Mechanisms and treatment issues for neuropathic pain

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Comparison of azithromycin and clarithromycin in triple therapy regimens for the eradication of Helicobacter pylori

OBJECTIVE: We sought to compare an azithromycin-based regimen with an already established clarithromycin-based regimen in the eradication of Helicobacter pylori infection. METHODS: A prospective, randomized, blinded comparative analysis was performed on 56 patients with upper GI symptoms who presented to the Gastroenterology Department at the Naval Medical Center Portsmouth. All patients had documented H. pylori infection on endoscopy via rapid urease test and histopathology. Patients were randomized to a treatment arm, which consisted of bismuth, clarithromycin, amoxicillin, and lansoprazole (B-LAC) or one consisting of bismuth, azithromycin, amoxicillin, and lansoprazole (B-LAA). To assess eradication, patients then received repeat endoscopy at 8 wk from entrance into the study. Rapid urease test and histopathology were again used to evaluate infection. Patients recorded all side effects. Comparison between the two groups was made using the chi2 method. RESULTS: Of the 56 patients included in the study, 27 went on to receive B-LAC, whereas 29 received B-LAA. The per protocol eradication rate was 84.6% with B-LAC and 55.5% with B-LAA (p = 0.021). Under intention to treat analysis, the eradication rates for B-LAC and B-LAA were 81% and 52%, respectively (p = 0.019). There was a significant difference between the two groups in number of subjects using nonsteroidal anti-inflammatory drugs (NSAIDs) (p = 0.013) and a trend toward a difference in histamine-2 (H2) blocker use (p = 0.066). Taking these two variables into account, a logistical regression was performed and continued to show a significant superiority in the B-LAC regimen (p = 0.03). CONCLUSIONS: The results of our study suggest that B-LAC is superior to B-LAA in the eradication of Helicobacter pylori. Our results also suggest that B-LAA is not a suitable regimen in the treatment of H. pylori because of its substandard eradication rate.     

Measuring program performance in methadone treatment using in-treatment outcomes: An illustration

Quality measurement and quality assurance in substance abuse treatment have, over the past few years, become a major policy issue. In addition, there is interest in the degree to which client outcomes can play a role in measuring treatment program performance. This article discusses the movement toward outcome-based performance measureemnt in substance abuse treatment. Examples of the products that such a performance measurement system might produce are provided. Why outcomes must be case-mix adjusted is discussed. In addition, using data from 18 methadone programs and more than 2,000 methadone clients from the Treatemnt Outcome Prospective Study, an illustration of case-mix-adjusted performance measurement is provided.     

Choice of payment plan in the Medicare capitation demonstration

This article identifies factors that influence the choice between joining an HMO and remaining with the traditional fee-for-service system among aged Medicare beneficiaries in three communities. Sources of marketing information were found to be strongly and positively related to the decision to join the HMO. Among beneficiaries who had to switch providers to join, persons who had a prior usual source of care and those who were satisfied with the amount of paperwork required to use that source of care were less likely to enroll in the HMO. Persons who did not have to switch providers to join the HMO were more likely to enroll in the prepaid program if they were satisfied with the amount of paperwork involved in using the HMO prior to the demonstration. Differences among the three communities suggest that the barrier to HMO enrollment presented by having a prior source of care who is not affiliated with the HMO may attenuate as the number of competing HMOs in the community increases, making the medical care environment more competitive. In the community with the most HMOs, persons who already had supplemental insurance were less likely to enroll than those who did not. None of the six HMOs studied experienced adverse selection, based on pre-enrollment health status.     

Measuring program performance in methadone treatment using in-treatment outcomes: an illustration

Quality measurement and quality assurance in substance abuse treatment have, over the past few years, become a major policy issue. In addition, there is interest in the degree to which client outcomes can play a role in measuring treatment program performance. This article discusses the movement toward outcome-based performance measurement in substance abuse treatment. Examples of the products that such a performance measurement system might produce are provided. Why outcomes must be case-mix adjusted is discussed. In addition, using data from 18 methadone programs and more than 2,000 methadone clients from the Treatment Outcome Prospective Study, an illustration of case-mix-adjusted performance measurement is provided.     

Levetiracetam as an adjunctive analgesic in neoplastic plexopathies: case series and commentary

Certain types of pain associated with cancer may be difficult to treat with standard therapies, often resulting in intractable pain and suffering for the patient. The use of an opioid as analgesic monotherapy can lead to poorly controlled pain as well as multiple side effects. Non-opioid adjunctive analgesics, such as antidepressants and antiepileptic drugs (AEDs) often improve both pain control, and side effect prevalence. Levetiracetam is an AED with unique mechanisms of action that may have analgesic properties in various pain syndromes. Seven patients with neoplasms involving neural structures (four invading the brachial plexus, and three the lumbosacral plexus) had severe pain of 8 to 9 out of 10 on a visual analog scale (VAS), despite the use of parenteral opioids and various adjunctive therapies. These patients were treated with oral levetiracetam titrated over days to two weeks, depending on the location of pain, drug response, and tolerance to tapering of opioid analgesics. Opioid and adjunctive analgesic use and VAS scores were recorded periodically. The maximum levetiracetam dose ranged from 500 mg to 1500 mg BID. All patients experienced pain control improvement after the addition of levetiracetam, with VAS scores decreasing from 8-9 out of 10 to 0-3 out of 10 within two to 14 days of therapy initiation. Overall opioid use decreased by at least an estimated 70%, without drug related adverse events. In this small series of patients, levetiracetam effectively and safely improved pain relief in patients with neoplastic plexopathies previously resistant to standard analgesic approaches.     

Anticipating and treating opioid-associated adverse effects

Opioids are frequently avoided as viable tools in the management of pain due to perceived dangerous or untoward adverse drug events. Whilst they are relatively safe options for the treatment of pain, side effects and toxicities do exist and should be anticipated by the provider. The central nervous, gastrointestinal, genito-urinary, integumentary, metabolic/endocrine, cardiovascular, pulmonary, hepatic/renal, ocular and immune systems all manifest changes associated with opioid therapy. These adverse events, ranging from nuisance to therapy-limiting, are manageable when addressed quickly and appropriately. Opioids are safe and efficacious analgesics when these effects are considered.