Factors contributing to poor post-operative abdominal pain management in adult patients: a review

Post-operative abdominal pain management can be a major issue facing medical and nursing staff in daily clinical practice. Effective pain control reduces post-operative morbidity as well as facilitates rehabilitation and accelerates recovery from surgery. In turn, poor pain control has been shown to alter body metabolic response that can lead to delayed recovery, with subsequent prolonged hospital stay and increased morbidity, and can lead to the development of a chronic pain state.Despite the significant developments in anaesthesia, delivery techniques and analgesia, post-operative abdominal pain management in adult patients remains suboptimal. Achieving effective pain management needs the implementation of an active approach in practice. This approach includes the provision of information and appropriate education tailored to the patients' needs and level of understanding, with the aim of reducing patient anxiety and avoiding unrealistic expectations. In addition, medical and nursing staff should continuously use the appropriate pain assessment tools to evaluate of post-operative pain in the surgical wards. Pain assessment needs to be regarded as the fifth vital sign and recorded on the patients observation chart.Analgesia should be used in a multimodal fashion and “by the clock” according to the patients needs. Moreover, governmental and professional guidelines need to be implemented to establish continuity of care, improve the quality of decision making and reduce unnecessary variations in practiceOverall, there is a need for improved post-operative abdominal pain management in adults to enhance recovery, patient safety and reduce morbidity. This can be achieved with the appropriate education backed up with robust policies and guidelines, supported by up to date evidence.     

Dental arch space changes following premature loss of primary first molars: a systematic review

PURPOSE: The purpose of this study was to consider the available evidence regarding premature loss of primary molars and the implications for treatment planning. METHODS: Electronic database searches were conducted--including published information available until July 2007--for available evidence. A methodological quality assessment was also applied. RESULTS: Although a significant number of published articles had dealt with premature primary molar loss, only 3 studies (including a total combined sample of 80 children) had the minimal methodological quality to be considered for this systematic review. CONCLUSION: A reported immediate space loss of 1.5 mm per arch side in the mandible and 1 mm in the maxilla--when normal growth changes were considered--was found. The magnitude, however, is not likely to be of clinical significance in most cases. Nevertheless, in cases with incisor and/or lip protrusion or a severe predisposition to arch length deficiency prior to any tooth loss, this amount of loss could have treatment implications.     

Optimization of high-resolution USPIO magnetic resonance imaging at 4.7 T using novel phantom with minimal structural interference

Purpose:

To characterize the effect of ultrasmall superparamagnetic iron oxides (USPIOs) on magnetic resonance imaging (MRI) signal at 4.7 T, and to find the highest sensitivity pulse sequence for high‐resolution USPIO MRI.

Materials and Methods:

A novel phantom was constructed for optimization of sequence parameters for neuroradiological MR applications, and a wide range of dilutions of the USPIO ferumoxtran‐10 was imaged using T₂/T₁‐, T₁‐, T₂‐, T* ₂‐, and PD‐weighted sequences. The effect of varying sequence parameters was investigated using phantom measurements and simulations.

Results:

The relaxivities r₁, r₂, and r*₂ of ferumoxtran‐10 at 4.7 T (21°C) were 5.1, 82.2, and 148.4 mmol^?1 L s^?1, respectively. Gradient echo sequences produced superior susceptibility artifacts at high concentrations; susceptibility artifacts were seen down to a concentration of 137 nmol Fe/mL. A concentration of 17.5 μmol Fe/mL caused a signal void independently of sequence and parameters, and at concentrations ≤273 nmol Fe/mL no signal void was caused. Signal enhancement on T₁‐weighted imaging was seen only at concentrations 137–547 nmol Fe/mL. For the same effective echo time T₂‐weighted rapid acquisition with relaxation enhancement (RARE) yielded significantly higher contrast‐to‐noise ratio with RARE factor 16 than with RARE factor 8.

Conclusion:

At nanomolar concentrations of USPIO, steady‐state free precession offers an alternative to T₂‐ and T* ₂‐weighted sequences. Optimum parameters depend highly on USPIO concentration. J. Magn. Reson. Imaging 2010;32:1184–1196. © 2010 Wiley‐Liss, Inc.

     

Evaluation of serum mesothelin in malignant and benign ovarian masses

Purpose

To evaluate the diagnostic accuracy of serum mesothelin levels in patients with ovarian masses in comparison to serum cancer antigen (CA) 125 levels.

Methods

This diagnostic accuracy study was conducted in a gynecological oncology unit at Ain Shams University Maternity hospital. Based on radiological and clinical findings, a total of 110 patients were consecutively recruited. Preoperative serum mesothelin levels were assessed using enzyme-linked immunosorbent assay (ELISA) technique, while CA125 levels were determined using electrochemiluminescence immunoassay. All patients underwent exploratory laparotomy. Preoperative serum levels of both markers were correlated to histopathological reports obtained from each patient.

Results

A total of 96 patients were finally analyzed. Of the included 96 patients, 58 (60.4 %) had a benign ovarian lesion, while 38 (39.6 %) had a malignant lesion. The median serum CA125 levels were significantly higher in patients with malignant ovarian lesions than in patients with benign ovarian lesions [335.5 mIU/mL (range 60–1,127 mIU/mL) versus 33.65 mIU/mL (range 10.36–174 mIU/mL), P < 0.001]. The median serum mesothelin level was significantly higher in patients with malignant ovarian lesions than in patients with benign ovarian lesions [104.1 nmol/L (range 6.5–215.4 nmol/L) versus 12.65 nmol/L (range 6.5–102 nmol/L), P < 0.001]. The diagnostic sensitivity and specificity for mesothelin and CA125 were 97.4 and 98.3 % and 97.4 and 56.9 %, respectively. The combination of mesothelin with CA125 did not add predictive value to mesothelin compared with mesothelin alone [same sensitivity (97.4 %) and same specificity (98.3 %)]. Serum mesothelin levels rather than serum CA125 levels were a significant predictor of early-stage ovarian malignancy [Area under the curve = 0.732, 95 % confidence interval (0.543–0.921), P = 0.031].

Conclusion

In ovarian cancer, mesothelin seemed to have the same sensitivity, but a higher specificity than CA125. Combination of mesothelin and CA125 had no advantage over mesothelin alone. Mesothelin rather than CA125 was a significant predictor of early-stage ovarian cancer (stage I/II).     

Yield of endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography for solid pancreatic neoplasms

Objective: Both endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) cytology may provide tissue diagnoses in solid pancreatic neoplasms. However, there are scant data comparing these two methods. This study aims at retrospectively comparing EUS-FNA and ERCP tissue sampling and ability of cytopathological diagnosis in solid pancreatic neoplasms and to determine usefulness and adverse events of combining both procedures. Material and methods: Two hundred and thirty four patients suspected to have solid pancreatic mass on abdominal ultrasound and/or computed tomography (CT) were enrolled. EUS-FNA (group A), ERCP cytology (group B) and combined procedures (Group C) performed in 105, 91 and 38 cases, respectively. Results: Sensitivity, specificity and accuracy were 98.9%, 93.3% and 98.1% for group A, and 72.1%, 60% and 71.4% for group B. Those for group C were all 100%. Sensitivity for malignancy in the pancreas head was 100% for group A and 82.4% for group B, and in the pancreas body and tail, 97.6% for group A and 57.1% for group B. EUS-FNA was more sensitive than ERCP cytology in diagnosing malignant pancreatic neoplasms 21–30?mm in size (p?=?0.0068), 31–40?mm (p?=?0.028) and?≥41?mm (p?Conclusions: EUS-FNA is superior to ERCP cytology for diagnosis of solid pancreatic neoplasms. Although combination of both procedures provide efficient tissue diagnosis and with a minimal adverse events rate, a prospective study including larger number of patients is required.     

Transcatheter administration of buffered Lidocaine for pain relief due to transarterial chemoembolization for HCC

Purpose

To assess the efficacy of intra-arterial Lidocaine on post-procedural pain and on length of hospital stay in hepatocellular carcinoma (HCC) patients undergoing chemoembolization.

Materials and methods

Thirty-nine transarterial chemoembolization (TACE) procedures were carried out for 21 consecutive patients (19M, 2F, age range 52–78).This is a prospective randomized controlled study. Lidocaine was used in 20 TACE and normal saline in 19 TACE. Visual analog scoring was used to assess pain (VAS).

Results

Patients’ demographic criteria, Child Pugh, tumor size and doses of chemotherapeutic emulsion and amount of used PV particles were not statistically significantly different between both groups. Average periprocedure VAS was 3.2 versus 7.4 for Lidocaine and Placebo groups, respectively (p = 0.0001). Postprocedure VAS in the Lidocaine group was 4.1 ± 1.6 and that for the Placebo group was 6.1 ± 1.3 (P = 0.001). Mean daily dose of Nalbuphine in the Lidocaine group was 8 mg versus 18 for patients in the Placebo group (p = 0.002). Average length of post procedure hospital stay was 3.7 and 3.8 days for Lidocaine and Placebo groups, respectively (P = 0.36).

Conclusions

Intra-arterial administration of buffered Lidocaine before infusing the embolization particle of TACE is safe and effective in dose as low as 50 mg for reducing peri and post-procedural pain and dosage of narcotic analgesics in patients with HCC.