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Biomedical subjects

R B Patt

Publications and source records attributed to R B Patt.

At least 19 recordsLinked to original sources
PubMed1998

Breakthrough pain in cancer patients: characteristics, prevalence, and treatment.

"Breakthrough pain" is a common clinical term that has not been conclusively defined or described. Breakthrough pain is a transitory flare of pain experienced when baseline pain has been reduced to a mild or moderate level. Breakthrough pain may be characterized by its relationship to a fixed around-the-clock (ATC) opioid dose, rapid onset and short duration, precipitating events, predictability, pathophysiology (with nociceptive pain being most easily controlled), and etiology. The only prospective study of breakthrough pain conducted to date found a 63% prevalence of breakthrough pain in cancer patients referred to a pain service. Although prevalence figures from other studies vary widely, partly due to the populations chosen, all of the studies verify that breakthrough pain is a serious problem in cancer patients. In fact, several studies have listed incident pain, a subset of breakthrough pain, as a predictor of poor response to analgesic therapy. Breakthrough pain is currently managed with oral or parenteral breakthrough pain medications given in addition to the ATC analgesic regimen. The ATC dosage may also be increased until limited by side effects. Newer agents with a more rapid onset of analgesia and shorter duration of effect may help in the management of breakthrough pain.

Administration, Oral↗
PubMed1997

Clinical realities and economic considerations: economics of intrathecal therapy.

The estimated annual cost of medical management of chronic back pain is $25 billion. Such management is often ineffective and overly costly. Most physicians who have employed intrathecal pain therapy attest to its efficacy in the management of intractable chronic pain. However, few economic analyses are available to evaluate the cost effectiveness of different modalities and to aid in clinical decision making and third-party reimbursement policies. Current analyses tend to focus on short-term cost-benefit measurements and to ignore variables such as quality of life and patient functioning. This bias has impaired the ability of payers to make appropriate decisions regarding the safety, cost effectiveness, and efficacy of intrathecal pain therapy in noncancer patients. Clinical data demonstrate that for cancer patients whose expectancies exceed 3 months, the overall costs of intrathecal pain therapy may be less than those of tunneled epidural catheters or external infusion devices. In nonmalignant pain, intrathecal therapy appears to be cost effective compared to conventional medical management at 22 months. Further debate and fine tuning of these economic models from all perspectives are required.

Analgesics, Opioid↗
PubMed1997

Palliation of intractable cancer pain by MRI-guided cingulotomy.

CASE REPORT: Three cases of intractable pain arising from widespread metastatic cancer with poor response to opioids were treated with MRI-guided cingulotomy. RESULTS AND CONCLUSIONS: In most cases, MRI-guided cingulotomy was associated with significant pain relief and reduced opioid use. To provide insight into the role of MRI-guided cingulotomy in oncologic pain refractory to more conservative measures, the relative risks and benefits of cingulotomy are discussed, along with the course of one patient who experienced postoperative cognitive impairment. This report also describes the relevant neurosurgical and pharmacotherapeutic issues associated with management of pain in patients with widespread metastatic disease.

Adult↗
PubMed1996

Psoas sheath chemical neurolysis for management of intractable leg pain from metastatic liposarcoma.

CASE REPORT: A 56-year-old man with widely metastatic liposarcoma, after left Tower extremity amputation, complained of severe right lower extremity pain. Trials of systemic opioids had resulted in poor pain control while introducing intolerable dose-limiting side effects. METHODS AND RESULTS: Initial inpatient management consisted of a lumbar epidural infusion of a dilute local anesthetic and preservative-free morphine. This provided satisfactory relief but was discontinued because of recrudescence of phantom limb pain. A lumbar epidural infusion of preservative-free morphine sulfate was associated with poor pain relief, central nervous system (CNS) side effects, and severe urinary retention resulting in acute renal failure. A repeated trial of parental opioids provided marginal pain relief with persistent CNS side effects. Chemical neurolysis of the lumbar plexus was performed with 10 ml of 10% aqueous phenol injected into the psoas muscle sheath. The pain gradually resolved over a 2-day period without apparent side effects. Motor function was preserved, pain was resolved, and as systemic opioids were reduced, cognitive function and overall well-being were improved.

Amputation, Surgical↗
PubMed1996

Effective but near disastrous subarachnoid neurolysis for mechanical root pain in a paraplegic cancer patient.

CASE REPORT: A 43-year-old white man with advanced renal cell carcinoma and consequent paraplegia complained of the new onset of lancinating pain involving the right upper chest wall. This pain, which was superimposed on well-controlled chronic back pain and was intermittent and related to activity, failed to respond to conventional pharmacologic management. METHODS AND RESULTS: A cisternal myelogram suggested an absence of gross rostral extension of spinal metastases, and subarachnoid neurolysis was performed with hyperbaric phenol. Unexpected contralateral brachial weakness developed towards the conclusion of the procedure, but resolved spontaneously. The target pain had not recurred at follow-up 8 months later.

Adult↗
PubMed1995

Subarachnoid neurolytic block under general anesthesia in a 3-year-old with neuroblastoma.

CASE REPORT: A 3-year-old boy with neuroblastoma complained of severe pain in the left lower extremity. Pharmacologic management had previously been attempted, but severe pain continued, and further upward titration was complicated by sedative effects. METHODS AND RESULTS: Because the focus of treatment had become the controlling of pain, a lumbosacral subarachnoid neurolytic block was performed under general anesthesia. One-time neurolysis was more acceptable to the family than a procedure like epidural analgesia, that requires greater management. Contrast medium was used to monitor the spread of the neurolytic. An epidural catheter was inserted during the neurolytic block procedure for possible future use. The short-term results were good--pain reports and opioid doses decreased greatly, although with increased incontinence. The boy had new abdominal distention and pain 5 days after neurolysis. Opioid doses and sedatives were increased. He died 3 days later.

Anesthesia, General↗
PubMed1994

The benzodiazepines as adjuvant analgesics.

There has been long-standing debate regarding whether benzodiazepines possess analgesic properties that are independent of their effects on mood and alertness. A careful review of the literature reveals insufficient evidence to support the contention that the benzodiazepines have meaningful analgesic properties in most clinical circumstances. Treatment with the benzodiazepines may reduce complaints of pain, but this seems to be an indirect effect related to their psychotropic properties, such as alleviation of anxiety and, in selected cases, depression. In the absence of definitive data, clinical experience suggests a potential role for treatment with benzodiazepines for acute muscle spasm, concomitant chronic pain and anxiety, and lancinating neropathic pain, in which case clonazepam and alprazolam may be the agents of choice. They should probably not be considered as first-line choices even for the above indications, since potential benefits must be considered in the context of potential for the development of cognitive impairment, physical and psychological dependence, worsening depression, overdose, and other side effects.

Adjuvants, Pharmaceutic↗
PubMed1994

The neuroleptics as adjuvant analgesics.

The role of neuroleptic drugs as adjuvant analgesics has been a subject of longstanding controversy. Despite frequent claims of efficacy, evidence from controlled trials supports neither claims of intrinsic analgesic properties nor the routine use of the neuroleptics as a means to reliably induce clinically useful analgesia. Methotrimeprazine is unique in that there is evidence for reliable dose-related analgesia that is comparable to opioid-mediated analgesia, although routine use is not recommended. Despite probable interaction with opioid receptors, there is insufficient evidence to support a role for the butyrophenone category of neuroleptics as adjuvant analgesics. Limited trials of the neuroleptics may be considered for pain that has been unresponsive to more conventional pharmacologic approaches, especially when associated with headache, nerve injury, or psychological distress. The neuroleptics have an important role in the symptomatic management of agitation, delirium, and nausea, particularly in patients with cancer.

Analgesics↗
PubMed1994

Pharmacotherapy for cancer pain: an anaesthesiologist's viewpoint.

Cancer pain is prevalent and undertreated despite the availability of therapeutic options that, taken together are highly effective, economical and safe. Improved understanding of the pharmacology of chronically-administered opioids has resulted in reduced concerns about addiction and an increased emphasis on their use. The anaesthetist may play a pivotal role in cancer pain management by the provision of nerve blocks and other interventions, but, to be a truly effective consultant, must also be expert in all aspects of pharmacotherapy. A rationale for the development of pharmacologic expertise together with a review of assessment and pharmacologic management of cancer pain are provided.

Analgesics↗
PubMed1994

Spinal neurolysis for cancer pain: indications and recent results.

Effective control of cancer pain can now be achieved in a high proportion of patients with rigorously applied pharmacologic treatment, reducing the need for more demanding invasive procedures. Ten to thirty percent of patients will, however, require some form of more aggressive management, ranging from the parenteral and spinal administration of opioids to neurodestructive procedures. Intrathecal neurolysis is a time-tested procedure that, although used less frequently than in the past, still has important indications. Guidelines for patient selection and results of a recent clinical series are presented here.

Clinical Protocols↗