Brief Alerts
September 1, 1999 3 minutes read
Brief Alerts
Pain: Mechanisms and Treatment
Sources:Carr DB, Goudas LC. Acute pain. Lancet 1999; 353:2051-2058; Cervero F, Laird JM. Visceral pain. Lancet 1999;353:2145-2148; McQuay H. Opioids in pain management. Lancet 1999;353:2229-2232; Chapman CR, Gavrin J. Suffering: The contributions of persistent pain. Lancet 1999; 353:2233-2237.
Pain is one of the most frequent symptoms brought to physicians and, especially, neurologists. Anesthesiologists have brought important, temporary treatment to the problem, but neither general nor regional anesthesia scores high in the management/treatment of chronic pain. Neurologists, despite their considerable contact with patients suffering chronic pain, have given only limited attention to increasing new knowledge about both new and chronic pain, as well as their different pathways to successful management. The Lancet, published in London and increasingly carrying information reports relevant to clinical neurology, has recently devoted 10 successive articles addressing new knowledge about pain mechanisms and their management. Starting with an overview of pain responses (Loeser JD, Melzack R. Lancet 1999; 353:1607-1609) and their neurobiology (Besson JM. Lancet 1999;353:1610-1615), the series proceeds with the following weekly informative chapters: cancer pain (Portenoy RK, Lesage P. Lancet 1999;353:1695-1700); assessment of patients’ reporting pain (Turk DC, Okifuji A. Lancet 1999;353:1784-1788); chronic pain management (Ashburn MA, Staats PS. Lancet 1999;353:1865-1869); and neuropathic pain (Woolf CJ, Mannion RJ. Lancet 1999;353:1959-1964). —fp
Oxygen for Carbon Monoxide Poisoning
Source: Scheinkestel CD, et al. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: A randomized controlled clinical trial. Med J Aust 1999;170:203-210.
Your editor, not having direct access to the original journal, presents here its critical points as summarized by the American College of Physicians Journal Club (ACP J Club 1999;131:11). The gist of the extraction is that of 191 patients with carbon monoxide poisoning, 104 were randomized to hyperbaric oxygen (HBO) at 2.8 atmospheres for 100 minutes ´ 3 days, whereas 87 patients were placed in the chamber and inhaled 100% oxygen at 1.0 atmosphere following the previous protocol. Patients who remained severely damaged repeated the pressure/atmosphere procedure for three extra treatments. All patients underwent a battery of seven neuropsychologic tests after they recovered to a reasonable steady state. Although more HBO patients had more second round treatments than the NBO group, differences in the groups’ ultimate neuropsychologic scores did not differ from each other except that the NBO group had better scores than the HBOs in auditory verbal learning.
Commentary
Your editor has long doubted the value of HBO in this setting. Small one-person pressure chambers have been placed entrepreneurially in the United States and, without scientific trial, recommended for improving outcome from asphyxia, brain trauma, or stroke. Indeed, the state of Florida actually reimburses the costs of these gadgets without any scientific evidence of their specific therapy. It’s time for neurologists to develop strong and ethical neurological rehabilitation centers based on strong scientific underpinnings, lest evermore dubious and expensive devices raise rehabilitation costs. —fp
Aspirin for Carotid Endarterectomy
Source: Taylor DW, et al. Low-dose and high-dose acetylsalicylic for patients undergoing carotid endarterectomy: A randomised, controlled trial. Lancet 1999;353:2179-2184.
Taylor and colleagues found that 2849 patients randomized for endarterectomy taking 81 or 325 mg of aspirin had a significantly (P = 0.002 [30 days] or P = 0.0002 [3 months]) lower risk of stroke, myocardial infarction, and death than did patients taking 650 mg or 1300 mg of the drug. The outcome speaks for itself. —fp
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