PC) > or =80% [PC is defined by this formulae: (100) (VAS(initial)-VAS(final))/VAS(initial)]. Follow-up at 1 month and 6 months compared PC and the number of pain-free hours of sleep. RESULTS: One hundred forty-one patients completed the study. The 4 groups had similar characteristics. At the 1-month and 6-month follow-up analysis based on the time between pain onset and treatment initiation showed that patients of group D, who received the Continuous epidural treatment, had significantly greater PC and significantly more pain-free hours of sleep compared with similar patients in Single injection. CONCLUSIONS: Therapy with continuous epidural local anesthetic and methylprednisolone provides better control of chronic cervicobrachial pain compared with Single injection. These results are discussed with respect to the possible mechanism of action of the drugs and may relate to the physiopathologic mechanisms associated with neuronal plasticity that result in chronic pain. [Abstract]

Yang Y, Chengyuan W
Guidelines on the basic outcome data from International Association for the Study of Pain.
Clin J Pain. 2007 Jul-Aug;23(6):549. [Abstract]

Gramke HF, de Rijke JM, van Kleef M, Raps F, Kessels AG, Peters ML, Sommer M, Marcus MA
The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital.
Clin J Pain. 2007 Jul-Aug;23(6):543-8.
OBJECTIVES: Although a great variety of surgical procedures are performed on an ambulatory basis, little is known about postoperative pain experience at home after ambulatory surgery. This study was performed to assess the prevalence and course of postoperative pain in the early postoperative period after ambulatory surgery. METHODS: Over a period of 4 months, 648 patients who underwent day-case surgery were included in our study. Data were collected with interviews and questionnaires. Pain intensity was measured using a visual analog scale (VAS) during 4 days after surgery. Side effects of anesthesia and analgesia techniques were also recorded. RESULTS: On the day of the operation, 26% of the patients had moderate to severe pain (defined as mean VAS >40 mm). Mean VAS-scores were greater than 40 mm in 21% on postoperative day (POD) 1, in 13% on POD 2, in 10% on POD 3, and in 9% on POD 4. Operations of nose and pharynx, abdominal operations, plastic surgery of the breasts, and orthopedic operations were the most painful procedures during the first 48 hours. DISCUSSION: This study showed that an important number of patients still experience moderate to severe pain in the postoperative period after day-case surgery even after a 4-day period. Furthermore, the type of operation should be considered when planning postoperative analgesia for ambulatory surgery. [Abstract]

Recent Articles in Acta Anaesthesiologica Scandinavica

Meyer P, Pernet P, Hejblum G, Baudel JL, Maury E, Offenstadt G, Guidet B
Haemodilution induced by hydroxyethyl starches 130/0.4 is similar in septic and non-septic patients.
Acta Anaesthesiol Scand. 2007 Nov 22; .
Background: Fluid therapy induces haemodilution related to plasma volume expansion. The aim of our study was to compare haemodilution after a single hydroxyethyl starches (HES) 130/0.4 infusion in two groups of patients, one with and one without sepsis. We hypothesized that a single HES challenge would induce similar sustained haemodilution in both groups. Methods: In this prospective preliminary study, patients predicted to require a single further volume-expander infusion were included immediately before receiving 500 ml of 6% HES 130/0.4 over a 15-min period. No additional fluid was administered over the next 8 h. Haematocrit, and serum albumin and protein were determined immediately before HES infusion then after 1, 2, 3, 4, and 8 h. Results: Twelve patients were included in each group. In both groups, all three haemodilution markers had significantly lower values after 1 h than at baseline. None of the values after 1 and 3 h differed significantly between the two groups. Neither did any of the other study variables show significant differences between the groups with and without sepsis. Conclusion: We found that a starch-based compound was as effective in inducing haemodilution in patients with sepsis as in controls without sepsis, suggesting that HES may remain within the intravascular space even in patients with sepsis. Haemodilution parameters such as haematocrit, serum albumin and serum protein are useful for assessing the duration of plasma volume expansion induced by fluid therapy in critically ill patients. [Abstract]

Malinovsky JM, Decagny S, Wessel F, Guilloux L, Mertes PM
Systematic follow-up increases incidence of anaphylaxis during adverse reactions in anesthetized patients.
Acta Anaesthesiol Scand. 2007 Nov 13;
Background: The incidence of hypersensitivity reactions during anesthesia is underestimated because clinical symptoms may vary and diagnosis is not obvious. Our aim was to investigate the consequences of a systematic follow-up of patients on the estimated incidence of allergic reactions during anesthesia. Methods: We conducted a prospective study over a 2-year period (70,000 anesthesias). When patients were suspected with hypersensitivity reactions or with unexplained adverse reactions during anesthesia, blood was sampled to measure histamine and tryptase, and then skin tests were performed 4-6 weeks later. Results: During the studied period, 39 patients were enrolled in the database. Eight were excluded because of lack of skin tests. Twenty-two patients had clinical features compatible with immediate hypersensitivity reaction, and nine had reactions rated as 'unexplained' by the attending physician. Following systematic investigation, we found 22 hypersensitivity reactions (15 patients with obvious and seven with unexplained reactions) during anesthesia. This increases the estimated incidence of hypersensitivity reactions from 1 : 4667 to 1 : 3180 anesthesias. Tryptase concentrations were increased in only 50% of these patients. In our series, positive and negative predictive values of tryptase at T(0) for the diagnosis of anaphylaxis were 100% and 60%, respectively. Latex was the major causative agent, followed by neuromuscular blocking agents and antibiotics. Conclusions: Systematic follow-up of patients with unexplained reactions during anesthesia increases the estimated incidence of IgE-mediated hypersensitivity reactions during anesthesia by 50%. [Abstract]

Lindgren S, Odenstedt H, Erlandsson K, Grivans C, Lundin S, Stenqvist O
Bronchoscopic suctioning may cause lung collapse: a lung model and clinical evaluation.
Acta Anaesthesiol Scand. 2007 Nov 13;
Objective: To assess lung volume changes during and after bronchoscopic suctioning during volume or pressure-controlled ventilation (VCV or PCV). Design: Bench test and patient study. Participants: Ventilator-treated acute lung injury (ALI) patients. Setting: University research laboratory and general adult intensive care unit of a university hospital. Interventions: Bronchoscopic suctioning with a 12 or 16 Fr bronchoscope during VCV or PCV. Measurements and results: Suction flow at vacuum levels of -20 to -80 kPa was measured with a Timeter(trade mark) instrument. In a water-filled lung model, airway pressure, functional residual capacity (FRC) and tidal volume were measured during bronchoscopic suctioning. In 13 ICU patients, a 16 Fr bronchoscope was inserted into the left or the right main bronchus during VCV or PCV and suctioning was performed. Ventilation was monitored with electric impedance tomography (EIT) and FRC with a modified N(2) washout/in technique. Airway pressure was measured via a pressure line in the endotracheal tube. Suction flow through the 16 Fr bronchoscope was 5 l/min at a vacuum level of -20 kPa and 17 l/min at -80 kPa. Derecruitment was pronounced during suctioning and FRC decreased with -479+/-472 ml, P<0.001. Conclusions: Suction flow through the bronchoscope at the vacuum levels commonly used is well above minute ventilation in most ALI patients. The ventilator was unable to deliver enough volume in either VCV or PCV to maintain FRC and tracheal pressure decreased below atmospheric pressure. [Abstract]

Rempf C, Helmke K, Gottschalk A, Farokhzad F, Burmeister MA
Intraoperative anisocoria in a child during renal transplantation.
Acta Anaesthesiol Scand. 2007 Nov 13;
Anisocoria during anaesthesia may indicate a serious neurological condition. Assessment by physical examination and diagnostic imaging is limited during surgery and anaesthesia. We report a case of a boy undergoing renal transplantation, who suffered from anisocoria during general anaesthesia. A transcranial sonography was performed, showing no intracranial pathology. However, retinal hypoperfusion detected with orbital doppler sonography was a plausible explanation for anisocoria. [Abstract]

Volmanen P, Sarvela J, Akural EI, Raudaskoski T, Korttila K, Alahuhta S
Intravenous remifentanil vs. epidural levobupivacaine with fentanyl for pain relief in early labour: a randomised, controlled, double-blinded study.
Acta Anaesthesiol Scand. 2007 Nov 13;
Background: We hypothesised that intravenous patient-controlled analgesia (IV PCA) with remifentanil could provide as satisfactory pain relief for labour as epidural analgesia. Methods: Fifty-two parturients with singleton uncomplicated pregnancies were randomised to receive either IV PCA with remifentanil or epidural analgesia with 20 ml levobupivacaine 0.625 mg/ml and fentanyl 2 mug/ml in saline. The PCA dose of remifentanil was given over 1 min with a lockout time of 1 min. The dose was increased starting from the bolus of 0.1 mug/kg and following a dose escalation scheme up until the individual-effective dose was reached. The parturients assessed contraction pain (0-10), pain relief (0-4), sedation and nausea during 60 min. Results: Forty-five parturients were included in the analysis. The median cervical opening was 4 cm before the study and 7 cm after the study. The median pain scores were 7.3 and 5.2 during remifentanil and epidural analgesia, respectively (P=0.009). The median pain relief scores were 2.5 and 2.8 (P=0.17). There was no difference between the groups in the proportion of parturients who discontinued due to ineffective analgesia, nor in the proportion of parturients who would have liked to continue the given medication at the end of the study. Sedation and low haemoglobin oxygen saturation were observed more often during remifentanil analgesia. Foetal heart rate tracing abnormalities were as common in both groups. Conclusions: In terms of pain scores, epidural analgesia is superior to that provided by IV remifentanil. However, there was no difference in the pain relief scores between the treatments. [Abstract]

Skulec R, Kovarnik T, Dostalova G, Kolar J, Linhart A
Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome.
Acta Anaesthesiol Scand. 2007 Nov 13;
Background: Induction of mild hypothermia (MH) in patients resuscitated from cardiac arrest improves their outcome. However, benefits and risks of MH in patients who remain in cardiogenic shock after the return of spontaneous circulation (ROSC) are unclear. We analysed all cardiac arrest survivors who were treated with MH in our intensive coronary care unit (CCU) and compared the outcome of patients with cardiogenic shock syndrome (CSS) with those who were circulatory stable. Methods: We performed retrospective analysis of all consecutive cardiac arrest survivors treated by MH in our CCU from November 2002 to August 2006. They were classified into two groups, according to whether they met the criteria for cardiogenic shock or not before MH initiation. Results: Out of 56 consecutive patients, 28 fulfilled criteria of cardiogenic shock before MH initiation (group A) and 28 were relatively stable (group B). In-hospital mortality was 57.1% in group A and 21.4% in group B patients (P=0.013). Favourable neurological outcome anytime during hospitalization was found in 67.9% of group A patients and in 82.1% of group B subjects (P=0.355). Favourable discharge neurological outcome was reached in 39.3% in group A and in 71.4% in group B (P=0.031). The complication rate in both groups did not differ. Conclusion: While in-hospital mortality in cardiac arrest survivors treated by MH was expectably higher in those with cardiogenic shock than in stable patients, the favourable neurological outcome during hospitalization was comparable in both groups. Therefore, induction of MH should be considered in cardiac arrest survivors with CSS after ROSC. [Abstract]

Lundorff L, Peuckmann V, Sjøgren P
Pain management of opioid-treated cancer patients in hospital settings in Denmark.
Acta Anaesthesiol Scand. 2007 Nov 13;
Aim: To evaluate the performance and quality of cancer pain management in hospital settings. Methods: Anaesthesiologists specialised in pain and palliative medicine studied pain management in departments of oncology and surgery. Study days were randomly chosen and patients treated with oral opioids were included. Information regarding pain aetiology and mechanisms, pain medications and opioid side effects were registered from the medical records and by examining patients. Pain intensity was assessed using the Brief Pain Inventory. Results: In total, 59 cancer patients were included. In 49 (83%) patients pain aetiology was assessed by the physicians of the departments of oncology and surgery. In only 19 (32%) patients they assessed pain mechanisms. The median oral morphine dose was 120 mg/day (range: 10-720 mg/day). Seventy-eight per cent of patients received opioids at adequate regular intervals according to the duration of action. In 88% of the patients supplemental short-acting oral opioids were given on demand and the median supplemental oral dose was 16.5% of the daily dose. Seven patients with neuropathic pain received adjuvant drugs, whereas six patients with non-neuropathic pain received adjuvant drugs. Regarding opioid side effects only constipation and nausea were treated in the majority of the patients. Average pain intensity in the last 24 h for the total number of patients (n=59) </=5 cm was 88.1% (confidence interval 77.1-95.1). Conclusion: Cancer pain was prevalent in opioid-treated patients in hospital settings: however, focussing on average pain intensity, the outcome seems favourable compared with other countries. Pain mechanisms were seldom examined and adjuvant drugs were not specifically used for neuropathic pain. Opioid dosing intervals and supplemental opioid doses were most often adequate. However, opioid side effects were highly prevalent and most side effects were left untreated. [Abstract]

Fredheim OM, Kaasa S, Fayers P, Saltnes T, Jordhøy M, Borchgrevink PC
Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients.
Acta Anaesthesiol Scand. 2007 Nov 13;
Background: Patients with chronic non-malignant pain (CNMP) conditions are known to report reduced health-related quality of life (HRQoL). The objective of this exploratory study was to compare HRQoL between patients admitted to a multidisciplinary pain centre, palliative cancer (PC) patients and national norms. Methods: HRQoL data from 288 patients with CNMP admitted to the multidisciplinary pain centre at Trondheim University Hospital were compared with 434 patients with advanced cancer included in a trial of comprehensive palliative care in the hospital palliative medicine unit and national norms. HRQoL was assessed using the EORTC QLQ-C30. Age- and gender-adjusted norm data were calculated and compared between the two groups. Results: Scores from both groups deviated from adjusted norm data on all scales, with poorer functioning and more symptoms. Compared with PC patients, CNMP patients reported a larger deviation (worse scores) on global quality of life, cognitive functioning, pain, sleep disturbances and financial difficulties. Deviations from norm data were similar for physical, social and emotional functioning, diarrhoea, dyspnoea and fatigue. PC patients reported worse scores on role functioning, nausea/vomiting, loss of appetite and constipation. Conclusion: CNMP patients admitted to multidisciplinary pain centres report significantly reduced HRQoL, in addition to severe pain. They consider their HRQoL to be as poor as HRQoL reported from dying cancer patients and substantially poorer than national norms. Factors other than the biological severity of the disease seem to be of major importance for self-reported HRQoL. [Abstract]

Ulvik A, Kvåle R, Wentzel-Larsen T, Flaatten H
Quality of life 2-7 years after major trauma.
Acta Anaesthesiol Scand. 2007 Nov 13;
Background: The aim of the present study was to assess potential long-term reduction in health-related quality of life (HRQOL) in adult trauma patients 2-7 years after discharge from an intensive care unit (ICU), and to study possible determinants of the HRQOL reduction. Methods: Follow-up study of a cohort of 341 trauma patients admitted to the ICU of a university hospital during 1998-2003. Of the 228 eligible patients, 210 (92%) completed the study. A telephone interview using the EuroQol 5-D (EQ-5D) was conducted. Patients reported their HRQOL both at present and before trauma. Results: Before trauma 88% reported in retrospect no problem in any EQ-5D dimension, compared with 20% at follow-up. After trauma (median 4.0 years) 58% suffered pain/discomfort, 44% reported alterations in usual activities, 40% reduced mobility, 35% anxiety/depression, and 15% limited autonomy. A total of 74% experienced reduction in HRQOL. Severe problems were reported by 16%. Women experienced more anxiety/depression than men. Simplified Acute Physiology Score (SAPS) II and Injury Severity Score (ISS) were significantly associated with impaired HRQOL, while age was not. Patients with severe head injury reported better HRQOL than those without severe head injury. Conclusion: More than 2 years post-injury, 74% reported impaired HRQOL but only 16% had severe problems. The majority still suffered pain/discomfort, indicating that pain management is a key factor in improving long-term outcome after severe trauma. [Abstract]

Kim KO, Choe G, Chung SH, Kim CS
Delayed pharmacological pre-conditioning effect of mitochondrial ATP-sensitive potassium channel opener on neurologic injury in a rabbit model of spinal cord ischemia.
Acta Anaesthesiol Scand. 2007 Nov 13;
Background: Diazoxide, pharmacological openers of mitochondrial ATP-sensitive potassium channels have been shown to induce early pre-conditioning in the spinal cord. Here, the authors investigated whether diazoxide also induce delayed pre-conditioning and thereby reduce neurologic complications using a rabbit model of spinal cord ischemia. Methods: Infrarenal blood flow was interrupted for 20 min in 21 rabbits. Non-treated control animals received no pre-treatment. Diazoxide (5 mg/kg) were given 48 h before 20 min ischemia in the 48-h DZ group, whereas 15-min DZ group received diazoxide (5 mg/kg) 15 min before 20-min ischemia. Neurological functions were evaluated using Johnson scores for 3 days after reperfusion, after which, spinal cords were procured for hematoxylin and eosin staining for cell counting. Results: Johnson scores revealed a marked improvement in both the diazoxide-treated groups vs. the non-treated control group at 3, 24, 48, and 72 h after reperfusion (P<0.01). The histologic changes were proportional to the Johnson scores, with better preservation of motor neuron numbers in the animals of the 48-h DZ and 15-min DZ group relative to the non-treated controls (81+/-12, 90+/-10, 50+/-23 motor neurons, respectively, P<0.01). No difference was found between the 48-h DZ group and 15-min DZ group with respect to the Johnson scores or neuron numbers. Conclusions: The study demonstrates that pre-treatment with diazoxide 48 h before ischemia, induce delayed pharmacological pre-conditioning, thereby significantly improving clinical neurologic scores and histologic findings in this animal model. [Abstract]

Asheim P, Spigset O, Aasarød K, Walstad RA, Uggen PE, Zahlsen K, Aadahl P
Pharmacokinetics of intraperitoneally instilled aminophylline, terbutaline and tobramycin in pigs.
Acta Anaesthesiol Scand. 2007 Nov 13;
Introduction: Venous catheters are sometimes difficult or even impossible to insert and may also be associated with serious complications. This study was carried out to investigate whether intraperitoneal administration of drugs may be an alternative to the intravenous route in patients with limited vascular access. Materials and methods: Three drugs commonly in use in clinical practise, aminophylline, terbutaline and tobramycin, were administered to pigs intravenously and intraperitoneally in small volumes. Serum concentrations were analysed over a period of 6 h and pharmacokinetic key variables for each drug were calculated. Results: Aminophylline (theophylline), terbutaline and tobramycin were absorbed from the peritoneal space and into systemic circulation. For theophylline, the concentration/time profiles after intraperitoneal and after intravenous administration were almost identical, and the intraperitoneal bioavailability was calculated to 0.94. For terbutaline and tobramycin, the intraperitoneal absorption was delayed without any initial peak. Moreover, the intraperitoneal bioavailability was lower than for theophylline (0.71 and 0.65, respectively). Conclusion: The pharmacokinetic properties after intraperitoneal administration differed among the three drugs, but the results are encouraging and provide a basis for further investigation in humans. [Abstract]

Arai YC, Kandatsu N, Ito H, Sato Y, Satake Y, Mizutani M, Ushida T, Komatsu T
Induction and emergence behavior of children undergoing general anesthesia correlates with maternal salivary amylase activity before the anesthesia.
Acta Anaesthesiol Scand. 2007 Nov 14;
Background: The parents of the children who undergo surgery experience stress during the pre-anesthetic period. Such stress influences the mental status of their children, thereby inducing their pre-anesthetic anxiety and problematic behavior at emergence. Recently, measurement of salivary biomarkers was evaluated as stress biomarkers. Especially, alpha-amylase is utilized as an excellent index for psychological stress. In the present study, we tested whether salivary amylase activity of mothers before the surgery of their children correlates with the peri-operative children's behaviors. Methods: A total of 22 pairs of mothers and children were analyzed. Maternal salivary amylase activity was evaluated at the entrance of the operation room. The children underwent minor plastic surgery under general anesthesia, and induction and emergence behaviors were assessed. Results: The higher the maternal salivary amylase activity, the severer the children's induction anxiety (r(s)=-0.667, n=22, P<0.0001), and the higher the maternal amylase activity, the severer the children's emergence agitation (r(s)=0.705, n=22, P<0.0001). Conclusion: Induction and emergence behaviors of children undergoing general anesthesia significantly correlated with their respective maternal salivary amylase activity during the pre-anesthetic period. [Abstract]

Twigg E, Humphris G, Jones C, Bramwell R, Griffiths RD
Use of a screening questionnaire for post-traumatic stress disorder (PTSD) on a sample of UK ICU patients.
Acta Anaesthesiol Scand. 2007 Nov 14;
Background: Although rates vary across studies, research in recent years shows that prevalence of post-traumatic stress disorder (PTSD) following intensive care unit (ICU) can be high. Presently no screening tool assessing all three PTSD symptom categories has been validated in ICU patients. The aim of the study was to conduct a preliminary validation of such a measure, the UK- Post-Traumatic Stress Syndrome 14-Questions Inventory (UK-PTSS-14). Methods: A case series cohort study performed at two ICUs in two UK district general hospitals. The UK-PTSS-14 was administered at three time-points (4-14 days, 2 months and 3 months post-ICU discharge). At time-point three participants also completed the Post-traumatic Stress Diagnostic Scale (PDS) and the Impact of Events Scale (IES). Results: Forty-four patients completed the 3-month follow up. The UK-PTSS-14 was internally reliable at all three time-points (Cronbach's alpha=0.89, 0.86 and 0.84, respectively). Test-retest reliability was highest between time-points two and three (ICC=0.90). Concurrent validity at time-point three was high against the PDS (r=0.86) and the IES (r=0.71). Predictive validity was highest at time-point two (r=0.85 with the PDS and r=0.71 with the IES). Receiver operator characteristic curve analysis suggested the highest levels of sensitivity (86%) and specificity (97%) for diagnosis of PTSD were at time-point two, with an optimum decision threshold of 45 points. Conclusion: This preliminary validation study suggests that the UK-PTSS-14 could be reliably used as a screening instrument at 2 months post-discharge from the ICU to identify those patients in need of referral to specialist psychological services. [Abstract]

Huupponen E, Maksimow A, Lapinlampi P, Särkelä M, Saastamoinen A, Snapir A, Scheinin H, Scheinin M, Meriläinen P, Himanen SL, Jääskeläinen S
Electroencephalogram spindle activity during dexmedetomidine sedation and physiological sleep.
Acta Anaesthesiol Scand. 2007 Nov 14;
Background: Dexmedetomidine, a selective alpha(2)-adrenoceptor agonist, induces a unique, sleep-like state of sedation. The objective of the present work was to study human electroencephalogram (EEG) sleep spindles during dexmedetomidine sedation and compare them with spindles during normal physiological sleep, to test the hypothesis that dexmedetomidine exerts its effects via normal sleep-promoting pathways. Methods: EEG was continuously recorded from a bipolar frontopolar-laterofrontal derivation with Entropy Module (GE Healthcare) during light and deep dexmedetomidine sedation (target-controlled infusions set at 0.5 and 3.2 ng/ml) in 11 healthy subjects, and during physiological sleep in 10 healthy control subjects. Sleep spindles were visually scored and quantitatively analyzed for density, duration, amplitude (band-pass filtering) and frequency content (matching pursuit approach), and compared between the two groups. Results: In visual analysis, EEG activity during dexmedetomidine sedation was similar to physiological stage 2 (S2) sleep with slight to moderate amount of slow-wave activity and abundant sleep spindle activity. In quantitative EEG analyses, sleep spindles were similar during dexmedetomidine sedation and normal sleep. No statistically significant differences were found in spindle density, amplitude or frequency content, but the spindles during dexmedetomidine sedation had longer duration (mean 1.11 s, SD 0.14 s) than spindles in normal sleep (mean 0.88 s, SD 0.14 s; P=0.0014). Conclusions: Analysis of sleep spindles shows that dexmedetomidine produces a state closely resembling physiological S2 sleep in humans, which gives further support to earlier experimental evidence for activation of normal non-rapid eye movement sleep-promoting pathways by this sedative agent. [Abstract]

Nyberg A, Jakob SM, Seeman-Lodding H, Porta F, Bracht H, Bischofberger H, Jern C, Takala J, Aneman A
Time- and dose-related regional fluxes of tissue-type plasminogen activator in anesthetized endotoxemic pigs.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: Acute endotoxinemia elicits an early fibrinolytic response. This study analyzes the effects of the dose and duration of endotoxin infusion on arterial levels of tissue-type plasminogen activator (tPA) and pulmonary, mesenteric and hepatic plasma tPA fluxes. Methods: Pigs were randomized to receive an acute, high-dose (for 6 h, n=13, high ETX) or a prolonged, low-dose (for 18 h, n=18, low ETX) infusion of endotoxin or saline vehicle alone (for 18 h, n=14, control). All animals were fluid resuscitated to maintain a normodynamic circulation. Systemic and regional blood flows were measured and arterial, pulmonary arterial, portal and hepatic venous blood samples were analyzed to calculate regional net fluxes of tPA. Plasma tumor necrosis factor (TNF-alpha) levels were analyzed. Results: Mesenteric tPA release and hepatic uptake increased maximally at 1.5 h in ETX groups related to dose. Maximal mesenteric tPA release [high ETX 612 (138-1185) mug/min/kg, low ETX 72 (32-94) mug/min/kg, median+/-interquartile range] and hepatic tPA uptake [high ETX -1549 (-1134 to -2194) mug/min/kg, low ETX -153 (-105 to -307) mug/min/kg] correlated to TNF-alpha levels. Regional tPA fluxes returned to baseline levels at 6 h in both ETX groups and also remained low during sustained low ETX. No changes were observed in control animals. Conclusions: Endotoxemia induces an early increase in mesenteric tPA release and hepatic tPA uptake related to the severity of endotoxemia. The time patterns of changes in mesenteric and hepatic tPA fluxes are similar in acute high-dose endotoxemia and sustained low-dose endotoxemia. [Abstract]

Salgado DR, Rocco JR, Rosso Verdeal JC
Adrenal function in different subgroups of septic shock patients.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: Relative adrenal insufficiency (RAI) is a common complication during septic shock and may be more frequent in specific subgroups. The main objectives of this study were to determine the adrenal function and the RAI incidence in different subgroups of septic shock patients considering: main admission categories (medical, elective or emergency surgery); source of infection; nosocomial or community-acquired infections; gender, age <65 years or >65 years; and the presence or absence of neurological diseases, acute respiratory distress syndrome (ARDS) and bacteremia. Methods: Prospective study in a medical-surgical ICU, including adults with septic shock, from May 2002 to May 2005. All patients had total serum cortisol measured at baseline and 60 min after a high-dose ACTH test within the first 96 h of shock onset. RAI was defined as a serum cortisol increment after ACTH test (Deltamax(249)) <90 mug/l. Results: One hundred and two subjects were enrolled, and the overall RAI incidence was 22.5%. Patients with ARDS before ACTH test or bacteremia showed lower Deltamax(249) values than patients with ARDS after ACTH test (96 vs. 153 mug/l, P=0.02) or without bacteremia (140 vs. 175 mug/l, P=0.04). Multivariate regression analysis revealed that female gender, development of ARDS before ACTH test, and bacteremia were associated with greater RAI incidence. There was no difference in RAI incidence considering neurological diseases, age, type and source of infection and the main admission categories. Conclusions: Female gender, bacteremia and early-onset ARDS were variables independently associated with greater RAI incidence in septic shock patients. There was no difference in the RAI incidence concerning other subgroups. [Abstract]

Kramer-Johansen J, Dorph E, Steen PA
Detection of carbon dioxide in expired air after oesophageal intubation; the role of bystander mouth-to-mouth ventilation.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: The identification of a correctly placed tube during anaesthesia routinely depends on the detection of carbon dioxide (CO(2)) in the expired air. Results: We describe a previously unreported cause of false-positive prediction in two patients with high initial values of CO(2) in expired air after oesophageal intubation. Both patients had received bystander cardiopulmonary resuscitation with mouth-to-mouth ventilation, and the CO(2) from the rescuers' expired air was trapped and subsequently detected after oesophageal intubation. [Abstract]

Gürkan Y, Ho?ten T, Solak M, Toker K
Lateral sagittal infraclavicular block: clinical experience in 380 patients.
Acta Anaesthesiol Scand. 2007 Nov 9;
Background: The purpose of this study was to evaluate the clinical utility and block success rate of 'lateral sagittal infraclavicular block (LSIB)' in a large-scale clinical study. Methods: Adult patients scheduled for hand, wrist and forearm surgery between March 2005 and June 2007 were prospectively included into the study. Using a nerve stimulator LSIB was performed. In the LSIB technique the puncture site is immediately adjacent to the most medial point of the coracoid process and the anterior surface of the clavicula. The needle is inserted caudally in a sagittal plane, 20 degrees dorsally (downwards), until muscle twitches are observed in synchrony with the stimulation. A Local anesthetic mixture of either 20 ml bupivacaine 5 mg/ml or 20 ml of levobupivacaine 5 mg/ml and 20 ml of lidocaine 20 mg/ml with 5 mug/ml epinephrine (total volume 40 ml) was administered following electrolocation of the median, radial or ulnar nerve. Results: Three-hundred and eighty patients were included into the study. Block was successful in 341 (89.7%) patients without any need for local anesthetic supplementation. We had complete failure in 17 (4.5%) patients and these patients received general anesthesia. Twenty-two (5.8%) patients needed either infiltration of local anesthetic at the site of skin incision or supplementation of the block at the axilla. No other complications other than vascular punctures - 25 patients (6.6%) - were observed. Conclusions: LSIB provided a clinically acceptable success rate and our results are in agreement with other studies assessing this approach. [Abstract]

Yokoyama T, Ushida T, Yamasaki F, Inoue S, Sluka KA
Epidural puncture can be confirmed by the Queckenstedt-test procedure in patients with cervical spinal canal stenosis.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: The loss-of-resistance test is the most popular method for identifying the epidural space, but it cannot confirm epidural puncture. Therefore, we developed a new method to confirm epidural puncture by assessing indirect changes in epidural pressure using the Queckenstedt-test procedure, which increases subarachnoid pressure by compressing the internal jugular veins. Because this new method depends on the dynamics of cerebrospinal fluid, blockade of cerebrospinal fluid flow, as with severe spinal stenosis, is predicted to reduce changes in epidural pressure. Thus, in this study, we examined the effect of spinal stenosis on the Queckenstedt-test procedure. Methods: Epidural puncture using the loss-of-resistance test was utilized to insert an electrode in patients undergoing cervical spine surgery. Epidural pressure was monitored during bilateral compression of the internal jugular veins to confirm epidural puncture. The insertion of the electrode into the epidural space was confirmed by observation of muscle twitch evoked by electric stimulation. Results: In 60 patients, epidural puncture was performed with the loss-of-resistance test; a second trial was required in 13 patients. Increased epidural pressure was observed in 57/73 trials. When increased epidural pressure was observed, epidural puncture was always successful. The sensitivity and specificity of this method was 92.0% and 100%, respectively. The positive and negative predictive values were 100% and 66.7%, respectively. Conclusion: An increase in epidural pressure during bilateral compression of the internal jugular veins could offer a reliable method for confirming epidural puncture in combination with the loss-of-resistance test, even if patients have potential spinal canal narrowing. [Abstract]

Häggmark S, Haney MF, Johansson G, Reiz S, Näslund U
Contributions of myocardial ischemia and heart rate to ST segment changes in patients with or without coronary artery disease.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: ST changes related to ischemia at different heart rates (HRs) have not been well described. We aimed to analyze ST dynamic changes by vectorcardiography (VCG) during pacing-induced HR changes for subjects with proven coronary artery disease (CAD) and without (non-CAD). Methods: Symptomatic CAD patients scheduled for elective surgery were enrolled along with a non-CAD group. During anesthesia, both groups were placed at multiple ascending levels. VCG ST data, and in particular in ST change vector magnitude (STC-VM) from baseline, along with arterial and great coronary artery vein (GCV) blood samples were collected to determine regional myocardial lactate production. Results: A total of 35 CAD and 10 non-CAD patients were studied over six incremental 10 beat/min HR increases. STC-VM mean levels increased in the CAD group from 9+/-5 to 131+/-37 muV (standard deviation) compared with non-CAD subjects with 8+/-3-76+/-34 muV. Myocardial ischemia (lactate production) was noted at higher HRs and the positive predictive value for STC-VM to detect ischemia was 58% with the negative predictive value being 88%. STC-VM at 54 muV showed a sensitivity of 88% and a specificity of 75% for identification of ischemia. Conclusions: Both HR and ischemia at higher HRs contribute to VCG ST elevation. Established ST ischemia detection concerning HR levels is suboptimal, and further attention to the effects of HR on ST segments is needed to improve electrocardiographic ischemia criteria. [Abstract]

Bay-Nielsen M, Kehlet H
Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: Randomised studies suggest regional anaesthesia to have the highest morbidity and local infiltration anaesthesia to have the lowest morbidity after groin hernia repair. However, implications and results of this evidence for general practice are not known. Methods: Prospective nation-wide data collection in a cohort of n=29,033 elective groin hernia repairs, registered in the Danish Hernia Database in three periods, namely July 1998-June 1999, July 2000-June 2001 and July 2002-June 2003. Retrospective analysis of complications in discharge abstracts, identified from re-admission within 30 days post-operatively, prolonged length of stay (>2 days post-operatively) or death. Results: Complications after groin hernia repair were more frequent in patients 65+ years (4.5%), compared with younger patients (2.7%) (P<0.001). In patients 65+ years, medical complications were more frequent after regional anaesthesia (1.17%), compared with general anaesthesia (0.59%) (P=0.003) and urological complications were more frequent after regional anaesthesia (0.87%), compared with local infiltration anaesthesia (0.09%) (P=0.006). Seventeen prostatectomies occurred after post-operative urinary retention, but with no case after local anaesthesia. Mortality within 30 days after elective groin hernia repair was 0.12%. Regional anaesthesia was disproportionately more often used in patients dying within 1 week post-operatively. Conclusion: Choice of the anaesthetic technique should be adjusted to available procedure-specific scientific evidence and the use of regional anaesthesia in elderly patients undergoing groin hernia repair is not supported by existing evidence. [Abstract]

Wang TF, Liu YH, Chu CC, Shieh JP, Tzeng JI, Wang JJ
Low-dose haloperidol prevents post-operative nausea and vomiting after ambulatory laparoscopic surgery.
Acta Anaesthesiol Scand. 2007 Nov 12;
Background: We evaluated the prophylactic effect of low-dose haloperidol (1 mg) on post-operative nausea and vomiting (PONV) in women undergoing ambulatory laparoscopic surgery. Droperidol (0.625 mg) and saline were controls. Methods: One hundred and fifty women undergoing ambulatory laparoscopic surgery under general anaesthesia were enrolled in this randomized, double-blind, and placebo-controlled study. After tracheal intubation, the haloperidol group (n=50) received intravenous haloperidol (1 mg), the droperidol group (n=50) received intravenous droperidol (0.625 mg), and the saline group (n=50) received intravenous saline. Results: Haloperidol- and droperidol-group patients reported a lower incidence of PONV [24% and 23% vs. 49% (saline group); P<0.05] and requested fewer doses of rescue antiemetics [13% and 16% vs. 38% (saline group); P<0.05] during the first four post-operative hours. During the 24-h post-operative period, haloperidol- and droperidol-group patients also reported a lower incidence of PONV [31% and 32% vs. 62% (saline group); P<0.01]. No differences were found between the haloperidol and droperidol groups. Conclusion: Like droperidol (0.625 mg), prophylactic intravenous haloperidol (1 mg) significantly reduced the incidence of PONV in women undergoing ambulatory laparoscopic surgery. [Abstract]

Väyrynen T, Kuisma M, Määttä T, Boyd J
Medical futility in asystolic out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand. 2007 Nov 8;
Objectives: To study the factors associated with short- and long-term survival after asystolic out-of-hospital cardiac arrest, with a reference to medical futility. Methods: This is a retrospective observational study conducted in Helsinki, Finland during 1 January 1997 to 31 December 2005. All out-of-hospital cardiac arrests were prospectively registered in the cardiac arrest database. Of 3291 arrests, 1455 had asystole as the first registered rhythm. These patients represent the study population. Results: A short time interval to the initiation of advanced life support (ALS) was associated with a long-term benefit, but a short first responding unit (FRU) response time had only a short-term benefit. Conversion of asystole into a shockable rhythm provided only a short-term benefit. The prognosis was poor if the FRU response time was over 10 min or the ALS response time was over 11 min in bystander-witnessed arrests, and if the duration of resuscitation was over 8 min in emergency medical services (EMS)-witnessed arrests. Bystander-CPR was associated with increased 30-day mortality. The 30-day survival rate after an unwitnessed arrest (n=548) was 0.5%. All survivors in this group were either hypothermic or were victims of near-drowning. Conclusions: Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near-drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10-15 min in bystander-witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander-CPR. Early initiation of ALS should be prioritised in the treatment of out-of-hospital asystole. [Abstract]

Lenz H, Raeder J, Hoymork SC
Administration of fentanyl before remifentanil-based anaesthesia has no influence on post-operative pain or analgesic consumption.
Acta Anaesthesiol Scand. 2007 Nov 8;
Background: Remifentanil's short-acting analgesic effect and the potential of producing hyperalgesia is a challenge to post-operative pain control. This study investigated whether pre-treating the patients with fentanyl before remifentanil-based anaesthesia could reduce post-operative pain or analgesic consumption. Methods: One-hundred patients admitted for anterior cruciate ligament repair were included in a double-blind study. Propofol and remifentanil were used for general anaesthesia. Group Pre received fentanyl 1.5 mug/kg intravenously (IV) and Group Post placebo before the remifentanil infusion. At the end of surgery, Group Pre received 1.5 mug/kg and Group Post received 3.0 mug/kg. Patient-controlled analgesia with fentanyl was used as analgesic rescue medication during the first 4 h post-operatively. Oxycodone 5 mg orally was taken as needed during the subsequent 4-24-h period. Results: A mean dose of remifentanil 0.43 mug/kg/min was used for 90 min during surgery in both groups. There were no differences in the verbal rate scale (VRS) score or need of rescue analgesic medication between the groups during the first 4 h. Group Post had significantly less pain in the 4-24-h period after surgery, with a median VRS score of 'slight pain' vs. 'moderate pain' in Group Pre (P<0.05). The oxycodone consumption was similar in both groups. Conclusion: Pre-treatment with fentanyl 1.5 mug/kg IV yielded no reduction in post-operative pain or analgesic consumption after 90 min of remifentanil-based anaesthesia with 0.43 mug/kg/min of remifentanil. [Abstract]

Segerdahl M, Warrén-Stomberg M, Rawal N, Brattwall M, Jakobsson J
Clinical practice and routines for day surgery in Sweden: results from a nation-wide survey.
Acta Anaesthesiol Scand. 2007 Nov 8;
Background: Day surgery has expanded considerably during the last decades. Routines and standards have developed but differ between and within countries. Methods: We studied the practice of day surgery in Sweden by an extensive questionnaire survey sent to all 92 hospitals. Results: The proportion of day surgery vs. in-hospital procedures was overall 43%, with 43% in adults and 46% in children. Orthopaedic (33%), general (29%) and gynaecological (17%) surgery were the most common ambulatory procedures. Most patients (>90%) underwent pre-operative assessment by an anaesthesiologist. Patient self-assessment questionnaires were common (86%). Risk stratification for post-operative nausea and vomiting was used by 70% of the departments. Anxiolytic pre-medication was uncommon. Most anaesthesiologists (95%) used pre-operative oral analgesics to initiate post-operative analgesia, the most common being paracetamol (95%), NSAIDs (73%) and coxibs (15%). A balanced general anaesthesia technique was preferred. Post-operatively, 93% of the units routinely assessed patients' pain. Analgesic combinations of paracetamol, NSAIDs and weak opioids were used by 94% of the units. Most hospitals (80%) had standardised discharge criteria based on clinical assessment, and many required a patient escort at home for 24 h post-operatively. Assessments of unplanned admission, re-admission and post-operative complications were not performed routinely. Follow-up telephone calls within 1-2 days were performed regularly in about 40% of the units, or in selected patients only (37%). Pain was the most frequent complaint on follow-up. Conclusions: In Sweden, a high degree of standardised regime for day surgical practice was found. Post-operative pain is the most common complaint after discharge. [Abstract]

Burgos E, Gómez-Arnau JI, Díez R, Muñoz L, Fernández-Guisasola J, Garcia Del Valle S
Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients.
Acta Anaesthesiol Scand. 2007 Nov 8;
Background: Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly. Methods: We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve. Results: The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality. Conclusions: A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery. [Abstract]

Cavaliere F, Conti G, Costa R, Spinazzola G, Proietti R, Sciuto A, Masieri S
Exposure to noise during continuous positive airway pressure: influence of interfaces and delivery systems.
Acta Anaesthesiol Scand. 2007 Nov 8;
Background: We measured noise intensity and perceived noisiness during continuous positive airway pressure (CPAP) performed with two interfaces (face-mask, helmet) and four delivery systems. Methods: Eight healthy volunteers received CPAP in random order with: two systems provided with a flow generator using the Venturi effect and a mechanical expiratory valve (A: Venturi, Starmed; B: Whisperflow-2, Caradyne Ltd); one 'free-flow' system provided with high flow O(2) and air flowmeters, an inspiratory gas reservoir, and a water valve (C: CF800, Drägerwerk, AG); and a standard mechanical ventilator (Servoventilator 300, Siemens-Elema). Systems A, B, and C were tested with a face-mask and a helmet at a CPAP value of 10 cm H(2)O; the mechanical ventilator was only tested with the face mask. Noise intensity was measured with a sound-level meter. After each test, participants scored noisiness on a visual analog scale (VAS). Results: The noise levels measured ranged from 57+/-11 dBA (mechanical ventilator plus mask) to 93+/-1 and 94+/-2 dBA (systems A and B plus helmet) and were significantly affected by CPAP systems (A and B noisier than C and D) and interfaces (helmet CPAP noisier than mask CPAP). Subjective evaluation showed that systems A and B plus helmet were perceived as noisier than system C plus mask or helmet. Conclusions: Maximum noise levels observed in this study may potentially cause patient discomfort. Less noisy CPAP systems (not using Venturi effect) and interfaces (facial mask better than helmet) should be preferred, particularly for long or nocturnal treatments. [Abstract]

Asbjørnsen H, Kuwelker M, Søfteland E
A case of unexpected difficult airway due to lingual tonsil hypertrophy.
Acta Anaesthesiol Scand. 2007 Nov 8;
Clinical value of preoperative bedside screening tests for predicting difficult airway remains limited. Asymptomatic lingual tonsil hypertrophy is a known cause of unexpected difficult airway. We report a case as a reminder of this. [Abstract]

Yan M, Chen C, Zhang F, Chen G
Lidocaine abolishes the myocardial protective effect of sevoflurane post-conditioning.
Acta Anaesthesiol Scand. 2007 Nov 8;
Background: Post-ischemic administration of volatile anesthetics activates ischemia-reperfusion injury salvage process and decreases myocardial damage. However, the mechanisms underlying anesthetic post-conditioning and effects of lidocaine on it remain unclear. Here we report the cardioprotection of sevoflurane-induced post-conditioning and the effects of lidocaine on it. Methods: Isolated perfused rat hearts were exposed to 40 min of ischemia followed by 1 h of reperfusion. Volatile anesthetic post-conditioning was induced by 15 min of 3 vol% sevourane (1.5 minimum alveolar concentration) administered at the onset of reperfusion. In some experiments, lidocaine was coadministered with sevoflurane in different concentrations (2, 10 and 20 mug/ml). Infarct size was determined by dividing the total necrotic area of the left ventricle by the total left ventricular slice area (percent necrotic area). Results: Sevoflurane-induced post-conditioning signicantly improved post-ischemia functional recovery and decreased infarct size (47.3+/-5.6% in unprotected hearts vs. 18.6+/-3.1% in anesthetic post-conditioning, P<0.05). Sevourane-mediated cardioprotection was abolished by 20 mug/ml lidocaine. Conclusions: Sevourane-induced post-conditioning effectively protected myocardium against reperfusion damage and its cytoprotection was reversed by 20 mug/ml lidocaine. [Abstract]

Thierry S, Giroux Leprieur E, Lecuyer L, Brocas E, van de Louw A
Echocardiographic features, mortality, and adrenal function in patients with cirrhosis and septic shock.
Acta Anaesthesiol Scand. 2007 Nov 8;
Objectives: Cirrhosis of the liver is associated with an increased susceptibility to bacterial infections capable of causing septic shock and with a basal hyperdynamic circulatory state. The primary objective of this study was to delineate the echocardiographic characteristics and outcomes of septic shock in patients with liver cirrhosis. The secondary objective was to determine whether adrenal insufficiency, which may contribute to hyperdynamic syndrome, was more marked in patients with cirrhosis than in other patients with septic shock. Design: Prospective single-center cohort study. Patients and methods: Thirty-four patients admitted to the intensive care unit (ICU) for septic shocks were included, 14 with and 20 without liver cirrhosis. Echocardiography was performed within the first 24 h to measure the cardiac index (CI), systolic index (SI), and left ventricular ejection fraction (LVEF). A Synacthen test was performed. Results: Patients with cirrhosis had higher values for the CI (3.69+/-1.0 vs. 2.86+/-0.8 l/min/m(2); P=0.02), SI (37.5+/-8 vs. 32.4+/-7 ml/m(2); P=0.04), and LVEF (67+/-7 vs. 55.9+/-12%; P=0.005). ICU mortality was 53% overall, 64% in patients with cirrhosis, and 45% in patients without cirrhosis (P=0.27). Serum cortisol levels under basal conditions (H0) and after stimulation (H1) showed no significant differences between patients with and without cirrhosis. The proportion of patients with no response to Synacthen was 77% among patients with cirrhosis and 50% among patients without cirrhosis (P=0.18). Conclusion: In a population with septic shock, left ventricular function was more hyperdynamic in the subset with cirrhosis. Relative adrenal insufficiency occurred in similar proportions of patients with and without cirrhosis. [Abstract]

Recent Articles in European Journal of Pain

Claydon LS, Chesterton LS, Barlas P, Sim J
Effects of simultaneous dual-site TENS stimulation on experimental pain.
Eur J Pain. 2007 Dec 7; .
Transcutaneous electrical nerve stimulation (TENS) is commonly used for pain relief. However, little robust research exists regarding the combination of parameters required to provide effective doses. This study investigated the hypoalgesic effects of different parameter combinations, applied simultaneously at two sites (segmental and extrasegmental), on pressure pain threshold (PPT) in pain-free humans. Two-hundred and eight volunteers (median age 22 years, range 20-26) were randomized to eight groups: six active TENS groups, placebo and control. Parameter combinations were such that frequency always differed at each site (110Hz or 4Hz), but intensity could be either the same or different levels: high (to tolerance without pain) or low (strong but comfortable). TENS was administered to the forearm over the radial nerve and the ipsilateral leg below the fibular head for 30min with monitoring for 30 further minutes. PPT measurements were taken bilaterally from the mid-point of first dorsal interosseous muscle, by an independent blinded rater, at baseline and at six subsequent 10-min intervals. Log-transformed data were analysed using repeated-measures analysis of covariance (baseline values and gender as covariates). Those groups using high-intensity stimulation at the segmental stimulation sites showed significantly greater hypoalgesia than placebo (p<0.025 in each case). The largest hypoalgesic effect was for simultaneous high-intensity stimulation at segmental and extrasegmental sites, using different frequencies. These results reaffirm that high-intensity stimulation (regardless of frequency) is of fundamental importance in effective dosage. [Abstract]

Kosson D, Klinowiecka A, Kosson P, Bonney I, Carr DB, Mayzner-Zawadzka E, Lipkowski AW
Intrathecal antinociceptive interaction between the NMDA antagonist ketamine and the opioids, morphine and biphalin.
Eur J Pain. 2007 Dec 6;
Biphalin is an opioid peptide analogue that currently is under clinical development as a new type of site-directed analgesic. In rats, the intrathecal (i.t.) analgesic potency of biphalin is 1000-fold greater than morphine. Such a high activity may reflect this compound's activation of three types of opioid receptors (mu, delta and kappa). NMDA receptors also play an important role in nociceptive processing. Therefore, we investigated in rats whether an NMDA antagonist may influence biphalin-induced antinociception. In the present study, ketamine was chosen because of the widespread safe use of this drug in clinical practice. I.t. application of ketamine alone had relatively little analgesic effect and its excitatory effects limited possible doses of the drug. Co-administration of ketamine with biphalin or morphine produced markedly greater antinociception than biphalin or morphine alone in acute, thermal tail flick testing. These results suggest that NMDA antagonists may be useful potentiators of biphalin analgesia. Thus, to obtain the same spinal antinociceptive effect, lower doses of biphalin or morphine are required when ketamine is co-administered. [Abstract]

Kosek E, Januszewska A
Mechanisms of pain referral in patients with whiplash associated disorder.
Eur J Pain. 2007 Dec 6;
The aim was to investigate the mechanisms of pain referral in patients with whiplash associated disorder. Pain was induced in 12 controls and 12 patients with whiplash associated disorder by intramuscular electrical stimulation in the infraspinatus muscle and the ipsilateral upper arm, i.e., the area where all subjects perceived referred pain during conditioning stimulation in the infraspinatus muscle. Conditioning stimulation amounted to a pain intensity rated as 2/10 and 4/10. During conditioning stimulation in the infraspinatus muscle, sensitivity to test stimuli was assessed in the referred pain area (i.e., upper arm) and vice versa. Test stimuli consisted of intramuscular electrical stimulation corresponding to innocuous perception threshold, electrical pain threshold, and pain intensities rated as 2/10, 4/10 and 6/10, respectively. Compared to controls, patients with whiplash associated disorder had increased pain sensitivity (p0.01) and indicated larger areas of referred pain ((p0.003) during stimulation at the infraspinatus muscle; p0.03 during stimulation at the upper arm), including proximal referral of pain which was never reported by controls (p0.05). During conditioning stimulation in the infraspinatus muscle (4/10) all subjects reported referred pain in the upper arm (corresponding to the test site) and innocuous perception thresholds (p<0.05)(patients) and electrical pain thresholds (p<0.001) (controls) decreased. Conditioning stimulation in the upper arm did not affect sensitivity to test stimuli in the infraspinatus muscle. In conclusion, patients with whiplash associated disorder had increased sensitivity to painful stimulation, reported larger areas of referred pain during the same subjectively painful conditioning stimulation (i.e., lower absolute stimulus intensities), including proximal pain referral which was never seen in controls, indicating aberrant processing of nociceptive input. The perceptual integration of nociceptive stimuli during simultaneous stimulation did not differ between groups suggesting that divergence of nociceptive input from the focal pain area leading to excitation of neurones with projected fields in the referred pain area most likely explains referred pain in both groups alike. [Abstract]

Kuhad A, Sharma S, Chopra K
Lycopene attenuates thermal hyperalgesia in a diabetic mouse model of neuropathic pain.
Eur J Pain. 2007 Dec 3;
Diabetic neuropathic pain, an important microvascular complication of diabetes mellitus is recognized as one of the most difficult types of pain to treat. The development of tolerance, inadequate relief and potential toxicity of classical antinociceptives warrant the investigation of the newer agents to relieve this pain. The aim of the present study was to explore the antinociceptive effect of lycopene and its effect on tumour necrosis factor-alpha (TNF-alpha) and nitric oxide (NO) release in streptozotocin induced diabetic mice. Four weeks after a single intraperitoneal injection of streptozotocin (200mg/kg), mice were tested in the tail immersion and hot-plate assays. Diabetic mice exhibited significant hyperalgesia alongwith increased plasma glucose and decreased body weights as compared with control mice. Lycopene (1, 2 and 4mg/kg body weight; per oral) treatment, from the 4th to 8th week after streptozotocin injection, significantly attenuated thermal hyperalgesia and the hot-plate latencies. Lycopene also inhibited the TNF-alpha and NO release in a dose dependent manner. These results indicate an antinociceptive activity of lycopene possibly through its inhibitory action on NO and TNF-alpha release and point towards its potential to attenuate diabetic neuropathic pain. [Abstract]

Wesseldijk F, Huygen FJ, Heijmans-Antonissen C, Niehof SP, Zijlstra FJ
Tumor necrosis factor-alpha and interleukin-6 are not correlated with the characteristics of Complex Regional Pain Syndrome type 1 in 66 patients.
Eur J Pain. 2007 Dec 3;
It was previously shown in a group of 9 patients with complex regional pain syndrome type 1 (CRPS1) that levels of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) are higher in blister fluid from the involved side. We hypothesize that local inflammation is responsible for the characteristics of CRPS1. The aim of this study was to confirm the previous observation in a large group of CRPS1 patients, repeating the measurement of TNF-alpha and IL-6 in blister fluid. Furthermore, we sought to determine whether these cytokines are responsible for the characteristics of CRPS1 and characterize the relationship between cytokine levels and duration of the disease. Sixty-six patients with CRPS1 participated. Skin blisters were artificially induced for measurement of cytokines in both extremities. The following disease characteristics were assessed: pain and differences in temperature, volume, and mobility between the extremities. TNF-alpha and IL-6 levels were significantly higher in blister fluid from the involved side. However, cytokine levels did not correlate with the characteristics or duration of the disease. Our findings confirm the presence of local inflammation in a population of 66 patients in the first 2 years of CRPS1. Proinflammatory cytokines seem to be only partly involved in the pathophysiology of CRPS1, as indicated by the lack of coherence between TNF-alpha and IL-6 levels and the signs and symptoms of inflammation and disease duration. Other inflammatory mediators and mechanisms, such as central sensitization, are probably involved in the early stages of CRPS1. [Abstract]

Usichenko TI, Edinger H, Witstruck T, Pavlovic D, Zach M, Lange J, Gizhko V, Wendt M, Koch B, Lehmann C
Millimetre wave therapy for pain relief after total knee arthroplasty: A randomised controlled trial.
Eur J Pain. 2007 Nov 23;
Millimetre wave therapy (MWT) is a promising complementary method for pain relief, however rigorous investigations of its effectiveness are needed. The purpose of this study was to examine if MWT can reduce opioid requirement compared to sham procedure applied for relief of acute pain in patients after total knee arthroplasty (TKA). Eighty patients undergoing TKA were randomly assigned to receive MWT or sham procedure. Patients and evaluators were blinded to the group allocation. MWT consisted of six sessions, each session of 30min duration. During each session the knee wound was exposed to electromagnetic waves with frequency 50-75GHz and power density 4.2mW/cm(2). Postoperative analgesia with piritramide, a weak opioid with 0.7 potency of morphine delivered via patient-controlled analgesia pump, was directed to achieve pain intensity of less than 40 on a 100mm visual analogue scale (VAS). The primary outcome measure was postoperative piritramide requirement for three days after surgery. Secondary outcome measures were: total ibuprofen requirement from the fourth postoperative day to discharge; success of patients' blinding; patients' satisfaction with pain relief; incidence of analgesia-related side effects; heart rate and blood pressure. Piritramide requirement was similar in both groups whereby all patients reported adequate pain relief measured on a VAS. Secondary outcome measures were also comparable in both groups. The majority of patients in both groups believed they had received true MWT and wanted to repeat it in future. Millimetre waves applied to surfaces of surgical wounds did not reduce opioid requirement compared to the sham procedure after TKA. [Abstract]

Zheng Z, Guo RJ, Helme RD, Muir A, Da Costa C, Xue CC
The effect of electroacupuncture on opioid-like medication consumption by chronic pain patients: A pilot randomized controlled clinical trial.
Eur J Pain. 2007 Nov 20;
Opioid-like medications (OLM) are commonly used by patients with various types of chronic pain, but their long-term benefit is questionable. Electroacupuncture (EA) has been previously shown beneficial in reducing post-operative acute OLM consumption. In this pilot randomized controlled trial, the effect of EA on OLM usage and associated side effects in chronic pain patients was evaluated. After a two-week baseline assessment, participants using OLM for their non-malignant chronic pain were randomly assigned to receive either real EA (REA, n=17) or sham EA (SEA, n=18) treatment twice weekly for 6 weeks before entering a 12-week follow-up. Pain, OLM consumption and their side effects were recorded daily. Participants also completed the McGill Pain Questionnaire (MPQ), SF-36 and Beck Depression Inventory (BDI) at baseline, and at the 5th, 8th, 12th, 16th and 20th week. Nine participants withdrew during the treatment period with another three during the follow-up period. Intention to treat analysis was applied. At the end of treatment period, reductions of OLM consumption in REA and SEA were 39% and 25%, respectively (p=0.056), but this effect did not last more than 8 weeks after treatment. There was no difference between the two groups with respect to reduction of side effects and pain and the improvement of depression and quality of life. In conclusion, REA demonstrates promising short-term reduction of OLM for participants with chronic non-malignant pain, but such effect needs to be confirmed by trials with adequate sample sizes. [Abstract]

Cöster L, Kendall S, Gerdle B, Henriksson C, Henriksson KG, Bengtsson A
Chronic widespread musculoskeletal pain - A comparison of those who meet criteria for fibromyalgia and those who do not.
Eur J Pain. 2007 Nov 14;
Fibromyalgia is currently classified as chronic widespread pain with widespread allodynia to pressure pain. There are few data describing pain characteristics, quality of life, consequences for daily living, and psychosocial status in patients who meet the classification criteria for fibromyalgia proposed by the American College of Rheumatology compared with patients with chronic widespread pain but not widespread allodynia. This study used a randomly selected sample from the general population. A postal questionnaire and a pain mannequin were sent to 9952 people. The response rate was 76.7%. The pain drawings showed that 345 people had widespread pain; that is, they noted pain in all four extremities and axially. Clinical examination, which included a manual tender point examination, was performed in 125 subjects. These people answered commonly used questionnaires on pain, quality of life, coping strategies, depression, and anxiety. Compared with chronic widespread pain without widespread allodynia, fibromyalgia was associated with more severe symptoms/consequences for daily life and higher pain severity. Similar coping strategies were found. Chronic widespread pain without widespread allodynia to pressure pain was found in 4.5% in the population and fibromyalgia in 2.5%. [Abstract]

Valeberg BT, Rustøen T, Bjordal K, Hanestad BR, Paul S, Miaskowski C
Self-reported prevalence, etiology, and characteristics of pain in oncology outpatients.
Eur J Pain. 2007 Nov 13;
PURPOSE: To determine the self-reported prevalence rates for cancer, non-cancer, and both cancer and non-cancer pain and to determine if there were differences in demographic, clinical, and pain characteristics among the three pain groups. METHODS: Patients were screened in outpatient oncology clinics for the presence of pain and/or analgesic use. Patients who reported pain completed the study questionnaires. RESULTS: A total of 1790 patients were available for screening in the outpatient clinics and 1549 (86.5%) completed the screening questionnaire. Out of them, 332 (21.4%) reported pain or used analgesics. Of the 217 patients who completed the study questionnaires, 53% had only cancer pain (pain due to cancer and/or treatment), 25.3% had non-cancer pain, and 21.7% had both cancer and non-cancer pain. No differences were found, among the three pain groups, in pain intensity or pain duration. However patients in the cancer and non-cancer pain group had higher pain interference scores, higher severity scores for various pain descriptors, and a higher number of pain locations. CONCLUSIONS: These findings suggest that outpatients with a combination of cancer and non-cancer pain may be at greater risk for under-treatment of pain. Oncology clinicians and primary care providers need to perform a comprehensive pain assessment of all oncology patients in order to be able to formulate an effective pain management plan. [Abstract]

Benbouzid M, Pallage V, Rajalu M, Waltisperger E, Doridot S, Poisbeau P, Freund-Mercier MJ, Barrot M
Sciatic nerve cuffing in mice: A model of sustained neuropathic pain.
Eur J Pain. 2007 Nov 12;
Because of its severity, chronicity, resistance to usual therapy and its consequences on quality of life, neuropathic pain represents a real clinical challenge. Fundamental research on this pathology uses metabolic, pharmacological or traumatic models in rodents that reproduce the characteristic human pain symptoms. In 1996, Mosconi and Kruger morphologically described a model of peripheral neuropathy in which a cuff of polyethylene tubing was placed around the sciatic nerve in rats. In the present study, we evaluated the behavioral consequences of this neuropathic pain model in C57Bl/6J mice which is the main genetic background used for studies in transgenic mice. A short cuff of polyethylene tubing was unilaterally placed around the main branch of the sciatic nerve. It induced an ipsilateral heat thermal hyperalgesia lasting around 3 weeks, and a sustained ipsilateral mechanical allodynia lasting at least 2 months. We showed that this neuropathic pain model is insensitive to ketoprofen, a non-steroidal anti-inflammatory drug. Morphine treatment acutely suppressed the mechanical allodynia, but tolerance to this effect rapidly developed. The analysis of video recordings revealed that most aspects of spontaneous behavior remained unaffected on the long term, excepted for a decrease in the time spent at social interaction for the neuropathic mice. Using the elevated plus-maze and the marble-burying test, we also showed that neuropathic mice develop an anxiety phenotype. Our data indicate that sciatic nerve cuffing in mice is a pertinent model for the study of nociceptive and emotional consequences of sustained neuropathic pain. [Abstract]

Stancák A, Kozák J, Vrba I, Tintera J, Vrána J, Polácek H, Stancák M
Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients.
Eur J Pain. 2008 Feb;12(2):
Spinal cord stimulation (SCS) consisting of electrical stimulation of the dorsal spinal cord using epidural electrodes has been shown to relieve chronic neuropathic pain. To analyze the cerebral activation patterns related to SCS, and to evaluate the effects of SCS on the processing of acute experimental pain, we performed functional magnetic resonance imaging (fMRI) on eight patients suffering from failed back surgery syndrome who were also being treated with SCS for severe pain in their legs and lower back. Three types of stimulation were used, each lasting 36s: (i) SCS, (ii) heat pain (HP) applied to the leg affected by neuropathic pain, and (iii) simultaneous HP and SCS. During SCS, we found increased activation of the medial primary sensorimotor cortex somatotopically corresponding to the foot and/or perineal region, contralateral posterior insula, and the ipsilateral secondary somatosensory cortex (S2). Decreased activation was seen in the bilateral primary motor cortices and the ipsilateral primary somatosensory cortex corresponding to the shoulder, elbow and hand. Compared to separately presented HP and SCS, simultaneous HP and SCS showed statistically significant activation of the bilateral inferior temporal cortex and the ipsilateral cerebellar cortex. The activation of the primary motor cortex, insula and S2 during SCS may directly interfere with the processing of neuropathic pain. When SCS is associated with heat pain, the paralimbic association cortex and cerebellum show activation exceeding the sum of activations resulting from separate SCS and heat pain stimulation. The explanation of this could possibly rest with the continuous comparisons of simultaneous pain and somatosensory sensations occurring in a single dermatome. [Abstract]

Arendt-Nielsen L, Schipper KP, Dimcevski G, Sumikura H, Krarup AL, Giamberardino MA, Drewes AM
Viscero-somatic reflexes in referred pain areas evoked by capsaicin stimulation of the human gut.
Eur J Pain. 2007 Oct 29;
The interaction between visceral pain and the sympathetic nervous system is only sparsely investigated in quantitative human studies. Referred visceral pain can be evoked experimentally by application of substances such as capsaicin (the pungent substance of chilli pepper) to the gut. The aim of the present study was to induce referred visceral pain from the small and large intestine in 32 volunteers via the stomal opening in patients with ileo- or colostomy and quantify the viscero-somatic reflex responses in these referred pain areas by thermography and laser doppler flowmetry. Capsaicin evoked pain and referred pain areas in all subjects. In the referred pain area, the temperature increased by approximately 0.6 degrees C (P<0.001) and the blood flow by approximately 35AU (P<0.001). Saline was used in a control experiment, and no temperature and blood flow changes were found. The present quantitative human study of viscero-somatic reflexes showed dramatic sympathetic responses in the referred pain areas after experimentally induced gut pain. [Abstract]

Sanoja R, Cervero F
Estrogen modulation of ovariectomy-induced hyperalgesia in adult mice.
Eur J Pain. 2007 Oct 22;
Some chronic pain conditions are more prevalent in women. However, the evidence from both human and animal studies as to whether estrogen is pro- or anti-nociceptive is inconsistent. We have used a model of functional abdominal pain in mice to examine the role of estrogen in the modulation of a hyperalgesic state induced by ovariectomy. C57/BL6 female mice were either ovariectomized (OVX), received the same surgery without removing the ovaries or were tested without any surgical procedure. Mechanical hyperalgesia was assessed by von Frey filaments and thermal pain was measured using a hot-plate at 50 degrees C. OVX mice, but not sham-operated, developed mechanical hyperalgesia localized to the abdominal region, the hindlimbs and the proximal tail, 4-5 weeks after OVX as well as a reduction in response latency to the hot plate. OVX animals were implanted with 17beta-estradiol pellets or with similar pellets with no hormone five weeks after OVX, when the hyperalgesic state was fully developed, and the estrogen reversed both mechanical and thermal hyperalgesia. Vaginal smears were taken to record the phase of the cycle at the time of the test from all animals and no significant differences were detected in mechanical hyperalgesia or in thermal pain threshold between normal animals in different phases of their estrous cycle. These results show that OVX induces a hyperalgesic state of slow onset and long duration that can be reversed by estrogen. We have also observed no estrous cycle modulation of pain sensitivity in normal animals. [Abstract]

Strickland IT, Martindale JC, Woodhams PL, Reeve AJ, Chessell IP, McQueen DS
Changes in the expression of Na(V)1.7, Na(V)1.8 and Na(V)1.9 in a distinct population of dorsal root ganglia innervating the rat knee joint in a model of chronic inflammatory joint pain.
Eur J Pain. 2007 Oct 17;
Voltage-gated sodium channels play an essential role in regulating the excitability of nociceptive primary afferent neurones. In particular the tetrodotoxin-sensitive (TTX-S) Na(V)1.7 and the tetrodotoxin-resistant (TTX-R) Na(V)1.8 and Na(V)1.9 channels have been suggested to play a role in inflammatory pain. Previous work has revealed acute administration of inflammatory mediators, such as Freund's complete adjuvant (FCA) or carrageenan caused an upregulation in the levels of Na(V)1.7 and Na(V)1.8 protein in DRG (dorsal root ganglia) tissue up to 4 days post-insult. In the present study, the expression of Na(V)1.7, Na(V)1.8 and Na(V)1.9 was examined over a 28 day timecourse during a rat model of FCA-induced chronic inflammatory joint pain. Using the retrograde tracer Fast Blue (FB) and specific Na(V)1.7, Na(V)1.8 and Na(V)1.9 sodium channel antibodies, immunohistochemical staining techniques were used to study sodium channel expression in a distinct population of L3-L5 knee joint afferent DRGs. In the ganglia, counts were made of positively labelled cells in the FB population. The results demonstrate that, following FCA injection, Na(V)1.9 expression is upregulated at days 14, 21 and 28 post-FCA, with Na(V)1.7 and Na(V)1.8 showing increased channel expression at days 14 and 28. These observations are accompanied by a unilateral joint hypersensitivity in the FCA-injected knee indicated by a behavioural shift in weight distribution measured using an incapacitance tester. The increased presence of these channels suggests that Na(V)1.7, Na(V)1.8 and Na(V)1.9 play a role, at least in part, in the maintenance of chronic inflammatory pain several weeks after the initial insult. [Abstract]

Coffeen U, López-Avila A, Ortega-Legaspi JM, Del Ángel R, López-Muñoz FJ, Pellicer F
Dopamine receptors in the anterior insular cortex modulate long-term nociception in the rat.
Eur J Pain. 2007 Oct 11;
The rostral agranular insular cortex (RAIC) receives dopaminergic projections from the mesolimbic system, which has been involved in the modulation of nociceptive processes. In this study we determined the contribution of dopamine D(1) and D(2) receptors in the RAIC regarding nociception processing in a neuropathic pain model, as well as inflammatory articular nociception measured as pain-induced functional impairment in the rat (PIFIR). Microinjection of vehicle or substances into the RAIC was performed after the induction of nociception. The groups were treated with: a dopamine D(1) receptor antagonist (SCH-23390), a dopamine D(1) receptor agonist (SKF-38393), a dopamine D(2) receptor agonist (TNPA) and a dopamine D(2) receptor antagonist (spiperone). Chronic nociception, induced by denervation, was measured by the autotomy score in which onset and incidence were also determined. The SCH-23390 and TNPA groups showed a decrease in the autotomy score and a delay on the onset as compared to control, whereas the PIFIR groups did not show statistical differences. This work shows the differential role of dopamine receptors within the RAIC in which the activation of D(2) or the blockade of D(1) receptors elicit antinociception. [Abstract]

Bernardes SF, Keogh E, Lima ML
Bridging the gap between pain and gender research: A selective literature review.
Eur J Pain. 2007 Oct 11;
Evidence suggests that males and females differ with respect to the perception and experience of pain. Much of this work focuses on biological factors, yet it is also acknowledged that psychosocial issues are important. Within humans, socially and culturally constructed meanings of being and acting as a man or a woman should help us understand sex-related differences in pain. However, such an approach has not been widely adopted, partly because of problems conveying sex and gender concepts. We argue here for an assimilation of gender studies concepts into pain research as a means of developing our understanding of the psychosocial influences on pain in men and women. In order to bridge the gap between gender studies and pain, we draw on theoretical developments in such gender concepts, and illustrate their application to pain. We make use of Doise's [Doise W. Levels of explanation in social psychology [Mapstone E, Trans.]. Cambridge (UK): Cambridge University Press. 1986 [original work published 1982]] meta-theoretical model of levels of explanation in social psychology to show how gender may be conceptualized at an intra-individual, situational, positional and ideological level of analysis. We then selectively review existing gender and pain research using these different levels of explanation. In doing so we also highlight that by considering the gender conceptualizations underpinning such studies we are able to point to directions for future research. We conclude by arguing that this approach opens up a new avenue for pain researchers, which we hope will further our understanding of this interesting phenomena. [Abstract]

Roh DH, Kim HW, Yoon SY, Seo HS, Kwon YB, Han HJ, Beitz AJ, Lee JH
Depletion of capsaicin sensitive afferents prevents lamina-dependent increases in spinal N-methyl-d-aspartate receptor subunit 1 expression and phosphorylation associated with thermal hyperalgesia in neuropathic rats.
Eur J Pain. 2007 Oct 12;
Phosphorylation of the N-methyl-d-aspartate (NMDA) receptor NR1 subunit (pNR1) in the spinal cord is associated with increased neuronal responsiveness, which underlies the process of central sensitization. Because of the importance of NR1 in central sensitization, the first goal of this study was to examine both time- and lamina-dependent changes in spinal NR1 and pNR1 expression in a chronic constriction injury (CCI) model of neuropathic pain. Increased excitability of capsaicin sensitive primary afferents (CSPAs), which express TRPV1 receptors, also contributes to central sensitization. Thus, we next examined whether the depletion of CSPAs with resiniferatoxin (RTX) modified the change of spinal NR1 and pNR1 expression induced by CCI. Experimental rats were euthanized at 1, 3, 7, 14, and 28 days post-CCI surgery and spinal cords processed for NR1 or pNR1 immunostaining. The number of NR1 or pNR1-immunoreactive neurons was significantly increased in all lamina (I-VI) of the ipsilateral L4/L5 dorsal horn from 1 or 7 days post-CCI, respectively. Pretreatment with RTX (0.3mg/kg, s.c. in the scruff of the neck or intraplantar) 2 days prior to CCI completely prevented induction of thermal hyperalgesia, but not mechanical allodynia in neuropathic rats. Interestingly, RTX treatment significantly attenuated the CCI-induced upregulation of NR1 and pNR1 in spinal laminae I-II and V-VI, but not laminae III-IV as compared with that of vehicle-treated CCI rats. These findings demonstrate that the increased expression of NR1 and pNR1 in spinal laminae I-II and V-VI is dependent on activation of CSPAs, which ultimately contribute to the development of thermal hyperalgesia in neuropathic rats. [Abstract]

Leffler AS, Hansson P
Painful traumatic peripheral partial nerve injury-sensory dysfunction profiles comparing outcomes of bedside examination and quantitative sensory testing.
Eur J Pain. 2007 Oct 10;
The primary aim of this retrospective study was to focusing on the relationship between individual outcomes of bedside examination (BE) and quantitative testing of somatosensory functions (QST) in 32 patients with painful traumatic partial nerve injury. In addition, the potential presence of common sensory dysfunction denominators has been probed. Patients with a history of traumatic partial nerve injury and ongoing pain were included if pain was confined to the entire or part of the innervation territory of the severed nerve and a bedside titration of the neuronanatomical borders confirmed sensory aberrations. An in-depth BE and QST was then performed in the most painful area. Categorization of normal and pathological outcome for both BE and QST was based on time honoured clinical decision-making using the healthy contralateral corresponding area as control. In patients with normal outcome or quantitative aberrations (i.e. hypo- or hyperesthesia) at BE and QST, the same individual outcome of touch sensation was reported by 48% of the patients, for cold in 54% and for warmth in 58%. The most common dysfunction found at both BE and QST was hypoesthesia, however with no common denominators in somatosensory dysfunction. In conclusion, this study demonstrated that not infrequently the individual outcome of BE and the corresponding QST measure differed, most frequently for touch sensibility. This finding is of outmost importance when QST outcomes are used to corroborate results from BE in the diagnostic situation. [Abstract]

Aggarwal VR, McBeth J, Zakrzewska JM, Lunt M, Macfarlane GJ
Are reports of mechanical dysfunction in chronic oro-facial pain related to somatisation? A population based study.
Eur J Pain. 2007 Oct 3;
OBJECTIVES: METHODS: A population based cross-sectional study of 4200 randomly selected adults registered with a General Medical Practice in North West, England. The study examined the association of chronic oro-facial pain with a variety of self-reported mechanical factors: teeth grinding, facial trauma, missing teeth and the feeling that the teeth did not fit together properly. Information was also collected on demographic factors, psychological factors and the reporting of other frequently unexplained syndromes. RESULTS: An adjusted response rate of 72% was achieved. Only two mechanical factors: teeth grinding (odds ratio (OR) 2.0, 95% CI 1.3-3.0) and facial trauma (OR 2.0; 95% CI 1.3-2.9) were independently associated with chronic oro-facial pain after adjusting for psychological factors. However, these factors were also commonly associated with the reporting of other frequently unexplained syndromes: teeth grinding (odds ratio (OR) 1.8, 95% CI 1.5-2.2), facial trauma (OR 2.1; 95% CI 1.7-2.6). CONCLUSIONS: Self-reported mechanical factors associated with chronic oro-facial pain are confounded, in part, by psychological factors and are equally common across other frequently unexplained syndromes. They may represent another feature of somatisation. Therefore the use of extensive invasive therapy such as occlusal adjustments and surgery to change mechanical factors may not be justified in many cases. [Abstract]

Xu Y, Tian XB, An K, Yang H, Tian YK
Lumbar transplantation of immortalized enkephalin-expressing astrocytes attenuates chronic neuropathic pain.
Eur J Pain. 2007 Sep 26;
Chronic neuropathic pain is a common symptom in clinical practice and patients with chronic pain are subject to a greatly impaired quality of life. Grafted genetically-modified cells secreting enkephalin have been considered an encouraging treatment for chronic pain. Importantly, the transplanted cell as a therapeutic agent should be reproducible, safe, and controllable. In this study, by combining a tetracycline-controlled (Tet-on) gene expression system and immortalized astrocytes, we attempted to engineer an immortalized astrocyte line carrying the human preproenkephalin gene (IASL/hPPE) under the transcriptional control of doxycycline. These cells were then implanted into the subarachnoid space of chronic constrictive injury (CCI) rats and their analgesic potential was investigated by behavioral tests. The results showed that the secretion of enkephalin from IASL/hPPE cells could be switched on and off under the regulation of doxycycline in a dose-dependent manner. In addition, the mechanical and thermal hyperalgesia induced by CCI was significantly alleviated during the 2-7week period after grafts of IASL/hPPE cells and the analgesic effect could be regulated by doxycycline. Moreover, spinal enkephalin level could be modulated by the presence or absence of doxycycline in drinking water. Taken together, these data suggest that regulatable release of enkephalin from transplanted cells near the spinal dorsal horn was able to reverse the development of chronic neuropathic pain. Although improvements in the Tet-on system are necessary, this may provide an alternative approach for ex vivo cell transplantation to treat chronic pain. [Abstract]

Kongsted A, Bendix T, Qerama E, Kasch H, Bach FW, Korsholm L, Jensen TS
Acute stress response and recovery after whiplash injuries. A one-year prospective study.
Eur J Pain. 2007 Sep 25;
Chronic whiplash-associated disorder (WAD) represents a major medical and psycho-social problem. The typical symptomatology presented in WAD is to some extent similar to symptoms of post traumatic stress disorder. In this study we examined if the acute stress reaction following a whiplash injury predicted long-term sequelae. Participants with acute whiplash-associated symptoms after a motor vehicle accident were recruited from emergency units and general practitioners. The predictor variable was the sum score of the impact of event scale (IES) completed within 10 days after the accident. The main outcome-measures were neck pain and headache, neck disability, general health, and working ability one year after the accident. A total of 737 participants were included and completed the IES, and 668 (91%) participated in the 1-year follow-up. A baseline IES-score denoting a moderate to severe stress response was obtained by 13% of the participants. This was associated with increased risk of considerable persistent pain (OR=3.3; 1.8-5.9), neck disability (OR=3.2; 1.7-6.0), reduced working ability (OR=2.8; 1.6-4.9), and lowered self-reported general health one year after the accident. These associations were modified by baseline neck pain intensity. It was not possible to distinguish between participants who recovered and those who did not by means of the IES (AUC=0.6). In conclusion, the association between the acute stress reaction and persistent WAD suggests that post traumatic stress reaction may be important to consider in the early management of whiplash injury. However, the emotional response did not predict chronicity in individuals. [Abstract]

Worsley MA, Clayton NM, Bountra C, Boissonade FM
The effects of ibuprofen and the neurokinin-1 receptor antagonist GR205171A on Fos expression in the ferret trigeminal nucleus following tooth pulp stimulation.
Eur J Pain. 2007 Sep 24;
We have developed a model to study central changes following inflammation of the tooth pulp in the ferret and have examined Fos expression in the trigeminal nucleus following stimulation of non-inflamed and inflamed tooth pulps. The aim of this study was to establish the ability of this model to predict analgesic efficacy in clinical studies of inflammatory pain. We addressed this by assessing the effects of the neurokinin-1 receptor antagonist GR205171A and ibuprofen on Fos expression following stimulation of the inflamed pulp and comparing this with known analgesic efficacy. Adult ferrets were prepared under anaesthesia to allow tooth pulp stimulation, recording from the digastric muscle and intravenous injections at a subsequent experiment. In some animals pulpal inflammation was induced, by introducing human caries into a deep buccal cavity. After 5 days, animals were reanaesthetised, treated with vehicle, GR205171A or ibuprofen and the teeth were stimulated at ten times the threshold of the jaw-opening reflex. Stimulation of all tooth pulps induced ipsilateral Fos in trigeminal subnuclei caudalis and oralis. GR205171A had no significant effect on Fos expression in the trigeminal nucleus of animals with either non-inflamed or inflamed tooth pulps. Ibuprofen reduced Fos expression in the trigeminal nucleus and this effect was most marked in animals with pulpal inflammation. These results differ from those previously described using a range of other animal models, but agree with known clinical efficacy of neurokinin-1 receptor antagonists and ibuprofen. Therefore this model is likely to be of use in accurately predicting the analgesic efficacy of novel compounds. [Abstract]

Viikari-Juntura E, Shiri R, Solovieva S, Karppinen J, Leino-Arjas P, Varonen H, Kalso E, Ukkola O
Risk factors of atherosclerosis and shoulder pain - Is there an association? A systematic review.
Eur J Pain. 2007 Sep 22;
BACKGROUND: Shoulder pain is prevalent and a common cause of disability at work and daily activities. Some studies suggest an association between risk factors of atherosclerosis and shoulder pain and disorders. AIM: To assess associations between risk factors of atherosclerosis and shoulder pain or disorders and to discuss possible pathophysiological pathways for found associations. METHODS: A systematic review was conducted searching Medline until June 2006. Two authors extracted data and assessed quality independently using the Cochrane criteria for the assessment of quality in non-experimental studies with slight modifications. Due to heterogeneity of studies, meta-analysis was not possible. Results were summarized and discussed paying attention to study design and quality. RESULTS: Fifteen papers from 14 studies were included in the review. Diabetes was consistently associated with clinically defined shoulder disorders in population studies. Overweight or obesity was associated with the incidence of shoulder symptoms in three studies and with clinically defined shoulder disorders in one case control study. A few studies showed a preventive effect of physical exercise. Associations between smoking and shoulder disorders were seen only in studies on occupational populations. CONCLUSIONS: A consistent association between diabetes and shoulder disorders, some associations for weight-related factors as well as a possible preventive effect from physical exercise and sports suggest a metabolic pathophysiological process in shoulder disorders. More prospective studies using appropriate analytical methods are needed. [Abstract]

Olsson GL, Meyerson BA, Linderoth B
Spinal cord stimulation in adolescents with complex regional pain syndrome type I (CRPS-I).
Eur J Pain. 2008 Jan;12(1):
Complex regional pain syndrome type I (CRPS-I) is not uncommon in children, particularly in adolescent girls. Most often, the condition involves a foot and is characterized by spontaneous pain, tactile allodynia and dysautonomic signs. There is usually a history of a minor, local trauma but sometimes no reasonable cause can be identified, and there are no signs of persistent tissue injury giving rise to ongoing nociception. Common analgesics are generally of no benefit, and the standard treatment includes sociopsychological support, physiotherapy, tricyclic antidepressants and antiepileptic drugs, sympathetic blocks (SB), and cognitive-behavioural therapy. For a minority of patients who prove to be resistant to such therapies, spinal cord stimulation (SCS) may be tried. The present study comprises seven girls, 11-14 years of age, presenting with severe, incapacitating and therapy-resistant CRPS-I, who were subjected to SCS. In two of them, percutaneous electrode implantation had to be performed in general anaesthesia. Trial stimulation was performed in all, but one. In two cases, it was not possible to produce paraesthesias that entirely covered the pain area. A pain relieving effect of SCS was usually not reported until after 1-2 weeks of trial stimulation. After another 2-6 weeks, pain alleviation was complete in five of the seven patients, one to eight years after the intervention. In one case, a local infection necessitated the removal of the electrode; nevertheless a few days of trial stimulation produced substantial pain relief that still persists. In four patients, the SCS use was gradually diminished and eventually the device could be removed. The favourable outcome in all seven cases with no or minor remaining symptoms and without severe recurrences illustrates that SCS may also be an efficient treatment in paediatric cases with exceptionally therapy resistant forms of CRPS I. [Abstract]

Schattschneider J, Scarano M, Binder A, Wasner G, Baron R
Modulation of sensitized C-fibers by adrenergic stimulation in human neuropathic pain.
Eur J Pain. 2007 Sep 19;
The chronic constriction injury model is widely used in studying mechanisms of neuropathic pain. In this model neuropathic pain can be influenced by sympathetic interventions. It is assumed that similar mechanisms as in animals are responsible for pain arising from nerve entrapment syndromes in humans. The aim of the present study was to investigate if in patients with nerve entrapment nociceptive afferents can be modulated by adrenergic stimulation. METHODS: Twenty patients with pain due to a unilateral entrapment of the median nerve and 10 controls were included in the study. Spontaneous pain, mechanical and thermal evoked pain were assessed within the innervation territory of the lesioned nerve and the corresponding contralateral segment in patients and on the right hand side in healthy volunteers. The examinations were performed at baseline, during whole body cooling (sympathetic activation) and whole body warming (sympathetic inhibition), and after norepinephrine iontophoresis. RESULTS: All patients reported spontaneous pain. Mechanical allodynia, punctate hyperalgesia and cold allodynia was not found. According to side-to-side differences in heat pain thresholds, patients were separated in patients with (n=10) and without (n=10) heat hyperalgesia. Adrenergic stimulation did not induce or enhance spontaneous or mechanical evoked pain in any patient or control subject. However in patients with pre-existing heat hyperalgesia sympathetic stimulation aggravated heat hyperalgesia significantly. Further in these patients the decrease in heat pain thresholds observed after norepinephrine iontophoresis was significantly higher compared to patients without pre-existing heat hyperalgesia. CONCLUSION: Sympathetic-afferent interaction does not play a major role in pain generation due to nerve entrapment. Nevertheless in a subgroup of patients nociceptive afferents show sensitivity to physiological and pharmacological sympathetic stimulation. This finding is important because it emphasises that despite there is no clinical detectable effect on pain sympathetic afferent interaction can be found. [Abstract]

Wicksell RK, Renöfält J, Olsson GL, Bond FW, Melin L
Avoidance and cognitive fusion - Central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS).
Eur J Pain. 2007 Sep 20;
Acceptance of pain and other associated negative private experiences has received increasing attention in recent years. This approach is in stark contrast to the traditional approach of reducing or controlling symptoms of pain. The empirical support for treatments emphasizing exposure and acceptance, such as Acceptance and Commitment Therapy, is growing. However, to date, few instruments exist to assess the core processes in these types of treatments. This study describes the development and preliminary validation of the Psychological Inflexibility in Pain Scale. Principal components analysis (PCA) suggests a 2-factor solution with a total of 16 items measuring avoidance of pain and cognitive fusion with pain. Results also indicate adequate reliability and validity for the scale. Implications of these findings for clinical assessment, as well as for research on pain related disability, are discussed along with suggestions for further research in this area. [Abstract]

Risti? D, Spangenberg P, Ellrich J
Analgesic and antinociceptive effects of peripheral nerve neurostimulation in an advanced human experimental model.
Eur J Pain. 2007 Sep 17;
Electrical peripheral nerve neurostimulation (PNS) is reported to be an effective pain treatment. An objective proof of antinociceptive effect is lacking. The human experimental study addressed PNS effects on nociception and pain by electrophysiology and psychophysics. In 23 healthy volunteers, 39 sessions were conducted. Three experiments (PNS ipsilateral, PNS contralateral, Control) consisted of 13 sessions each. Conditioning PNS (100Hz) of left (PNS ipsilateral) or right (PNS contralateral) superficial radial nerve trunk evoked non-painful, tingling sensations on the hand dorsum. Local cutaneous anesthesia at PNS site provided for preferential nerve trunk stimulation. Cortical laser-evoked potentials (LEP) after painful stimulation at left hand dorsum were recorded together with mechanical and thermal perception thresholds at the same site before (T1), during (T2), and after (T3) PNS or a no stimulation period (Control). Mechanical and thermal perception decreased in the anesthetized area. Late LEP amplitude decreased independently of PNS site. Exclusively under ipsilateral PNS, N2 latency increased and laser ratings decreased. Mechanical detection threshold transiently increased during ipsilateral PNS at hand dorsum. PNS induced strong reduction of mechanical perception due to peripheral collision of orthodromic (test stimulus) and antidromic (PNS) selective Abeta fiber excitation. Delay of N2 component and reduction of laser pain were specific to ipsilateral PNS. Divergent and common effects of ipsilateral and contralateral PNS suggest a combination of peripheral and central antinociceptive mechanisms. The study in man documents inhibition of nociception and pain by PNS and provides with an experimental model for future objectives in neuromodulation. [Abstract]

Ju H, Feng Y, Yang BX, Wang J
Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post-thoracotomy pain control.
Eur J Pain. 2007 Sep 14;
Epidural analgesia is regarded as the gold method for controlling post-thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post-thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated randomly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia. Acute pain scores and opioid-related side effects were evaluated for three postoperative days. Chronic pain information, including the incidence, severity, and allodynia-like pain, was acquired on the first, third, sixth and twelfth months postoperatively. There was no significant difference on numeral rating scales (NRS) at rest or on motion between the two groups during the three postoperative days. The patient satisfaction results were also similar between the groups. The side effects, especially mild pruritus, were reported more often in the epidural group. Both groups showed high incidence of chronic pain (42.1-72.1%), and no significance between the groups. The incidence of allodynia-like pain reported in cryo group was higher than that in Epidural group on any postoperative month, with significance on the sixth and the twelfth months postoperatively (P<0.05). More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life (P<0.05). Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post-thoracotomy acute pain. The incidence of post-thoracotomy chronic pain is high. Cryoanalgesia may be a factor that increases the incidence of neuropathic pain. [Abstract]

Verbunt JA, Sieben J, Vlaeyen JW, Portegijs P, André Knottnerus J
A new episode of low back pain: Who relies on bed rest?
Eur J Pain. 2007 Sep 14;
Bed rest has been shown to be an ineffective treatment for non-specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non-specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR=1.05 per bed rest category p<0.01)) and fear of injury (OR=1.05 per category p<0.01) rather than specific pain related factors (pain history (OR=0.61 per category p=0.16) and pain intensity (OR=1.00 per category p=0.63)) were associated with bed rest. Patients with prolonged bed rest in an early phase of pain were still more disabled after one year (p<0.01). Based on these results we conclude that prolonged bed rest in the early phase of pain is associated with a higher long term disability level. In preventing low back disability, GP screening for catastrophizing and fear of injury in LBP patients who had prolonged bed rest merits consideration. [Abstract]

Castral TC, Warnock F, Leite AM, Haas VJ, Scochi CG
The effects of skin-to-skin contact during acute pain in preterm newborns.
Eur J Pain. 2007 Sep 13;
BACKGROUND AND PURPOSE: Several promising non-pharmacological interventions have been developed to reduce acute pain in preterm infants including skin-to-skin contact between a mother and her infant. However, variability in physiological outcomes of existing studies on skin-to-skin makes it difficult to determine treatment effects of this naturalistic approach for the preterm infant. The aim of this study was to test the efficacy of mother and infant skin-to-skin contact during heel prick in premature infants. METHOD: Fifty nine stable preterm infants (born at least 30 weeks gestational age) who were undergoing routine heel lance were randomly assigned to either 15min of skin-to-skin contact before, during and following heel prick (n=31, treatment group), or to regular care (n=28, control group). Throughout the heel lance procedure, all infants were assessed for change in facial action (NFCS), behavioral state, crying, and heart rate. RESULTS: Statistically significant differences were noted between the treatment and control groups during the puncture, heel squeeze and the post phases of heel prick. Infants who received skin-to-skin contact were more likely to show lower NFCS scores throughout the procedure. Both groups of infants cried and showed increased heart rate during puncture and heel squeeze although changes in these measures were less for the treated infants. CONCLUSIONS: Skin-to-skin contact promoted reduction in behavioral measures and less physiological increase during procedure. It is recommended that skin-to-skin contact be used as a non-pharmacologic intervention to relieve acute pain in stable premature infants born 30 weeks gestational age or older. [Abstract]

Recent Articles in European Journal of Anaesthesiology

Sommer M, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Geurts JW, Gramke HF, Marcus MA
The prevalence of postoperative pain in a sample of 1490 surgical inpatients.
Eur J Anaesthesiol. 2007 Dec 6;1-8.
SummaryBackground and objectiveTo measure the prevalence of postoperative pain, an assessment was made of 1490 surgical inpatients who were receiving postoperative pain treatment according to an acute pain protocol. METHODS: Measurements of pain (scores from 0 to 100 on a visual analogue scale) were obtained three times a day on the day before surgery and on days 0-4 postoperatively; mean pain intensity scores were calculated. Patients were classified as having no pain (score 0-5), mild pain (score 6-40), moderate pain (score 41-74) or severe pain (score 75-100). RESULTS: Moderate or severe pain was reported by 41% of the patients on day 0, 30% on days 1 and 19%, 16% and 14% on days 2, 3 and 4. The prevalence of moderate or severe pain in the abdominal surgery group was high on postoperative days 0-1 (30-55%). A high prevalence of moderate or severe pain was found during the whole of days 1-4 in the extremity surgery group (20-71%) and in the back/spinal surgery group (30-64%).ConclusionWe conclude that despite an acute pain protocol, postoperative pain treatment was unsatisfactory, especially after intermediate and major surgical procedures on an extremity or on the spine. [Abstract]

Richa F, Yazigi A
Effect of dexmedetomidine on blood pressure and bleeding in maxillo-facial surgery.
Eur J Anaesthesiol. 2007 Nov;24(11):985-6. [Abstract]

Lema G, Merino W, Salinas C
Changes in renal function in valvular and coronary patients.
Eur J Anaesthesiol. 2007 Nov;24(11):984-5. [Abstract]

Jeon YS, Kim YS, Joo JD, Kang EG, In JH, Choi JW, Cho SM
Partial airway obstruction caused by dissection of a reinforced endotracheal tube.
Eur J Anaesthesiol. 2007 Nov;24(11):983-4. [Abstract]

Palomero MA, Vargas MC, Peláez EM, Rodríguez-Cerón A, Sánchez-Conde P, Muriel C
Spinal anaesthesia for emergency Caesarean section in an achondroplastic patient.
Eur J Anaesthesiol. 2007 Nov;24(11):981-2. [Abstract]

Bansal S, Jones MJ
ProSeal LMA: a potentially dangerous modification.
Eur J Anaesthesiol. 2007 Nov;24(11):980-1. [Abstract]

Souvatzis X, Askitopoulou H
Malfunction of an adjustable pressure limit valve.
Eur J Anaesthesiol. 2007 Nov;24(11):978-80. [Abstract]

Ridley S, Lwin A, Wyncoll D, Lippett S, Watson D, Gunning K, Higgins D
Drotrecogin alfa (activated): diffusion from clinical trials to clinical practice.
Eur J Anaesthesiol. 2007 Nov 22;1-6.
SummaryBackgound and objectiveAlthough the PROWESS trial demonstrated a mortality benefit, subsequent studies in different patient populations have not reproduced the effect. As a result, concerns have been expressed about the clinical effectiveness of drotrecogin alfa (activated). Therefore the aim of this audit was to review the clinical impact of drotrecogin alfa (activated) when used outside clinical trials. METHODS: A retrospective review of ICU charts and medical records of patients who had received drotrecogin alfa (activated) in the five largest users of drotrecogin alfa (activated) in England. Patients characteristics details at ICU admission and vital status at hospital discharge were recorded. The severity of illness was assessed by the APACHE II score (using first 24 h admission data) and the number of organ dysfunctions. Adverse incidents were recorded and any sequence effect explored. RESULTS: In all, 351 patients received drotrecogin alfa (activated) between December 2002 and November 2005. Of those, 201 (57.2%) were male, and 177 (50.4%) were admitted after recent surgery. The patients' average age was 61.8 yr. The mean admission APACHE II score was 23.3 and the average number of dysfunctional organs on admission was 3.3. The hospital mortality was 46.7% (164 deaths). The expected number of deaths calculated by using the APACHE II risk of death was 173 (49.3%) and by number of sepsis induced organ failures 210 (59.7%). Overall, there were 33 (9.4%) adverse incidents. CONCLUSIONS: Expected mortality derived from both the APACHE II score and organ dysfunctions suggests that drotrecogin alfa (activated) does reduce mortality. Serious adverse incidents occurred in 5.1% patients; however, the direct contributing effect of drotrecogin alfa (activated) cannot be established from this type of audit. [Abstract]

Martin-Castro C, Montero A
Flexible laryngeal mask as an alternative to reinforced tracheal tube for upper chest, head and neck oncoplastic surgery.
Eur J Anaesthesiol. 2007 Nov 21;1-6.
SummaryBackground and objectiveThe flexible laryngeal mask airway has been mostly used in spontaneous ventilated children during short procedures to avoid the risk of kinking; little information has been reported about its airway morbidity. The aim of the study was to compare this airway device with the reinforced tracheal tube in mechanically ventilated adult patients. METHODS: 120 adult patients undergoing general anaesthesia for breast, head and neck oncoplastic surgery, expected to last up to 3 h, were stratified into two airway groups: flexible laryngeal mask airway (n = 60) or reinforced tracheal tube (n = 60). Within each group, patients were randomly allocated to one of the two maintenance anaesthetic subgroups: propofol (n = 30) or sevoflurane (n = 30). Ease of insertion and haemodynamic stress response to placement, ventilation and postoperative morbidity were studied. RESULTS: Easy insertion rate was greater for the flexible laryngeal mask airway (93% vs. 77%, P = 0.01), and the overall success in insertion rate was 100% for both groups. Haemodynamic changes were significantly higher after inserting reinforced tracheal tube (P < 0.001). Oxygen saturation and capnography were comparable in both groups but airway pressure was lower with flexible laryngeal mask airway (P = 0.002). Sore throat, cough and dysphonia were lest frequent with flexible laryngeal mask airway (P < 0.01); also more patients in this group felt comfortable. Sevoflurane gave better results in emergence time, regardless of the airway device used.ConclusionDuring anaesthesia in mechanically ventilated adult patients, both devices function adequately, are stable and protect the airway. Flexible laryngeal mask airway results in less postoperative morbidity than reinforced tracheal tube. [Abstract]

Becchi C, Al Malyan M, Coppini R, Campolo M, Magherini M, Boncinelli S
Opioid-free analgesia by continuous psoas compartment block after total hip arthroplasty. A randomized study.
Eur J Anaesthesiol. 2007 Nov 21;1-6.
SummaryBackground and objectiveAdequate analgesia is needed after total hip arthroplasty to control pain at rest and during rehabilitation. Our aim was to compare, in a randomized study, the efficacy of two analgesia regimens in control of postoperative pain after total hip arthroplasty: opioid-free continuous psoas compartment block vs. an opioid/non-steroidal anti-inflammatory drugs continuous intravenous infusion. METHODS: In all, 73 patients (ASA I-III), aged 61-82 yr, undergoing total hip arthroplasty were prospectively enrolled in a single-blind randomized trial. Patients were allocated either to the study group (Group A, n = 37) or to the control group (Group B, n = 36). Patients in Group A underwent preoperative placement of a catheter in the psoas compartment and, 30 min before the end of surgery, the catheter was primed with a loading dose of 0.75% ropivacaine (0.4 mL kg-1) followed by a continuous infusion of 10 mL h-1 ropivacaine 0.2% for 48 h. Patients in Group B received, from 1 h before the end of surgery, a continuous intravenous infusion of 0.1% morphine and 0.12% ketorolac at 2 mL h-1 for 48 h. Both groups received spinal anaesthesia for surgery. Pain scores at rest and after mobilization, amount of rescue analgesia, nausea/vomiting and haemodynamic parameters were recorded. RESULTS: In Group A, median pain scores were very low during the whole study duration both at rest and during physiotherapy in comparison to Group B. Less rescue analgesia was needed and less nausea and vomiting was observed in Group A. CONCLUSIONS: Opioid-free continuous psoas compartment block seems to be an appropriate and reliable technique in providing effective postoperative analgesia at rest and during physiotherapy after total hip arthroplasty when compared to intravenous morphine/ketorolac infusion. [Abstract]

Renner J, Cavus E, Gruenewald M, Steinfath M, Scholz J, Lutter G, Steffen M, Bein B
Myocardial performance index during rapidly changing loading conditions: impact of different tidal ventilation.
Eur J Anaesthesiol. 2007 Nov 21;1-7.
SummaryBackground and objectivesThe myocardial performance index is a non-geometric, heart rate-independent echocardiography-derived index of left ventricular performance combining systolic and diastolic function. There is an ongoing debate whether the myocardial performance index is affected by preload or not. Moreover, a systematic evaluation of the effect of changing tidal volume ventilation on the myocardial performance index is still lacking. The aim of our study was to assess whether acute changes in preload and/or different depth of tidal volume ventilation affect the myocardial performance index. METHODS: In all, 14 anesthetized pigs (35 +/- 2 kg) were studied during changing tidal volumes (VT 5, 10 and 15 mL kg-1) at baseline, after removal of 500 cm3 of blood (haemorrhage) and after retransfusion of shed blood plus additional 500 cm3 6% hydroxyethyl starch (fluid loading). Echocardiographic measurements at each experimental stage included myocardial performance index, left ventricular end-diastolic area and fractional area change. Central venous pressure, pulmonary capillary wedge pressure, cardiac output and stroke volume index were obtained by a pulmonary artery catheter. Global end-diastolic volume was obtained by transpulmonary thermodilution. RESULTS: Comparing different loading conditions, we found significant changes in cardiac output, stroke volume index, central venous pressure, pulmonary capillary wedge pressure, global end diastolic volume and left ventricular end-diastolic area, indicating clinically relevant changes in preload. In the haemorrhage group, there was a significant reduction in the myocardial performance index (P < 0.05) independent of tidal volume applied and this was reversed after fluid loading. However, myocardial performance index was significantly impaired (P < 0.05) by high tidal volume ventilation (15 mL kg-1), while tidal volumes of 5 and 10 mL kg-1 had no effect. CONCLUSIONS: The myocardial performance index is largely dependent on changes in preload. Moreover, high tidal volume ventilation significantly impaired the myocardial performance index. [Abstract]

Winterhalter M, Brandl K, Rahe-Meyer N, Osthaus A, Hecker H, Hagl C, Adams HA, Piepenbrock S
Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl.
Eur J Anaesthesiol. 2007 Nov 16;1-10.
SummaryBackground and objectiveOur aim was to compare a continuous infusion of remifentanil with intermittent boluses of fentanyl as regards the perioperative hormonal stress response and inflammatory activation in coronary artery bypass graft patients under sevoflurane-based anaesthesia. METHODS: In all, 42 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were prospectively randomized to a fentanyl group (n = 21, total fentanyl dose 2.6 +/- 0.3 mg), or a remifentanil group (n = 21, infusion rate 0.25 mug kg-1 min-1). Haemodynamics, plasma levels of epinephrine, norepinephrine, antidiuretic hormone, adrenocorticotropic hormone, cortisol, complement activation (C3a, C5b-9), interleukin (IL)-6, IL-8 and tumour necrosis factor-alpha were measured at T1: baseline, T2: intubation, T3: sternotomy, T4: 30 min on cardiopulmonary bypass, T5: end of surgery and T6: 8 h postoperatively. Troponin T and creatine kinase-MB were measured postoperatively. RESULTS: Patients in the remifentanil group were extubated significantly earlier than fentanyl patients (240 +/- 182 min vs. 418 +/- 212 min, P = 0.006). Stress hormones 30 min after start of cardiopulmonary bypass showed higher values in the fentanyl group compared to the remifentanil group (antidiuretic hormone (ADH): 39.94 +/- 30.98 vs. 11.7 +/- 22.8 pg mL-1, P = 0.002; adrenocorticotropic hormone: 111.5 +/- 116.8 vs. 21.81 +/- 24.71 pg mL-1, P = 0.01; cortisol 185 +/- 86 vs. 131 +/- 82 ng mL-1, P = 0.04). The interleukins were significantly higher at some perioperative time points in the fentanyl group compared to the remifentanil group (tumour necrosis factor: T5: 3.57 vs. 2.37; IL-6: T5: 4.62 vs. 3.73; and IL-8: T5: 4.43 vs. 2.65 and T6: 2.61 vs. 1.13). However, cardiopulmonary bypass times and aortic cross-clamp times were longer in the fentanyl group, which may to some extent account for the differences. CONCLUSIONS: The perioperative endocrine stress response was attenuated in patients supplemented with continuous remifentanil infusion as compared to intermittent fentanyl. [Abstract]

Ghori K, Harmon D, Lan W, Seigne P, Walsh F, Shorten GD
The effect of midazolam on cerebral endothelial (P-selectin and ICAM-1) adhesion molecule expression during hypoxia-reperfusion injury in vitro.
Eur J Anaesthesiol. 2007 Nov 16;1-5.
SummaryBackground and objectiveHypoxia-reperfusion injury is an important determinant of secondary brain injury. In the acute phase of cerebral reperfusion, pro-inflammatory events enhance expression of cerebral endothelial (intercellular adhesion molecule-1 and P-selectin) adhesion molecules, which play an important role in brain hypoxia-reperfusion injury. Midazolam is the most commonly used sedative in patients with brain injury. The objective of this investigation was to examine the effect of midazolam on the expression of cerebral endothelial intercellular adhesion molecule-1 and P-selectin during hypoxia-reperfusion injury in vitro. METHODS: The up-regulation of mouse cerebral endothelial cells intercellular adhesion molecule-1 and P-selectin was assessed following hypoxia-reoxygenation (hypoxia-reperfusion). Cells were pre-treated with three different concentrations of midazolam (0, 5 and 50 mug mL-1) prior to hypoxia. Flow cytometry was used to estimate adhesion molecule expression mean channel fluorescence. Data are presented as mean +/- SD. RESULTS: Mouse cerebral endothelial cell intercellular adhesion molecule-1 and P-selectin expression was greater after exposure to hypoxia-reoxygenation compared to normoxia (mean channel fluorescence) 241 +/- 12 vs. 140 +/- 7 and 120 +/- 14 vs. 46 +/- 7, respectively, P < 0.05. Intercellular adhesion molecule-1 and P-selectin expression was decreased by midazolam (5 mug mL-1) pre-incubation compared to control, mean channel fluorescence 184 +/- 10 vs. 241 +/- 12 and 51 +/- 7 vs. 120 +/- 14, respectively, P < 0.05. Midazolam at 50 mug mL-1 had the same effect as 5 mug mL-1.ConclusionPre-treatment with midazolam diminishes increased expression of cerebral endothelial intercellular adhesion molecule-1 and P-selectin expression following hypoxia-reoxygenation. [Abstract]

Yilmaz M, Gajic O
Optimal ventilator settings in acute lung injury and acute respiratory distress syndrome.
Eur J Anaesthesiol. 2007 Nov 16;1-8.
SummaryDespite recent advances in intensive care medicine, acute lung injury and its more severe form, acute respiratory distress syndrome pose major therapeutic problems. While mechanical ventilation is integral to the care of these patients, its adverse consequences including ventilator-induced lung injury are determinants of disease progression and prognosis. Among several important ventilator parameters, the use of low tidal volumes is probably the most important feature of lung-protective mechanical ventilation. Intensivists should be trained to recognize acute lung injury and acute respiratory distress syndrome and encouraged to use low-tidal-volume ventilation in clinical practice. Alternative modes of ventilation such as high-frequency ventilation and prone position should be reserved for selected patients in whom conventional lung-protective ventilation strategies have failed. [Abstract]

Missant C, Rex S, Wouters PF
Accuracy of cardiac output measurements with pulse contour analysis (PulseCOtrade mark) and Doppler echocardiography during off-pump coronary artery bypass grafting.
Eur J Anaesthesiol. 2007 Nov 9;1-6.
SummaryBackground and objectiveDuring off-pump coronary bypass grafting, surgical manipulation and dislocation of the heart may cause cardiovascular instability. Monitoring of cardiac output facilitates intraoperative haemodynamic management but pulmonary artery catheters are often considered too invasive. Pulse contour analysis and transoesophageal echocardiography could serve as alternatives, but there is controversy about their accuracies. We validated pulse contour analysis using a standard radial arterial catheter (PulseCOtrade mark) and aortic Doppler flowmetry with transoesophageal echocardiography in patients undergoing off-pump coronary bypass surgery. Pulmonary arterial thermodilution served as the reference technique. METHODS: In 20 patients undergoing off-pump coronary bypass, cardiac output was measured with bolus thermodilution (COTD), pulse contour analysis (COPC), and transoesophageal echocardiography (COecho) at fixed time intervals during the procedure. Data were compared using linear regression and Bland-Altman analysis. At the end of the procedure, dobutamine was infused at a rate of 2.5 mug kg-1 min-1 in six patients to study the agreement between methods in quantifying changes in cardiac output. RESULTS: Comparison between COPC and COTD showed a bias +/- limits of agreement of -0.03 +/- 1.30 L min-1 (mean error 29%). Doppler echocardiography was not always feasible when the heart was displaced from the oesophagus and had lower accuracy: bias +/- limits of agreement vs. COTD was 0.45 +/- 1.93 (mean error 43%). Increases in cardiac output induced by dobutamine were well quantified both by pulse contour analysis (COPC = 0.76 x COTD + 0.58; r2 = 0.65) and Doppler, although the latter tended to overestimate these changes (COecho = 1.58 x COTD - 0.13; r2 = 0.53). CONCLUSIONS: Calibrated pulse contour analysis using the PulseCO system is an acceptable technique to measure cardiac output non-invasively in off-pump coronary bypass patients. Doppler echocardiography performs less well and is not always feasible with transoesophageal echocardiography when the heart is displaced. [Abstract]

Mahajan RP, Batra YK, Rajeev S
Intravenous phenytoin and percutaneous arterial cannulation: the purple-glove syndrome.
Eur J Anaesthesiol. 2007 Oct;24(10):900-1. [Abstract]

Staikou C, Tsaroucha A, Fassoulaki A
Anaesthetic management and perioperative monitoring of a patient with narcolepsy.
Eur J Anaesthesiol. 2007 Oct;24(10):898-900. [Abstract]

Thorning G, Raghavan K
Fatal phenytoin-induced thrombocytopaenia in a neurosurgical patient.
Eur J Anaesthesiol. 2007 Oct;24(10):897-8. [Abstract]

Chethan DB, Rassam S
Cannot ventilate, difficult to intubate.
Eur J Anaesthesiol. 2007 Oct;24(10):895-6; author reply 896. [Abstract]

Sorbello M, Guarino A, Merli G, Petrini F, Frova G
Difficult to intubate, mandatory to oxygenate.
Eur J Anaesthesiol. 2007 Oct;24(10):894-5; author reply 896. [Abstract]

Davidson IJ
Deleterious renal effects of hydroxyethyl starch 130/0.4 and 200/0.5 solutions.
Eur J Anaesthesiol. 2007 Oct;24(10):892-3. [Abstract]

Boldt J
Renal impact of fluid management with colloids.
Eur J Anaesthesiol. 2007 Oct;24(10):891-2. [Abstract]

Dieperink W, Knol JA, Boersma HJ, Eindhoven GB, Aarts LP, Goorhuis JF, Nijsten MW
Combination of heliox and CPAP without a ventilator: bench test and clinical observations.
Eur J Anaesthesiol. 2007 Oct;24(10):889-91. [Abstract]

Sener M, Yilmazer C, Yilmaz I, Caliskan E, Donmez A, Arslan G
Patient-controlled analgesia with lornoxicam vs. dipyrone for acute postoperative pain relief after septorhinoplasty: a prospective, randomized, double-blind, placebo-controlled study.
Eur J Anaesthesiol. 2007 Oct 22;1-6.
SummaryBackground and objectiveWe compared the efficacy of intravenous lornoxicam vs. dipyrone in patient-controlled analgesia for postoperative analgesia. METHODS: The study included 105 patients who had undergone elective septorhinoplasty after receiving general anaesthesia. Patients were divided into three groups to receive lornoxicam (24 mg day-1), dipyrone (5 g day-1) or placebo. Pain was evaluated using a 0-100 mm visual analogue scale at 2, 4, 6, 8, 12, 16, 20 and 24 h postoperatively. Pethidine (1 mg kg-1) was administered intramuscularly to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24 h postoperatively, and treatment-related adverse effects were noted. RESULTS: Postoperative pain scores were significantly lower with lornoxicam compared with dipyrone at 8 h (P = 0.016). No significant differences regarding pain scores at 2, 4, 6, 12, 16, 20 and 24 h were found. Significantly fewer patients in the lornoxicam group required rescue analgesics (vs. dipyrone, P = 0.046; vs. placebo, P = 0.001); fewer patients in the dipyrone group required rescue analgesics compared with placebo (P = 0.008). Significantly fewer patients in the lornoxicam group had nausea (vs. dipyrone, P = 0.022; vs. placebo, P = 0.006); no significant differences were found between the other two groups. Antiemetic use was significantly lower in the lornoxicam group (vs. dipyrone, P = 0.002; vs. placebo, P = 0.001). CONCLUSIONS: Lornoxicam has better tolerability and is a more effective analgesic than dipyrone when administered by patient-controlled analgesia for postoperative analgesia after septorhinoplasty. [Abstract]

Horduna M, Legaye J
Influence of the sagittal anatomy of the pelvis on the intercrestal line position.
Eur J Anaesthesiol. 2007 Oct 22;1-6.
SummaryBackground and objectiveThe line joining the two iliac crests is classically regarded as the anatomical landmark determining the inter-vertebral space L4-L5 for the spinal punctures. Its variability has been reported but never related to predictive clinical anatomic factors identifying patients groups in which there is increased risk of miscalculation of the spinal level. METHODS: Two sagittal pelvic anatomical angles, called 'pelvic incidence' and 'pelvic lordosis' were measured on lateral X-rays of the pelvis of 132 normal individuals and 49 spondylolysis patients. The values were compared with the sagittal projection of the intercrestal line on the disco-vertebral lumbar structures. RESULTS: A strict relation was observed between this projection of the intercrestal line and the sagittal pelvic anatomical angles. The greater the pelvic incidence, the higher the intercrestal line was projected, all the more in patients with spondylolysis with a listhesis or a disc narrowing. CONCLUSIONS: The relation between the pelvic sagittal angles and the intercrestal line projection explains the variability described for this anatomical landmark. It implies precautions minimizing neurological risk in the case of a puncture carried out more cranially than expected, particularly for high values of pelvic incidence occurring in spinal pathologies such as spondylolysis, in the elderly or in the obese patients. In these cases, we recommend the use of spinal imaging during the procedure to assist selection of the desired insertion level. [Abstract]

Renner J, Scholz J, Bein B, Cremer J
Echocardiographic detection of pooled air in the right upper pulmonary vein after minimal invasive atrial septal defect closure: an alternative approach of de-airing.
Eur J Anaesthesiol. 2007 Sep;24(9):814-6. [Abstract]

Eisenhut M
Conditions involving release of pro-inflammatory cytokines predispose to ARDS.
Eur J Anaesthesiol. 2007 Sep;24(9):813-4. [Abstract]

Al-Shaikh B, Dixit V, van Zundert A
Comparison of LMA Unique, Ambu laryngeal mask and Soft Seal laryngeal mask during routine surgical procedures.
Eur J Anaesthesiol. 2007 Sep;24(9):812-3. [Abstract]

Tzabaziz AZ, Koppert W
Opioid-induced hyperalgesia or opioid-withdrawal hyperalgesia?
Eur J Anaesthesiol. 2007 Sep;24(9):811-2. [Abstract]

Yamakage M, Hayase T, Satoh JI, Namiki A
Work stress in medical anaesthesiology trainees.
Eur J Anaesthesiol. 2007 Sep;24(9):809-11. [Abstract]

Recent Articles in Regional Anesthesia and Pain Medicine

Abstracts of the XXVI Annual ESRA (European Society of Regional Anaesthesia) Congress, 12-15 September 2007, Valencia, Spain.
Reg Anesth Pain Med. 2007 Sep-Oct;32(5 Suppl 1):1-187. [Abstract]

Chi J, Greensmith JE
Saphenous nerve block technique with neurostimulation.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):548-9. [Abstract]

Planté T, Chaubard M, Delbos A
Unintentional transient sciatic nerve block after knee infiltration with local anesthetics.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):547-8. [Abstract]

Saranteas T, Chantzi C, Iatrou C, Kostopanagiotou G, Dimitriou V
Ultrasound and regional anesthesia techniques-is there any limitation?
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):546-7. [Abstract]

Rathmell JP
Reply to drs. Joshi, kehlet, and rawal.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):545. [Abstract]

Williams BA
Seeds, trees, and shade-personal experience in research career development.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):545-6. [Abstract]

Perlas A, Niazi A, Chan VW
Reply to drs. Bollini and cacheiro.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):543-5. [Abstract]

Bollini CA, Cacheiro FJ
Ultrasound, paresthesia, and motor response.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):542-3. [Abstract]

Price D
High thoracic epidural plus suprascapular nerve block analgesia for thoracoscapular fusion.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):541-2. [Abstract]

Gadalla F, Rieth EF, Abramovitz SE
Comparison of two 3.5 inch hustead needles.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):540-1. [Abstract]

Saberski L
Rediscovery of Ganglion Impar Block via Coccygeal Joints.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):539. [Abstract]

Saranteas T, Anagnostopoulou S, Chantzi C
Obturator nerve anatomy and ultrasound imaging.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):539-40. [Abstract]

Feltracco P, Ori C
A new look at the paravertebral block: a percutaneous video-assisted technique.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):538-9. [Abstract]

Saranteas T, Chantzi C, Paraskeuopoulos T, Alevizou A, Zogojiannis J, Dimitriou V, Kostopanagiotou G
Imaging in Anesthesia: The Role of 4 MHz to 7 MHz Sector Array Ultrasound Probe in the Identification of the Sciatic Nerve at Different Anatomic Locations.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):537-8. [Abstract]

Janik JE, Wania-Galicia L, Kalauokalani D
Bee stings-a remedy for postherpetic neuralgia? A case report.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):533-5.
OBJECTIVE: This case report describes the effects of bee stings on painful postherpetic neuralgia in a 51-year-old man. CASE REPORT: The patient was stung by 3 bees in the distribution in which he had been experiencing postherpetic neuralgia. One day after the bee stings, the patient's painful postherpetic neuralgia was completely relieved, and the relief lasted for 1 and a half months. Subsequently, the patient's pain returned, but at significantly less intensity and frequency than what he had experienced prior to the bee stings. CONCLUSIONS: Bee venom and bee sting therapy have been shown to have both antinociceptive and anti-inflammatory properties, which may explain why the bee stings relieved the patient's postherpetic neuralgia. Bee sting or bee venom therapy should be further investigated as a potential treatment modality for postherpetic neuralgia. [Abstract]

Werdehausen R, Braun S, Hermanns H, Krauspe R, Lipfert P, Stevens MF
Stimulating catheter as a tool to evaluate peripheral nerve function during hip rotationplasty.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):528-32.
OBJECTIVE: Stimulating catheters have been introduced into clinical practice to confirm perineural localization of the catheters. The muscular twitch induced over the catheter may be used to evaluate nerve function intraoperatively. Therefore, the function of the sciatic nerve was evaluated during major cancer surgery of the femur. CASE REPORT: A 7-year-old boy (29 kg) was scheduled for hip rotationplasty for resection of an osteosarcoma of the left femur under general anesthesia and postoperative pain therapy with an epidural stimulating catheter. In hip rotationplasty the femur is resected, the lower limb and foot are rotated 180 degrees and the tibia plateau is attached to the pelvic acetabulum to form a new hip joint. During preparation of the left thigh and the sciatic nerve, motor responses to stimulation of the catheter were preserved, but the stimulation threshold increased. After vascular anastomosis the foot remained cold, therefore ropivacaine was applied epidurally and subsequently a warming of the foot was observed. At the end of the operation, the patient was free of pain, a good capillary pulse of the leg was observed, and the patient was able to move the foot and toes of the rotated leg. CONCLUSIONS: The use of epidural stimulating catheters as a tool to monitor nerve function is a novel and simple procedure to monitor nerve function intraoperatively and to enable good postoperative pain control. [Abstract]

Mello SS, Saraiva RA, Marques RS, Gasparini JR, Assis CN, Gonçalves MH
Posterior Lumbar Plexus Block in Children: A New Anatomical Landmark.
Reg Anesth Pain Med. 2007 Nov;32(6):522-527.
BACKGROUND AND OBJECTIVES: Posterior lumbar plexus block is a well established anesthetic technique for lower limb surgeries. Both magnetic resonance imaging and clinical prospective studies were performed to verify if a new palpable landmark could be used for lumbar plexus block in pediatric patients. METHODS: Twenty-five magnetic resonance imaging exams were analyzed to verify the relationship between the ipsilateral lumbar plexus and the sulcus formed by the division between the longissimus and the iliocostal muscles. The mean angle between the point of needle introduction and the lumbar plexus was measured. In a prospective series, 100 consecutive patients (1 to 15 years old) were given posterior lumbar plexus block. Under general anesthesia, the first palpable depression found by sliding the finger laterally at the L4 spine level was used as a landmark. A needle was introduced perpendicularly at the point where this sulcus crossed the line connecting the iliac crests. The ease of sulcus palpation, time spent in the block procedure, and postoperative pain score at 3 time points (M1, awake; M2, discharge from the postanesthesia care unit; M3, the fifth postoperative hour) were registered. RESULTS: The mean angle found in 25 magnetic resonance images was 5.6 degrees. Clinical data from 99 patients were analyzed. The intramuscular groove was easily palpable in 93% of the patients. More than 95% of the blocks were completed in less than 5 minutes. The median pain scores were 0 for M1/M2 and 1 for M3. The block was effective in 97% of patients (95% confidence interval, 93.6%-100%). There was 1 case of subarachnoid puncture (95% confidence interval, 0%-3%). CONCLUSIONS: The sulcus formed by the division between the longissimus and the iliocostal muscles is a simple, direct, and easy-to-identify landmark for posterior lumbar plexus block in children. [Abstract]

Foxall GL, Hardman JG, Bedforth NM
Three-Dimensional, Multiplanar, Ultrasound-Guided, Radial Nerve Block.
Reg Anesth Pain Med. 2007 Nov;32(6):516-521.
OBJECTIVE: We describe the use of 3-dimensional, multiplanar ultrasound imaging for peripheral nerve block. CASE REPORT: To illustrate the potential usefulness of the technique, we present a case in which real-time 3-dimensional, multiplanar ultrasound was used to assist in the performance of a radial nerve block. CONCLUSIONS: Three-dimensional, multiplanar ultrasound in real-time has the potential to improve nerve identification and accuracy of needle placement in regional anesthesia. [Abstract]

Goldschneider KR, Racadio JM, Weidner NJ
Celiac Plexus Blockade in Children Using a Three-Dimensional Fluoroscopic Reconstruction Technique: Case Reports.
Reg Anesth Pain Med. 2007 Nov;32(6):510-515.
BACKGROUND AND OBJECTIVES: We present three cases wherein a new radiologic technique was used to facilitate performance of retrocrural celiac plexus blockade. Three patients presented to our institution for performance of celiac plexus block for relief of intractable upper abdominal pain. One carried the diagnosis of chronic pancreatitis, one abdominal pain and gastrointestinal dysmotility, the other adrenocortical carcinoma. METHODS: We applied the technology used in 3-dimensional rotational angiography to determine spread of the injected medication in three dimensions, and facilitate the blocks. RESULTS: Three-dimensional rotational angiography was used with clinical success. CONCLUSIONS: Three-dimensional rotational angiography shows promise for understanding the spread of medication necessary to accomplish a successful block, and may help explain failures in cases where anatomic distortion may interfere with proper injectate flow. [Abstract]

Busoni P
Difficulties in controlling pain in children.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):505-9. [Abstract]

van Zundert A
Carl Koller Gold Medal Award to Paolo Busoni at the Silver Anniversary ESRA Annual Congress, Monte Carlo, Monaco, September 6-9, 2006.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):504. [Abstract]

Cohen SP, Bajwa ZH, Kraemer JJ, Dragovich A, Williams KA, Stream J, Sireci A, McKnight G, Hurley RW
Factors predicting success and failure for cervical facet radiofrequency denervation: a multi-center analysis.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):495-503.
BACKGROUND AND OBJECTIVES: The concept of radiofrequency denervation has recently come under question in light of several studies showing minimal to no benefit. One possibility proposed for these negative outcomes is poor selection criteria. Unlike virtually all other spine interventions, the factors associated with success and failure for cervical facet denervation have yet to be determined. The purpose of this study is to determine which demographic, clinical and treatment factors are associated with cervical facet radiofrequency denervation outcomes. METHODS: Data were garnered from 3 academic medical centers on 92 patients with chronic neck pain who underwent radiofrequency denervation after a positive response to diagnostic local anesthetic blocks. Success was defined as at least 50% pain relief lasting at least 6 months. Variables evaluated for their association with outcome included age, sex, duration of pain, opioid use, pain referral pattern, paraspinal tenderness, pain exacerbated by extension/rotation, magnetic resonance image abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery, and levels treated. RESULTS: The only clinical variable associated with success was paraspinal tenderness. Factors associated with treatment failure included radiation to the head, opioid use, and pain exacerbated by neck extension and/or rotation. CONCLUSIONS: Selecting patients based on key clinical variables may increase the chance of treatment success for cervical facet radiofrequency denervation. [Abstract]

Feigl GC, Anderhuber F, Dorn C, Pipam W, Rosmarin W, Likar R
Modified lateral block of the suprascapular nerve: a safe approach and how much to inject? A morphological study.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):488-94.
BACKGROUND AND OBJECTIVES: This paper presents an evaluation of a modified lateral suprascapular nerve block with easy orientation, low risk of displacement of the needle, and with an assessment of 2 different volumes to propose an ideal volume for a successful block. METHODS: Both shoulders of 34 cadavers were investigated. Insertion point of the needle was determined in the angle of the lateral end of the clavicle, acromion, and the spine of the scapula. The needle was directed toward the medial, dorsal, and caudad direction. Ten mL of diluted contrast agent for computerized tomography was injected in the 34 right sides (group A) and 5 mL in the 34 left sides (group B). Immediately after injection, all shoulders were investigated by computerized tomography scans and 3-dimensional reconstruction to document the constrast dissemination. Five sides of each group were injected with colored contrast and dissected after computerized tomography investigation. RESULTS: Group A showed a distribution to the entire supraspinous fossa in all cases and the contrast was pressed out of the suprascapular notch in 4 cases with a maximal extension into the axillary fossa in 3 cases. In group B, the supraspinous fossa was filled in 24 cases, with a maximal extension to the axillary fossa in 2 cases. In 9 cases, the contrast agent stayed in the lateral half of the supraspinous fossa. In 1 case we had a medial spread only which still surrounded the suprascapular notch, in another case a superficial spread with misplacement of the needle. CONCLUSION: Based on this cadaver study, the lateral modified approach appears to be a safe technique for a suprascapular nerve block, which might be preferred as a single shot technique. A 5 mL volume appears sufficient to fill the supraspinous fossa and to reach the suprascapular nerve, which branches in this anatomical compartment. [Abstract]

Hermanns H, Braun S, Werdehausen R, Werner A, Lipfert P, Stevens MF
Skin temperature after interscalene brachial plexus blockade.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):481-7.
BACKGROUND AND OBJECTIVES: In neuraxial anesthesia, increase of skin temperature is an early sign of successful block. Yet, during peripheral nerve block of the lower extremity, increase in skin temperature is a highly sensitive, but late sign of a successful block. We hypothesized that after interscalene brachial plexus block, a rise in skin temperature follows impairment of sensation during successful nerve block and occurs only distally, as observed in the lower extremity. METHODS: In the present study, we prospectively evaluated the changes in skin temperature after interscalene brachial plexus blockade in 45 patients scheduled for elective shoulder surgery. We assessed pinprick and cold sensation as well as skin temperature at sites of the skin innervated by the median, ulnar, radial, axillary and musculocutaneous nerve. RESULTS: At the skin areas innervated by the axillary and musculocutaneous nerve, skin temperature did not increase after successful block. At the distal sites, innervated by the median, ulnar, and radial nerve, skin temperature increased significantly (1.9-2.1 degrees C within 30 min) after successful block while it did not after failed nerve block or on the contralateral side. In these areas attenuation of skin sensation preceded a measurable rise in skin temperature (>/=1 degrees C) in 56.3% of nerve blocks, occurred at the same time in 35.2%, and in 8.5% the temperature rise occurred first. CONCLUSIONS: Assessment of skin temperature cannot predict the success of an interscalene brachial plexus block of the axillary and musculocutaneous nerve. Distally, the increase of skin temperature has a high sensitivity and specificity but occurs later than the loss of sensory and motor functions. Therefore, the measurement of skin temperature during interscalene blockade is of limited clinical value. [Abstract]

Sitsen E, van Poorten F, van Alphen W, Rose L, Dahan A, Stienstra R
Postoperative Epidural Analgesia After Total Knee Arthroplasty With Sufentanil 1 mug/mL Combined With Ropivacaine 0.2%, Ropivacaine 0.125%, or Levobupivacaine 0.125%: A Randomized, Double-Blind Comparison.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):475-80.
BACKGROUND AND OBJECTIVES: Total knee replacement is associated with severe postoperative pain that, if treated insufficiently, interferes with early rehabilitation. The purpose of the present study is to compare the efficacy of ropivacaine (0.2% and 0.125%) and levobupivacaine (0.125%), all in combination with sufentanil 1 mug/mL with regard to postoperative pain relief and absence of motor block in a patient-controlled epidural analgesia setting. METHODS: The study design was randomized and double-blind. Sixty-three patients scheduled for total knee replacement under combined spinal-epidural anesthesia were randomly allocated to receive ropivacaine 0.2%/sufentanil 1 mug/mL (group 1), ropivacaine 0.125%/sufentanil 1 mug/mL (group 2), or levobupivacaine 0.125%/sufentanil 1 mug/mL (group 3) for postoperative epidural pain relief. Primary endpoints were numerical rating scores for pain and patient satisfaction, motor block scores, time to first demand of the patient-controlled epidural analgesia device and average hourly consumption of local anesthetic and sufentanil. RESULTS: There were no significant differences between the 3 groups regarding numerical rating scores for pain, patient satisfaction, and motor block scores at any of the time intervals; time to first demand and average hourly sufentanil consumption were similar. Patients in group 1 used significantly more local anesthetic than patients in groups 2 and 3. CONCLUSIONS: All 3 solutions provided adequate analgesia and minimal motor block. The higher concentration of ropivacaine 0.2% was associated with a higher consumption of local anesthetic and did not result in a decrease in the consumption of sufentanil. Under the conditions of this study, patient-controlled epidural analgesia consumption of the epidural mixture was predominantly determined by sufentanil. [Abstract]

Kim JT, Lee JH, Yoon SZ, Lim YJ, Bahk JH, Kim CS, Jeon Y
Effect of lumbar flexion on the extent of epidural blockade.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):471-4.
BACKGROUND AND OBJECTIVES: This study examined the effect of lumbar flexion on the extent of the epidural block during lumbar epidural anesthesia. METHODS: The epidural catheter was introduced at the L3-4 interspace with the patient in the lateral decubitus position with the surgical side down. After administering a test drug (3 mL of 2% lidocaine and 15 mug of epinephrine), the patients were randomly allocated to 1 of 2 groups: Group F (n = 16, lumbar spine flexed) and Group N (n = 17, lumbar spine in the neutral position). In both groups, 2% lidocaine (16 mL) mixed with sodium bicarbonate (2 mL) was administered through the epidural catheter while the patient maintained the lateral decubitus position with the lumbar spine either flexed or in the neutral position. All the patients maintained their respective positions for 5 minutes and were subsequently turned to the supine position. The pinprick block level and the degree of motor blockade were assessed every 10 minutes for 60 minutes after administering the local anesthetics. A 2-dermatomal difference in uppermost block between groups was determined to be clinically significant. RESULTS: The median difference between groups in the uppermost pinprick block level was only 1.5 dermatomes and it did not satisfy our criteria for clinical significance. There were no significant differences between the 2 groups in the lowermost pinprick block level and the degree of motor block. CONCLUSIONS: Lumbar flexion has no clinically relevant effect on sensory spread during epidural anesthesia. [Abstract]

Ueta K, Suzuki T, Sugimoto M, Uchida I, Mashimo T
Local Anesthetics Have Different Mechanisms and Sites of Action at Recombinant 5-HT(3) Receptors.
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):462-70.
BACKGROUND AND OBJECTIVES: In addition to their blockade of voltage-dependent sodium channels, the action of local anesthetics at 5-hydroxytryptamine-3 (5-HT(3)) receptors may be clinically relevant. Because local anesthetics have different clinical properties, we have tested the hypothesis that differences in interactions at the 5-HT(3) receptor may be clinically relevant by investigating the effects of 4 local anesthetics on recombinant wild-type and 4 mutant 5-HT(3A) receptors. METHODS: The cRNAs from human wild-type and 4 mutant 5-HT(3A) subunit clones were synthesized in vitro and expressed in Xenopus oocytes. Four mutant receptors were obtained by site-directed mutagenesis in the N-terminal extracellular region, which contains the agonist binding domain. Tryptophan (W) at positions 62 and 155 were replaced by tyrosine (Y) and glutamate (E) at position 101 by aspartate (D) or asparagine (N). The 2-electrode voltage clamp technique was used to measure peak currents induced by 5-HT in these receptors in the presence and absence of local anesthetics. RESULTS: All local anesthetics inhibited 5-HT-induced currents in a dose-dependent manner in the wild-type receptor. Inhibition by procaine and tetracaine were competitive whereas those of bupivacaine and lidocaine were both noncompetitive and competitive. The 4 mutants (W62Y, W155Y, E101D, E101N) could all form functional receptors. All mutant receptors exhibited a major increase (> 10-fold) in the half-maximum inhibitory concentration for procaine. The half-maximum inhibitory concentrations of tetracaine, bupivacaine, and lidocaine in mutant receptors were increased 2- to 3-fold except that of tetracaine in W62Y receptor (6-fold). CONCLUSIONS: The ester type local anesthetics, procaine and tetracaine, may act at a different site on the 5-HT(3A) receptor and with a different mechanism than the amide-type local anesthetics. Clinical differences between local anesthetics may be at least partially due to differences in interactions at the 5-HT(3A) receptor. [Abstract]

Butterworth JF
Which actions of local anesthetics are relevant to the medical care of humans?
Reg Anesth Pain Med. 2007 Nov-Dec;32(6):459-61. [Abstract]

Sen S, Martin DP, Bacon DR
Reply to dr. Benedetti.
Reg Anesth Pain Med. 2007 Sep-Oct;32(5):465-6. [Abstract]

Ward M, Langley KJ
Ultrasound guidance for brachial plexus localization with Volkmann's contracture of forearm, and decompressed compartment syndrome.
Reg Anesth Pain Med. 2007 Sep-Oct;32(5):464. [Abstract]