三阶梯止痛法治疗晚期癌痛62例临床分析

目的为了证实三阶梯止痛法的可行性和疗效。方法应用去痛片──强痛定─—盐酸二氢埃托啡（ｄｒｏｅｔｏｒｐｈｉｎｅ）组成的三阶梯止痛法治疗６２例晚期癌痛病人，按时定量口服给药。结果疼痛完全缓解２９例、部分缓解２５例、轻度缓解６例、无效２例。总有效率为９６．７７％（６０／６２）。副反应发生率为３３．８７％（２１／６２）。结论三阶梯止痛方法对绝大部分晚期癌症患者有止痛效果且副反应轻，可以耐受。     

Medical Student Knowledge of Morphine for the Management of Cancer Pain

Inadequate training of physicians contributes to the undertreatment of cancer pain. To address these concerns, the University of Kentucky has introduced a 4-week course for final-year medical students that teaches the principles of clinical pharmacology and pain management. The purposes of this study are to assess the knowledge deficits of final-year medical students about the use of morphine for cancer pain and to assess the efficacy of a short course on cancer pain management. Eighty-six final-year medical students completed a 22-item questionnaire assessing their knowledge and attitudes toward the use of morphine for cancer pain. Students indicated their agreement with each statement on a four-point scale (one, strongly disagree; four, strongly agree). All students then completed a compulsory short course on pain management. The course content included a 1-hr lecture on chronic nonmalignant pain, a 1-hr lecture on acute pain management, and a 1-hr lecture on cancer pain management. In addition, students completed small-group, problem-based learning modules on several aspects of pain management. After the course, all students completed the same 22-item survey. The alpha reliability score of the pretest instrument was 0.55, and the posttest reliability was 0.86. Upon course completion, students agreed most strongly (mean ± SEM) that morphine should be given on a regular schedule for cancer pain (3.41 ± 0.08), that cancer pain management frequently requires co-analgesics (3.36 ± 0.06), and that patients with good pain relief function better than those with continuing pain (3.39 ± 0.08). A comparison of pretest and posttest means on specific items suggested that the greatest amount of learning took place in the following content areas: morphine is a good oral analgesic; increases in cancer pain should be treated by increasing the morphine dose; respiratory depression is not a concern for cancer pain patients; and morphine can be used over a wide range of doses. The regular use of morphine was recognized as the treatment drug of choice for cancer pain. The students showed improved knowledge scores on ten of the 22 items on the posttest survey. A significant increase in learning occurred on six knowledge and attitude items. On only one item (nausea as a side effect of morphine) did the knowledge scores decrease on the posttest. A significant minority (40%) of senior medical students had deficits in knowledge about the use of morphine for cancer pain. The risk of addiction, respiratory depression, and tolerance were misunderstood by a significant minority (25%) of students.     

癌症疼痛的治疗进展

疼痛是癌症病人急需解决的突出问题 ,现就癌症疼痛的治疗进展作一综述     

A validation study of the WHO analgesic ladder: a two-step vs three-step strategy

Goals of work The aims of the present study were to verify whether an innovative therapeutic strategy for the treatment of mild-moderate chronic cancer pain, passing directly from step I to step III of the WHO analgesic ladder, is more effective than the traditional three-step strategy and to evaluate the tolerability and therapeutic index in both strategies.Methods Patients aged 18 years or older with multiple viscera or bone metastases or with locally advanced disease were randomized. Pain intensity was assessed using a 0–10 numerical rating scale based on four questions selected from the validated Italian version of the Brief Pain Inventory. Treatment-specific variables and other symptoms were recorded at baseline up to a maximum follow-up of 90 days per patient.Results Fifty-four patients were randomized onto the study, and pain intensity was assessed over a period of 2,649 days. The innovative treatment presented a statistically significant advantage over the traditional strategy in terms of the percentage of days with worst pain 5 (22.8 vs 28.6%, p<0.001) and 7 (8.6 vs 11.2%, p=0.023). Grades 3 and 4 anorexia and constipation were more frequently reported in the innovative strategy arm, although prophylactic laxative therapy was used less in this setting.Conclusions Our preliminary data would seem to suggest that a direct move to the third step of the WHO analgesic ladder is feasible and could reduce some pain scores but also requires careful management of side effects.     

Cancer Pain: Progress Since the WHO Guidelines

Abstract: In has been 15 years since the WHO Guidelines for the management of cancer pain were developed. This article reviews the guideline development and its effectiveness. Current trends in cancer care utilizing aggressive chemotherapeutic and surgical protocols lead to many patients living longer with advanced cancer and an attendant increase in pain. Future trends in cancer pain care are outlined.     

The ACTTION-American Pain Society Pain Taxonomy (AAPT): An Evidence-Based and Multidimensional Approach to Classifying Chronic Pain Conditions

Current approaches to classification of chronic pain conditions suffer from the absence of a systematically implemented and evidence-based taxonomy. Moreover, existing diagnostic approaches typically fail to incorporate available knowledge regarding the biopsychosocial mechanisms contributing to pain conditions. To address these gaps, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration and the American Pain Society (APS) have joined together to develop an evidence-based chronic pain classification system called the ACTTION-APS Pain Taxonomy. This paper describes the outcome of an ACTTION-APS consensus meeting, at which experts agreed on a structure for this new taxonomy of chronic pain conditions. Several major issues around which discussion revolved are presented and summarized, and the structure of the taxonomy is presented. ACTTION-APS Pain Taxonomy will include the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. In coming months, expert working groups will apply this taxonomy to clusters of chronic pain conditions, thereby developing a set of diagnostic criteria that have been consistently and systematically implemented across nearly all common chronic pain conditions. It is anticipated that the availability of this evidence-based and mechanistic approach to pain classification will be of substantial benefit to chronic pain research and treatment.PerspectiveThe ACTTION-APS Pain Taxonomy is an evidence-based chronic pain classification system designed to classify chronic pain along the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.     

Transcutaneous Electrical Nerve Stimulation for Phantom Pain and Stump Pain in Adult Amputees

Abstract Following amputation, 50% to 90% of individuals experience phantom and/or stump pain. Transcutaneous electrical nerve stimulation (TENS) may prove to be a useful adjunct analgesic intervention, although a recent systematic review was unable to judge effectiveness owing to lack of quality evidence. The aim of this pilot study was to gather data on the effect of TENS on phantom pain and stump pain at rest and on movement. Ten individuals with a transtibial amputation and persistent moderate‐to‐severe phantom and/or stump pain were recruited. Inclusion criteria was a baseline pain score of ≥3 using 0 to 10 numerical rating scale (NRS). TENS was applied for 60 minutes to generate a strong but comfortable TENS sensation at the site of stump pain or projected into the site of phantom pain. Outcomes at rest and on movement before and during TENS at 30 minutes and 60 minutes were changes in the intensities of pain, nonpainful phantom sensation, and prosthesis embodiment. Mean (SD) pain intensity scores were reduced by 1.8 (1.6) at rest (P < 0.05) and 3.9 (1.9) on movement (P < 0.05) after 60 minutes of TENS. For five participants, it was possible to project TENS sensation into the phantom limb by placing the electrodes over transected afferent nerves. Nonpainful phantom sensations and prosthesis embodiment remained unchanged. This study has demonstrated that TENS has potential for reducing phantom pain and stump pain at rest and on movement. Projecting TENS sensation into the phantom limb might facilitate perceptual embodiment of prosthetic limbs. The findings support the delivery of a feasibility trial.     

正念减压疗法对宫颈癌患者术后性生活质量的影响

目的 构建科学、敏感的癌痛护理质量指标评价体系,为癌痛护理质量评价与监测提供依据。 方法 在三维质量结构理论基础上,采用文献分析法,由专家小组讨论初步筛选指标,编制函询问卷,运用 Delphi 法进行2轮专家函询,对癌痛护理质量敏感指标进行修正及确定。 结果 2 轮函询专家积极系数为92.50%与97.30%,权威系数为0.87与0.88,协调系数为第1轮指标重要性W=0.247, 指标可行性W=0.121(P＜0.001) ; 第2轮指标重要性W=0.228, 指标可行性W=0.098(P＜0.001);构建的癌痛护理质量敏感指标包含3个一级指标、9个二级指标、19个三级指标。结论 构建的癌痛护理质量敏感指标评价体系具有专科特色,可应用于临床,评价其效果,进而在癌痛护理中推广使用。     

AAPT Diagnostic Criteria for Chronic Cancer Pain Conditions

Chronic cancer pain is a serious complication of malignancy or its treatment. Currently, no comprehensive, universally accepted cancer pain classification system exists. Clarity in classification of common cancer pain syndromes would improve clinical assessment and management. Moreover, an evidence-based taxonomy would enhance cancer pain research efforts by providing consistent diagnostic criteria, ensuring comparability across clinical trials. As part of a collaborative effort between the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) and the American Pain Society (APS), the ACTTION-APS Pain Taxonomy initiative worked to develop the characteristics of an optimal diagnostic system. After the establishment of these characteristics, a working group consisting of clinicians and clinical and basic scientists with expertise in cancer and cancer-related pain was convened to generate core diagnostic criteria for an illustrative sample of 3 chronic pain syndromes associated with cancer (ie, bone pain and pancreatic cancer pain as models of pain related to a tumor) or its treatment (ie, chemotherapy-induced peripheral neuropathy). A systematic review and synthesis was conducted to provide evidence for the dimensions that comprise this cancer pain taxonomy. Future efforts will subject these diagnostic categories and criteria to systematic empirical evaluation of their feasibility, reliability, and validity and extension to other cancer-related pain syndromes.

经皮腹腔神经丛阻滞治疗癌性疼痛

目的:评价CT引导下经皮腹腔神经丛阻滞(NCBP)治疗癌性疼痛的安全性和疗效。方法:11例晚期肿瘤伴持续性疼痛患者,在CT引导下采用双侧后路膈脚前阻滞法阻滞腹腔神经丛。结果:11例NCBP技术成功率100%。术后1周完全缓解(CR)7例、部分缓解(PR)3例、轻度缓解(MR)1例,有效率90.9%。术后2个月CR:5例、PR:3例、MR:3例,有效率72.7%。3例发生体位性低血压,3例出现轻中度腹泻。结论:CT引导下经皮腹腔神经丛阻滞治疗癌性疼痛,是一种安全、有效的方法。     

Pain in birds: a review for veterinary nurses

Pain assessment and management in animals is still a new and growing field of research. Although it is still early days for pain research in birds, this article aims to provide information on the pain behaviours known so far, and describes current analgesic drugs and doses.     

中国人癌症疼痛评估工具效度与信度的分析

目的 探讨香港钟慧仪博士研制适合中国文化背景的多层面的疼痛评估表,《中国人癌症疼痛评估工具》（Chinese Cancer Pain Assesment tool,CCPAT)的效度与信度。方法 测查319名癌痛患者,其中30名同时用CCPAT和马克盖尔疼痛调查表（The Mcgill Pain Quesionnaire,MPQ) 进行问卷,使用因素分析寻找量度疼痛概念有多少因素;通过集中癌痛组的CCPAT和MPQ有关项目进行相关总分计算测试,确立CCPAT的效度。另抽出30名患者由两名调查员用CCPAT量表同时进行问卷,将CCPAT每一项目作半机率选择,计算其信度系数,然后将其他患者用CCPAT进行问卷,计算其系数的平均值,测试在内部的一致性。结果 测查319名癌痛患者,CCPA与MPQ的变数相连,建立一致的效度,比率信度是0．96,内部一致性系数0．88。结论 验证该癌痛评估工具信度、效度良好。对临床评估癌痛病人的疼痛强度有较好的参考价值。