经静脉与硬膜外两种自控镇痛方式效果的系统评价

目的系统评价术后经静脉与硬膜外自控镇痛的镇痛、镇静效果和不良反应。方法计算机检索Cochrane图书馆（2008年第9期）、Cochrane协作网麻醉组专业协作组数据库、MEDLINE（1966-2008．9）、EMbase（1966～2008．9）、PubMed（1966～2008．9）、中国生物医学文献数据库（1979～2008．9）、CNKI;手工检索《中华麻醉学杂志》、《临床麻醉学杂志》及国内外相关会议论文,收集术后经静脉与硬膜外自控镇痛的随机和半随机对照试验,并评价纳入研究的方法学质量。Meta分析采用RevMan4．2．8软件。结果共纳入13个研究,包括580例患者。Meta分析结果显示,在术后2、4、8、12及24h几个时点,其镇痛、镇静差异均无统计学意义;在镇痛效果相同的情况下,两组血浆芬太尼浓度差异无统计学意义;术后两组不良反应发生率差异亦无统计学意义。结论经静脉自控镇痛和经硬膜外自控镇痛均能得到满意的临床治疗效果。而且经静脉自控镇痛避免了硬膜外穿刺及其并发症的发生,还具有携带方便、操作简单、可减少医疗费用等优点。因本系统评价纳入研究的质量不高,病例数较少,上述结论尚需开展更多设计严谨的大样本随机对照试验加以验证。     

Laser-assisted Anesthesia Prior to Intravenous Cannulation in Volunteers: A Randomized, Controlled Trial

Background: Intravenous cannulation is common and painful. Absorption of topical anesthetics is limited by the stratum corneum, the outermost layer of the epidermis. A single pulse of an erbium:yttrium–aluminum–garnet (Er:YAG) laser irradiation can remove an area of the stratum corneum, leading to enhanced uptake of topical agents, such as lidocaine, while leaving the rest of the epidermis intact. Objective: The authors hypothesized that pretreatment of the skin with laser‐assisted anesthesia would reduce the pain of venous cannulation. Methods: This was a blinded, randomized, controlled clinical trial. Subjects were 30 healthy adult volunteers. Standardized venous cannulation was performed on the dorsum of both of each subject's hands. In the study hand, the area over the target vein was pretreated with a lightweight, portable Er:YAG unit, with a fluence of 3.5 J/cm², a pulse width of 600 microseconds, and a spot diameter of 6 mm. Lidocaine 4% cream was applied to the area. After 5 minutes, the cream was wiped off and a nurse inserted an intravenous (IV) catheter and verified placement. In the control hand, a sham laser was used. Pain of laser application and pain of IV cannulation were recorded on a validated 100‐mm visual analog scale (VAS) marked “most pain” at the high end. The presence of burns, infection, and scarring at one week and at three months after the study was also noted. The levels of pain of cannulation were compared using a paired t‐test. Results: Mean subject age was 32 years; 43% were female. The mean pain of cannulation after laser‐assisted lidocaine application (13 mm, 95% CI = 8 to 19) was significantly less than after application of sham laser (29 mm, 95% CI = 22 to 36; mean difference, 15 mm, 95% CI = 6 to 24). No subject had persistent erythema or scarring. Conclusions: Pretreatment of the skin with a laser device followed by a 5‐minute topical lidocaine application reduces the pain of IV cannulation in volunteers.     

The Effect of Position Support During Orthopedic Surgery on Postoperative Pain: A Randomized Controlled Trial

BackgroundPositional pain affect the patient’s healing process after the operation. Anti-pressure positioning pads are medical products used to support the patient positioning during surgical procedures.AimsThe aim of the study was to examine pain related to positioning when anti-pressure gel pads and current visoelastic sponge support options are used during orthopedic surgical cases.DesignThe randomized controlled experimental study.SettingsThe operating room of an educational research hospital.Participants/SubjectsThe study consisted of 100 patients (50 control group and 50 study group) undergoing surgery in a supine position.MethodsInformation form, McGill Melzack Pain Questionnaire, and Visual Analogue Scale were used for data collection. Routine institutional policy was applied to the control group. Study group patients were additionally supported with antipressure position gel pads on the operating table.ResultsThe rate of pain presence in areas other than the operative area was significantly lower in the patients in the study group (p = .001). The patients in the control group reported that preoperative pain in the waist area increased to unbearable levels during operation. In addition, it was noted that the “addition of the anti-pressure gel pads” resulted in study group patients being mobilized significantly early (p = .001).ConclusionsThe conclusion of this study demonstrated that postoperative pain related to positioning, not the surgical procedure itself, was decreased when antipressure gel pads and viscoelastic sponge support were used together. An unanticipated benefit discovered during the study was earlier mobilization of the study group compared to the control group.     

The THINK (Treatment of Headache with Intranasal Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine with Intravenous Metoclopramide

Background

Headache is a common chief complaint in the emergency department (ED) setting.

2种注射哌替啶镇痛方法在顺产产妇中的应用效果比较

目的比较顺产产妇自控镇痛泵注射哌替啶和护士注射哌替啶的效果。方法将64例宫颈口扩张3 cm的产妇采用随机数字表法分为两组,对照组由护士根据产妇的要求注射哌替啶,观察组由产妇进行自控镇痛,比较两组产妇的镇痛效果、用药量、用药后不良反应和满意度。结果产妇自控镇痛与护士根据产妇需要镇痛的镇痛效果相当,但产妇自控镇痛用药量大,新生儿窒息发生率高,满意度较低,差异有统计意义(P<0.05)。结论产妇自控镇痛的疗效等同于护士控制的镇痛,但由于哌替啶用量增大,对新生儿有一定的威胁,临床应谨慎使用。     

A Randomized Controlled Trial of Intravenous Aminophylline for Atropine-resistant Out-of-hospital Asystolic Cardiac Arrest

OBJECTIVES: Myocardial ischemia, during cardiopulmonary arrest, can lead to atropine-resistant bradyasystole from interstitial accumulation of endogenous adenosine. Aminophylline is a nonspecific adenosine receptor antagonist capable of reversing ischemia-induced bradyasystole in a variety of settings. The hypothesis of this study was that aminophylline improves the rate of return of spontaneous circulation (ROSC) in atropine-resistant asystolic out-of-hospital cardiac arrest when used early in the resuscitation effort. METHODS: This was a prospective, randomized, double-blinded, placebo-controlled trial set in an urban emergency medical services system serving a population of 250,000. All non-pregnant, normothermic adults suffering nontraumatic out-of-hospital cardiac arrest (February 1999 to August 2000) with asystole were eligible. Patients remaining in asystole after initial doses of epinephrine and atropine received either aminophylline 250 mg or matching placebo as a bolus injection through a peripheral intravenous line. All other aspects of the attempted resuscitation proceeded in accordance with standard Advanced Cardiac Life Support (ACLS) guidelines. A sample size of 102 patients was calculated to yield a power of 80% to show an absolute improvement of 25% in ROSC. The aminophylline and control groups were compared by calculating 95% confidence intervals (95% CIs) and the data were modeled using logistic regression. RESULTS: The investigators enrolled 112 consecutive patients. One subject was dropped prior to analysis because of missing data. Data for 111 patients were analyzed on an intention-to-treat basis. Baseline characteristics were similar for the two groups. Comparing the control and aminophylline groups, ROSC was achieved in 15.6% (95% CI = 6% to 29%) and 22.7% (95% CI = 13% to 35%), while reversal of asystole occurred in 26.7% (95% CI = 15% to 42%) and 40.9% (95% CI = 29% to 54%), respectively. Group allocation had an odds ratio of 1.8 (95% CI = 0.6 to 5.3) for ROSC. Witnessed arrest was an independent predictor of outcome with an odds ratio of 3.8 (95% CI = 1.3 to 11.2). CONCLUSIONS: Addition of aminophylline appears to be a promising new intervention in the ACLS treatment of atropine-resistant asystolic out-of-hospital cardiac arrest.     

A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain

Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain.

Objective

To determine whether neck manipulation is more effective for neck pain than mobilization.

Design

Randomized controlled trial with blind assessment of outcome.

Setting

Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.

Participants

Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner.

Interventions

Participants were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks.

Main Outcome Measure

The number of days taken to recover from the episode of neck pain.

Results

The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization (hazard ratio=.98; 95% confidence interval, .66-1.46).

Conclusions

Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.     

Oxytrex Minimizes Physical Dependence While Providing Effective Analgesia: A Randomized Controlled Trial in Low Back Pain

Physical dependence or withdrawal is an expected effect of prolonged opioid therapy. Oxytrex (oxycodone + ultralow-dose naltrexone) is an investigational drug shown here to minimize physical dependence while providing strong analgesia with twice-daily dosing. In this 719-patient, double-blind, placebo- and active-controlled Phase III clinical trial in chronic low back pain, patients were randomized to receive placebo, oxycodone qid, or oxytrex qid or bid. Each oxytrex tablet contains 1 microg naltrexone; oxytrex bid and qid treatments provide 2 and 4 microg naltrexone/day, respectively. Following a washout, patients with pain >or=5 on a 0-10 scale were dose-escalated weekly from 10 up to 80 mg/day until reaching adequate pain relief (相似文献   

Preemptive Analgesia in Laparoscopic Cholecystectomy: A Randomized Controlled Study

Abstract:   In pain control after laparoscopic cholecystectomy, subhepatic administration of bupivacaine immediately after the creation of pneumoperitoneum has been shown to be more effective than administration before the withdrawal of the trocars. We aimed to investigate the effect of intraperitoneal bupivacaine administration to the subhepatic area before the creation of the pneumoperitoneum. Eighty patients undergoing elective laparoscopic cholecystectomy under general anesthesia were included in a prospective, randomized study. Patients received 20 mL of 0.5% bupivacaine in the subhepatic area just after intubation, before pneumoperitoneum (group 1), immediately after the creation of the pneumoperitoneum (group 2), just before the removal of the trocars (group 3), or received no local anesthetic (group 4). The degree of the postoperative pain was assessed at 0, 4, 8, 12, and 24 hours after the surgery. The consumption of analgesics (diclofenac sodium) was also recorded. The pain scores and analgesic consumption did not differ among groups 1, 3, and 4. The pain scores of group 2 were lower at each time point compared to the other groups ( P  < 0.001). Postoperative analgesic consumption in group 2 was reduced compared to the other groups (23.4 ± 35.9 mg vs. 80.0 ± 66.3 mg, P  = 0.005 [group 1], 69.6 ± 62.2 mg, P  = 0.026 [group 3], and 70.0 ± 59.9 mg, P  = 0.022 [group 4]). The subhepatic infiltration of 20 mL of 0.5% bupivacaine offers good postoperative analgesia when applied just after the creation of the pneumoperitoneum, not before the pneumoperitoneum or after the termination of the pneumoperitoneum.     

Effects of Neurofeedback on Fibromyalgia: A Randomized Controlled Trial

BackgroundFibromyalgia is a chronic widespread pain condition that is associated with sleep disturbances and cognitive impairments. Neurofeedback has been demonstrated to improve pain, sleep quality, and fatigue. However, few studies have examined the effect of neurofeedback for patients with fibromyalgia.AimTo determine the effects of neurofeedback on pain intensity, symptom severity, sleep quality, and cognitive function in patients with fibromyalgia.DesignThis study was a randomized controlled trial.MethodEighty participants were randomized to a neurofeedback group (N = 60), receiving sensorimotor and alpha rhythm feedback for 8 weeks, or a telephone support group (N = 20).ResultsResults from the generalized estimating equation modelling revealed significant group-by-time interactions for Brief Pain Inventory pain severity (B = −1.35, SE = 0.46, p = .003) and pain interference (B = −1.75, SE = 0.41, p < .001), Revised Fibromyalgia Impact Questionnaire total scores (B = −16.41, SE = 3.76, p < .001), sleep onset latency (B = −25.33, SE = 9.02, p = .005), and Psychomotor Vigilance Test error (B = −1.38, SE = 0.55, p = .013) after adjustments for age, sex, duration of illness, and group differences at baseline.ConclusionsAn 8-week neurofeedback training regimen of sensorimotor rhythm and alpha brain waves significantly improved pain severity and interference, fibromyalgia symptom severity, sleep latency, and sustained attention in patients with fibromyalgia.     

A Qualitative Analysis of a Randomized Controlled Trial Comparing a Cognitive-Behavioral Treatment With Education

Cognitive behavioral therapy (CBT) is a widely accepted psychosocial treatment for chronic pain. However, the efficacy of CBT has not been investigated within a rural setting. Furthermore, few studies have utilized first-person accounts to qualitatively investigate the key treatment elements and processes of change underlying the well-documented quantitative improvements associated with CBT. To address these gaps, we conducted a randomized controlled trial (RCT) investigating the efficacy of group CBT compared to an active education condition (EDU) within a rural, low-literacy population. Posttreatment semistructured interviews of 28 CBT and 24 EDU treatment completers were qualitatively analyzed. Emerging themes were collated to depict a set of finalized thematic maps to visually represent the patterns inherent in the data. Patterns were separated into procedural elements and presumed change processes of treatment. Key themes, subthemes, and example extracts for CBT and EDU are presented; unique and shared aspects pertaining to the thematic maps are discussed. Results indicate that while both groups benefited from the program, the CBT group described more breadth and depth of change as compared to the EDU group. Importantly, this study identified key treatment elements and explored possible processes of change from the patients’ perspective.

Perspective

This qualitative article describes patient-identified key procedural elements and change process factors associated with psychosocial approaches for chronic pain management. Results may guide further adaptations to existing treatment protocols for use within unique, underserved chronic pain populations. Continued development of patient-centered approaches may help reduce health, treatment, and ethnicity disparities.     

术前经直肠超声评估直肠癌手术方案的随机对照试验

目的探讨经直肠超声（transrectal ultrasound，TRUS）术前评估对直肠癌手术方案选择的影响。方法纳入病理诊断为直肠癌且肿瘤下缘距齿状线≤10cm者110例，将患者根据电脑产生的随机序列随机分为A组和B组，每组各55例。A组患者术前行TRUS评估分期和Clinical Stage System（CS分期），B组患者术前只行CS分期。记录术前TRUS分期、CS分期和预计手术方案，与术后病理分期和实际手术方案进行比较。结果本研究纳入研究病例99例，A组49例，B组50例，两组基线差异无统计学意义。A组行TRUS分期的准确度为91．8％，B组行CS分期的准确度为48．0％，二者差异有统计学意义（P=0．000）。A组术前预测手术方案的准确度为93．9％，B组为76．0％，二者差异也有统计学意义（P=0．013）。结论TRUS评估直肠癌术前分期的准确性明显高于CS分期，运用TRUS进行术前评估可以使术前预估直肠癌手术方案的准确性明显提高，TRUS在直肠癌术前评估中具有较高的临床应用价值。     

Addressing Self-Control Cognitions in the Treatment of Trichotillomania: A Randomized Controlled Trial Comparing Cognitive Therapy to Behaviour Therapy

People with trichotillomania often have persistent negative beliefs about giving into one’s habit. Central in the present study was the hypothesis that the follow-up effects of cognitive therapy (CT), in which these negative beliefs are directly addressed, are better compared to the follow-up effects of behaviour therapy (BT). Fifty-six trichotillomania patients were randomly assigned to either six sessions CT or BT. Forty-eight completed their treatment. Follow-up measurements took place after a 3 months treatment-free period, and at 12 and 24 months. CT and BT both resulted in clear reductions of trichotillomania symptoms (severity, urge, inability to resist, and negative beliefs) immediately after treatment. There were no differences between the groups. Following the treatment-free period, there was a reoccurrence of symptoms. In contrast to our expectation, we failed to show that CT compared to BT resulted in lower relapse rates after the treatment-free period.     

A Randomized Controlled Clinical Trial Comparing Ventricular Fibrillation Detection Time Between Two Transvenous Defibrillator Models

The Ventak AV is an implantable cardioverter defibrillator with dual chamber pacing capability. Features include detection and treatment of ventricular arrhythmias, detection of atrial arrhythmias, as well as dual chamber pacing. The objective of the investigation was to verify the efficacy of the Ventak AV in detecting ventricular fibrillation in the presence of dual chamber pacing. Thirty-three patients, who were to receive an implantable defibrillator were randomized (1:1) in a paired comparison study to the Ventak AV (study device) and the Ventak Mini (control) during defibrillation threshold testing. In order to create a "worst case scenario" for sensing of ventricular fibrillation, pacing was performed at high lower rate limit values (Ventak AV DDD pacing at 150/min, Ventak Mini at VVI 100/min). Ventricularfibrillation was induced and the randomized device was allowed to detect and treat the arrhythmia. This test was repeated for each patient using the alternate device in a randomized order, such that all patients were tested with both devices. The mean ventricular fibrillation detection time for the Ventak AV was 2.0+/-0.11 seconds and for the control device the detection time was 1.8+/-0.11 seconds (P = 0.26). Appropriate tachyarrhythmia therapy decision was documented in all episodes for both devices. The study patient population demonstrated equivalent ventricular fibrillation detection time between the Ventak AV and the Ventak Mini. The Ventak AV demonstrated effectiveness in detecting ventricular fibrillation in the presence of high rate dual chamber pacing.