Sickle cell pain crisis.
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Analgesics, Opioid↗
Biomedical subjects
D A Cherry
Publications and source records attributed to D A Cherry.
"Foam dancing" could be infectious.
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Adult↗
Pharmacological management of chronic pain: a clinician's perspective.
Of the currently available mu agonist drugs, the following are relatively contraindicated: 1. Methadone--unpredictable duration of action [5]. 2. Pethidine--unwanted central effects, metabolised to an active metabolite and too short acting. 3. Codeine--too weak and with constipating side-effects. 4. Fentanyl--too short acting. 5. Oxycodone--too short acting although suppositories may overcome some theoretical disadvantages. 6. Dextropropoxyphene--weak agonist which is possibly metabolised to a cardiotoxic metabolite [6]. Morphine remains the drug of choice for chronic pain when administered in a sustained release preparation. MS Contin, a slow release oral formulation of morphine, is available and has a predictable duration of action lasting from 8-12 h, while improved formulations are about to be released in the near future in some countries. Prescribers need to take into account the relatively poor oral bioavailability of morphine when calculating the daily morphine dose.
Analgesics↗
Epidural opiates and local anaesthetics for the management of cancer pain.
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Analgesia, Epidural↗
Surgical procedures for the relief of acute and chronic pain.
OBJECTIVE: To review current surgical procedures for the relief of acute and chronic pain. CONCLUSIONS: Recent advances in knowledge of pain transmission and pain modulation have resulted in a more conservative approach to surgical intervention for the relief of pain. Those techniques which are contemporarily accepted as efficacious are outlined.
Acute Disease↗
The reproducibility of bioavailability of oral morphine from solution under fed and fasted conditions.
The reproducibility in bioavailability of orally administered morphine (as a solution) under fed and fasted conditions was studied in 5 patients with chronic pain on three occasions over 1 yr (0, 6, and 12 mo). During each study period (i.e.. 0, 6, and 12 mo), patients received the 50 mg oral dose both in the fasted state (10 hr since food) and immediately after a high fat content breakfast, in randomly determined sequence. Frequent blood samples were collected for 10 hr after the dose. There was no significant difference in the maximum blood morphine concentration (Cmax) or the time to Cmax among the three study periods or between the fed and fasted states. Bioavailability, as assessed by log(AUC), was significantly greater in the fed compared to the fasted state (P less than .01) but did not differ over the three study periods (Two-factor analysis of variance). Intrapatient variability contributed 32% and 54% to total variation in log(AUC) under fed and fasted conditions, respectively.
Administration, Oral↗
Leakage of fluid administered epidurally to rats into subcutaneous tissue.
Epidural catheters were implanted in rats under halothane/nitrous oxide anaesthesia. Contrast medium (Iopamidol) was injected via the catheter under fluoroscopic control 24-48 h after implantation. In 15 of 20 rats contrast could be seen leaking out of the epidural space, usually after only 25 microliters was administered. Leakage was associated with diminished antinociceptive response to morphine administered via the catheter. Both leakage and decreased response to morphine could be largely prevented by applying a drop of Supa-Glue over the site of entry of the catheter to the epidural space at the time of catheter implantation. Investigators using epidurally cannulated rats should document that leakage does not occur or discard results from rats showing evidence of leakage.
Analgesia, Epidural↗
Influence of a high-fat meal on the absorption of morphine from oral solutions.
The influence of a high-fat meal on blood morphine concentrations after the administration of a morphine solution (50 mg dose) was studied in 12 patients with chronic pain. The oral morphine dose was administered in a total volume of 200 ml to patients either immediately after food intake or while in the fasting state. There was a 34% increase in the area under the curve (AUC) when morphine was administered immediately after food when compared with the fasting state (p less than 0.02). However, there was no significant difference between the maximum blood morphine concentration (Cmax) or the time to maximum concentration (tmax) between the two treatment regimens. The shape of the blood morphine concentration-time curve was consistently altered in the fed patients compared with patients who were in the fasting state, inasmuch as the blood morphine concentrations were maintained at a higher level from 240 to 600 minutes after the dose when the morphine was administered with food (p less than 0.02). It is suggested that morphine concentrations are maintained at higher levels, possibly resulting in more prolonged pain relief, when morphine is administered with food compared with the same dose administered to patients who are in the fasting state.
Administration, Oral↗
Treatment of cancer pain with orally and spinally administered opioids.
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Administration, Oral↗
Balloon sphincterography. Clinical findings after 200 patients.
There are two muscular mechanisms of fecal continence. The anal sphincter squeezes the anal canal, thus lengthening it and increasing its resistance. The puborectalis kinks the distal rectum, preventing the transmission of intra-abdominal pressures into the anal canal. Balloon sphincterography simultaneously records the shape of the anal canal and distal rectum and measures the strength of the puborectalis and anal sphincter muscles. This allows the physician to evaluate the function of these important muscles in patients with symptomatic defecation disorders such as constipation, incontinence, and rectal prolapse. A cylindrical balloon is connected by a hose to a fluid reservoir filled with liquid barium. The deflated balloon is placed into the anal canal and inflated by raising the fluid reservoir in increments. Fluoroscopy visualizes the balloon's shape and video records the results. Quantitative sphincterogram measurements in patients with defecation disorders include (the three measurements in each category refer respectively to incontinent patients [N = 87], prolapse patients without incontinence [N = 26], and constipated patients [N = 65]); anorectal angle (degrees + S.D.): 114 + 28, 103 + 18, 95 + 19; anal canal length (mm + S.D.): 33 + 11, 38 + 10, 39 + 10; squeeze pressure (cm H2O + S.D.): 68 + 23, 80 + 16, 91 + 22, and opening pressure (cm H2O + S.D.): 52 + 25, 67 + 22, 81 + 24. The method is useful in identifying specific defects, such as paradoxic puborectalis contractions, that can cause constipation, and injuries to the sphincters that can cause incontinence. In over 280 patients with a wide variety of defecation disorders, sphincterography has yielded information not available by standard manometric techniques. It augments the findings of defecography.
Anal Canal↗
Pelvic floor physiology.
Pelvic floor physiology is poorly understood. The funnel shape of the pelvic floor and anal canal is uniquely developed to provide discriminatory continence of gas, liquid, and solid. Proximally, the pelvic floor consists of the pubococcygeus and iliococcygeus muscles. Distally, the anal canal is surrounded by the internal and external sphincter muscles. The anorectal ring is situated between the proximal pelvic floor and the distal anal canal. It is the site of the puborectalis muscle, which is anatomically, neurologically, and functionally merged with the deep portion of the external sphincter muscle. It is at this site that unique forces act to create both a flutter valve and the anorectal angle with the flap valve. Extrinsic pressures at this level reinforce both the flap valve and the flutter valve. Intrinsic pressures are generated by all of the surrounding muscles to produce a high-pressure zone. These factors are critical, but many other factors, such as rectal capacity, compliance, colonic transit, motility, and sensory mechanisms, also interact in a complex way to provide normal continence and defecation. Not surprisingly, no single test allows a complete assessment of the interactions of all these factors. Nevertheless, analysis of components thought to be important in pelvic floor physiology has contributed significantly to the understanding of normal as well as abnormal physiology. Although clinical evaluation continues to be the cornerstone of the diagnosis of pelvic floor disorders, anorectal physiological testing has contributed significantly to our understanding of the dynamics of the pelvic floor. With the refinement of existing techniques and the addition of new investigative tools, it is anticipated that knowledge of pelvic floor physiology will continue to grow.
Anal Canal↗
Sensitive gas liquid chromatography method for the determination of fentanyl concentrations in blood.
A method for the determination of fentanyl blood concentrations using gas liquid chromatography coupled to a nitrogen phosphorus detector (NPD) is presented. A highly inert fused-silica, megabore column coated with a methyl silicone stationary phase was used for the analysis. The mean coefficient of variation for the range of fentanyl concentrations tested (0.25-10 ng/ml) was 4.65%, ranging from 0.85% at 10 ng/ml to 10.8% at 0.25 ng/ml. The assay was used to quantify blood fentanyl concentrations collected from a 56-year-old woman who was administered fentanyl postoperatively via a patient-controlled on-demand analgesic computer (ODAC). The mean hourly fentanyl dose rate over the 44 hr study period was 41.8 micrograms/hr (range 20-120). The sixfold variation in hourly dose rate was not mirrored by similar fluctuations in the fentanyl blood concentration (mean 0.45 ng/ml, range 0.3-0.7 ng/ml). The patient thus titrated herself to a perceived minimum effective concentration (MEC) of fentanyl.
Cholecystectomy↗
Drug delivery systems for epidural administration of opioids.
From a practical and cost-effective viewpoint, the bolus administration of opiates via an implanted epidural catheter and portal injection system offers improved pain control for a good percentage of patients suffering pain secondary to cancer who are not responding to oral analgesia. However, considerable research is required into the mechanism of action, drug of choice, and optimal drug delivery system for the epidural administration of opiate drugs. Although this system is still in its infancy, it would be fair to say that it is one of the most significant advances for the control of pain in patients with cancer this century.
Catheters, Indwelling↗
Pain from an invasive facial tumor relieved by lumbar epidural morphine.
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Carcinoma, Squamous Cell↗
Epidural mass associated with lack of efficacy of epidural morphine and undetectable CSF morphine concentrations.
A case is presented in which epidurally administered morphine failed to provide the expected extent and duration of pain relief. The patient had severe back pain in the upper lumbar and low thoracic regions and epigastric pain which was presumed to be caused by widespread metastatic deposits in the vertebral column from a prostatic carcinoma. The lack of clinical effect of epidural morphine was shown to be related to the unexpected presence of an epidural mass which was located below the dermatomal region for the patient's pain. Myelography and a CT scan indicated that the mass effectively compressed the subarachnoid space, thereby preventing the rostral spread of morphine in the cerebrospinal fluid (CSF) following lumbar epidural administration, resulting in inadequate pain relief.
Aged↗
The use of temporary atrial electrodes to improve diagnostic capabilities with Holter monitoring after cardiac surgery.
The use of temporary atrial electrodes implanted during cardiac surgery has been advocated for diagnosis and treatment of cardiac arrhythmias in the postoperative period. We have adapted this technique to allow continuous ambulatory electrocardiographic (Holter) recording of atrial activity in patients after coronary artery surgery. The electrodes of one of the two leads of the Holter recorder were attached as a surface electrocardiographic lead, while the electrodes of the other were each attached to one of the two implanted atrial wires. The Holter record was then obtained in the usual way. A satisfactory recording of the atrial electrocardiogram and the simultaneous surface electrocardiogram was obtained in all 6 patients and resulted in improved diagnostic capabilities, specifically in differentiating supraventricular and ventricular arrhythmia. As has proven to be true in the post-myocardial infarction setting, arrhythmias that were not noted clinically despite continuous electrocardiographic monitoring were demonstrated on Holter records.
Arrhythmias, Cardiac↗
A technique for the insertion of an implantable portal system for the long-term epidural administration of opioids in the treatment of cancer pain.
The feasibility of using a subcutaneously implanted portal system attached to a conventional 16-gauge epidural catheter has been evaluated in 50 patients with sever pain associated with cancer. This technique allowed for the percutaneous epidural administration of morphine at 8-12-hourly intervals for pain control. The mean duration of implantation was 12 weeks and the longest period a portal remained in situ was 36 weeks. Five portals had to be removed for various reasons. The injection system has blocked on eight occasions due to catheter blockage (six times) and portal blockage (two occasions). These patients have continued to obtain excellent analgesia when either catheter or portal were replaced. In a cadaver, 300 injections were simulated using either 22-gauge Huber point needles or disposable needles (25 gauge) and the injectate examined by both light and scanning electron microscopy. Both needle types resulted in particulate contamination which was greater with the recommended Huber point needles.
Analgesia↗