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Am Fam Physician. 1998;57(8):1929-1930

Parents Can Effectively Manage Children's Pain After Surgery

(Annual Meeting of the American Society of Anesthesiologists) A survey of more than 450 parents whose children had undergone outpatient surgery revealed that parents are effective at managing their children's pain following surgery. The survey was also administered to the nurses of the children who had undergone surgery and found that there was a discrepancy between the nurses' ratings of the children's pain and the parents' ratings of the children's pain. The nurses reported that all of the children had minimal pain on discharge from the hospital. However, according to the parents, 18 percent of the children had moderate to severe pain on discharge. The children whose parents rated the pain as being higher than the nurses' rating were significantly more likely to actually have problems with postsurgical pain over the next 24 hours. Seventy-two percent of the parents noted that they gave the prescribed pain medication according to instructions (of the remaining 28 percent, 23 percent gave less medication than recommended and 5 percent gave more). Nearly 90 percent of the parents reported that they had no difficulty caring for their children at home following surgery. The investigators believe that the survey findings suggest parents have significant insight into their children's behavior and are better able to assess pain in their children than others.—hamish m. munro, m.d., et al., C.S. Mott Children's Hospital, Ann Arbor, Mich.

Data Challenges Theory That Epidural Anesthesia Causes More Cesareans

(American Society of Anesthesiologists) Results of a retrospective study that analyzed labor and delivery data for 6,928 consecutive patients indicate that labor epidural anesthesia does not increase a woman's risk of having a cesarean section delivery. The cesarean delivery rates in nulliparous mothers were compared during the 12 months before an on-demand epidural analgesia service became available at a hospital (3,195 women in group 1) and the 16 months after (3,733 women in group 2) the service became available. The delivery route, indications and risk factors for cesarean section were recorded. The same groups of obstetricians and anesthesiologists supervised all of the births and use of anesthetics. No significant differences in cesarean section rates were noted before or after the introduction of the epidural anesthesia service. The greater use of epidural analgesia in the women requiring dystocia cesarean section in group 2 supports the hypothesis of the investigators that severe labor pain and dystocia have a common etiology. Similar findings were reported in two other presentations at the meeting.—steven t. fogel, m.d., et al., Washington University School of Medicine, St. Louis.

New Anesthetics and New Drug Combinations Deliver Better Pain Relief

(American Society of Anesthesiologists) New drugs and new uses of local anesthetics may reduce the degree of pain that patients have, according to a presentation on the use of improved local anesthetics, new combinations of local anesthetics and improved methods of administration. The new drug ropivacaine, recently approved by the U.S. Food and Drug Administration, provides a high degree of numbness when used in a continuous infusion but does not inhibit movement as much as other local anesthetics. In addition, ropivacaine has a better safety profile than the most commonly used long-acting local anesthetic. Another medication, clonidine, a drug that is used to treat high blood pressure, can be used in a low-dose combination with local anesthetics and narcotics to provide nearly complete and long-lasting pain relief. Low doses of each drug are used, reducing the severity of side effects. Because clonidine is used to lower blood pressure, it may not be appropriate in some patients. New ways of administering pain-relieving medications include direct infiltration of the wound and the placement of catheters along the nerves that carry pain from the wound. One example of direct infiltration of the wound site with pain medication is the use of an aspirin-like drug after surgery for carpal tunnel syndrome, which reduces the amount of pain and pain medication required. The catheter technique allows a continuous infusion of the local anesthetic medication to be administered.—f. kayser enneking, m.d., University of Florida College of Medicine, Gainesville, Fla.

Common Criteria for Stroke Surgery May Underestimate Risk in Women

(83rd Scientific Assembly and Annual Meeting of the Radiological Society of North America) Criteria established by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) that are commonly used to determine if persons at risk of stroke should undergo endarterectomy or receive drug therapy may underestimate the risk of stroke in women and overestimate it in men. This was the conclusion of a study of 21 men and 19 women with carotid artery disease. The study determined that the normal internal carotid arteries of women are smaller than those in men. Results of computed tomographic evaluation showed that the average size of carotid arteries differed between men and women by a minimum of 10 to 15 percent. The NASCET criteria do not take into account a difference in the size of carotid arteries. The criteria state that persons of both sexes with 70 percent stenosis or greater may benefit from endarterectomy. Patients are usually treated with medication until a 70 percent stenosis is noted. The 70 percent stenosis criterion requires a smaller residual diameter and area for women, compared with men. The investigators believe that a different percentage of blockage should be considered to determine the threshold at which women and men need to undergo endarterectomy.—lisa tartaglino, m.d., et al., Thomas Jefferson University Hospital, Philadelphia.

Three-Dimensional Technique May Eliminate Unnecessary Breast Biopsies

(Radiological Society of North America) A widely available digital technology that can be adapted to create three-dimensional pictures of the breast shows promise in ruling out breast cancer in women who have suspicious findings on mammography, and may help avoid surgical biopsies in these women. This is the conclusion of a study that compared the efficacy of the three-dimensional technique with that of magnification mammography (a conventional radiograph technique that images a specific area of the breast) and two-dimensional images obtained with the stereotactic digital system. The study included 44 women with abnormal mammographic findings. The three-dimensional technique was accurate in 77 percent of the cases, compared with a 64 percent accuracy rate with the two-dimensional technique and 36 percent with the conventional radiograph technique. Of 14 cancers identified in the women, none were misdiagnosed by the three-dimensional technique. The three-dimensional technique is an adaptation of a digital technology used to guide needle biopsies in the diagnosis of breast cancer.—andrew d. maidment, ph.d., et al., Thomas Jefferson University Hospital, Philadelphia.

New Treatment Relieves Severe Foot Pain in Persons with Diabetes

(13th Annual Meeting of the American Orthopaedic Foot and Ankle Society) Results of a study of patients with diabetes indicate that the use of mexiletine may provide long-term relief of painful diabetic neuropathy and allow these patients to return to their former levels of activity. The study included 35 patients with diabetes who received 150 mg of mexiletine, a drug similar to the local anesthetic lidocaine, two or three times per day. The dosage was adjusted according to the patient response to the medication. The medication was continued for three months and then tapered off. If pain returned, the patients started treatment again with the lowest effective dose. Pain was reduced in 32 of the patients with an average rate of improvement of at least 50 percent. Three subjects reported nausea with the medication and dropped out of the study. About 50 percent of the patients had long-term improvement in their pain.—robert vander griend, m.d., Gainesville, Fla.

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