Chronic pain and opioids: dispelling myths and exploring the facts.

Opioid use for chronic non-malignant pain remains controversial and is surrounded by myths and misconceptions. As new research emphasises the importance of early effective pain management, comprehensive, well-researched guidelines may help the care of patients with chronic non-malignant pain.

An audit of 405 temporomandibular joint arthrocentesis with intra-articular morphine infusion.

The management of refractory pain in the temporomandibular joint (TMJ) is both challenging and controversial. Arthrocentesis is a simple technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. We undertook an audit of 405 arthrocenteses in 298 patients over a 10-year period who had refractory pain in the TMJ.

Stability of the sternoclavicular joint. A retrospective study.

Enlargement of the sternoclavicular joint is a well-documented but little recognised complication of radical neck dissection [AJR 3 (1971) 584]. We examined the stability of the sternoclavicular joint in 61 patients who had had radical neck dissection, functional neck dissection or sternomastoid division in the treatment of torticollis. Our findings support the hypothesis that postoperative stability of the sternoclavicular joint depends on the integrity of the accessory nerve and probably the proprioceptive branches of C3 and C4 of the cervical plexus.

Stabilising the leg to harvest a fibular flap: a new device.

A simple stabilisation device is described that facilitates easy harvesting of a fibular free flap.

A prospective randomised trial of two treatments for wound seroma after breast surgery.

Aims: Seroma formation is a recognised complication of breast surgery causing wound pain and discomfort. It was hypothesised that daily aspiration of symptomatic seromas that formed after breast surgery would encourage flap adherence to the chest wall, thereby allowing swifter resolution of seroma.

Methods: Thirty-six patients undergoing mastectomy and/or axillary clearance who formed seroma post operatively, were randomised into two groups either having daily aspiration of seroma or aspiration as required by patient symptoms.

A critical audit of the surgical management of intractable epistaxis using sphenopalatine artery ligation/diathermy.

An audit of the local practice of sphenopalatine artery (SPA) ligation/diathermy was undertaken following its introduction to the unit in April 1998. The authors looked to the literature for evidence of what was to be taken as a successful result and were surprised at the lack of published data on its efficacy or lack thereof. Fivehundredsixtythree patients were admitted for inpatient management of epistaxis over a two-year period.

Outcome after radial forearm, gastro-omental, and jejunal free flaps in oral and oropharyngeal reconstruction.

We undertook a retrospective study of the outcome of radial forearm, gastro-omental, and jejunal free tissue transfer for oral and oropharyngeal reconstruction in 30 patients (10 in each group). No significant differences were found between the type of free flap and the clinical outcome. More long-term difficulties were experienced with swallowing than with speech.

Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial.

Objectives: To evaluate cardiovascular fitness exercise in people with fibromyalgia.

Design: Randomised controlled trial.

Setting: Hospital rheumatology outpatients.

An education programme for people with cancer.

Evidence suggests that cancer patients want support, information and to be involved in treatment decisions. A course designed in the USA aims to help cancer patients learn more about the disease and become an informed part of the therapeutic team. The introduction of a similar course at one UK centre suggested that it is an effective way of informing and supporting people.

Obstetric anaesthetists' workload.

The current recommendation of one consultant session per 500 deliveries with full sessional cover for units over 3000 deliveries is arbitrary and is not based on workload. The Audit Commission has questioned the wide variability of anaesthetic staffing on labour wards. The aim of this study was to investigate whether there is a relationship between current workload and obstetric anaesthetic staffing in five maternity units.

Back pain management: a patient satisfaction study of services.

The objectives of this study were to assess patient satisfaction with the current services provided for back pain, and to increase the level of understanding from the patients' perspective on beliefs about their back pain and how it affects their daily life. The study was conducted in two parts combining both quantitative and qualitative methodology. The main findings in the study revealed a high level of satisfaction with the services provided by the physiotherapy department and mixed levels of satisfaction with the GP.

The diagnosis and consequences of Stickler syndrome.

The objective was to study the expressivity of Stickler syndrome in affected children and adults in the UK and to highlight issues for improving early diagnosis, treatment and counselling. A postal questionnaire survey of the 216 members of the Stickler Syndrome Support Group was carried out. Of the 153 (71%) who responded to the questionnaire, 48 (61%) of adults and 15 (20%) of children had experienced retinal detachment; 36 (49%) of the children and 18 (23%) of the adults were born with a cleft palate.

Improving pain management: breaking down the invisible barrier.

There is compelling evidence that despite growing research into the complex neurophysiology of pain, the development of acute pain services, increasing educational interest in pain management and the proliferation of literature, many patients continue to suffer from unrelieved acute pain while in hospital. Educational efforts to bring about a change in practice have been relatively unsuccessful or slow to have real impact. Although it is still recognized that poor knowledge of pain control by all healthcare professionals is the major barrier to improving pain management, contemporary studies show that other, more subtle barriers can just as effectively inhibit a timely and effective response to patients' reports of pain.

Later management of documented ischaemic heart disease: secondary prevention and rehabilitation.

Patients may present with a variety of syndromes related to ischaemic heart disease. These include unstable or stable angina pectoris, acute myocardial infarction, and occasionally cardiac failure without prior anginal pain or infarction. For the purposes of this review, it will generally be assumed that the condition has been stabilised, though one important aspect of the rehabilitation process is the recognition of continuing or recurrent problems such as angina pectoris and cardiac decompensation.

The use of a two-dimensional ultrasound time-of-flight system for location of the centre of gravity in posturography measurements.

A method has been developed for objective assessment of balance using ultrasound time-of-flight (ToF) posturography measurements to accurately locate the centre of gravity (CoG) of a subject. Two orthogonal 40 kHz ultrasound transmitters are mounted on the subject's waist at the height of the CoG. Anterior/posterior and lateral motions are detected independently by measuring variations in the ToF from the transmitters to appropriately positioned wall-mounted receivers.

Who wants second-line, palliative chemotherapy?

This paper reports on a study designed to measure the value attached to second-line, palliative chemotherapy by people with advanced cancer, compared with the value healthy people assume they would attach if they had cancer and to assess reasons for accepting or declining treatment. Subjects comprised 92 people with cancer, 76 healthy control subjects, 60 medical oncologists, 128 clinical oncologists, 72 palliative care physicians, 58 general practitioners and 59 qualified nurses working within oncology. Using a questionnaire presenting two typical but imaginary treatment scenarios, subjects indicated whether treatment would be acceptable to them and, if so, what minimum chance and duration of benefit would make treatment worthwhile.

Adult endomysial antibody-negative coeliac disease and cigarette smoking.

Objective: To determine the relative incidence and characteristics of endomysial antibody (EMA)-negative coeliac disease in adults.

Design: Retrospective analysis of prospectively collected data on adults with newly diagnosed coeliac disease, with determination of EMA status before gluten withdrawal.

Setting: District general hospital (secondary care institution).

The Poole Diabetes Study: how many cases of Type 2 diabetes are diagnosed each year during normal health care in a defined community?

Unlabelled: We have investigated the incidence of newly diagnosed Type 2 diabetes in the Poole area and extrapolated it to the rest of the UK.

Methods: this prospective observational study used a surveillance programme in primary and secondary care. We identified all cases of newly diagnosed Type 2 diabetes mellitus occurring from 1st May 1996 to 30th June 1998 through the normal health care process without any active screening in 186889 people registered with 24 primary care practices in the Poole area.

Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate.

Cleft lip and palate affects the child in many ways, particularly appearance, dental arch relationships, growth of the face, and speech development. The key to successful care is management in a multidisciplinary team adhering to a well-designed protocol, and careful audit of results. We present the intermediate outcome audit of 15 patients with complete bilateral and unilateral cleft lip and palate whose condition was managed in a multidisciplinary team according to a strict protocol.

Using competencies to promote a learning environment in intensive care.

Nurses need to be able to demonstrate not only a sound knowledge base but the ability to link theory to practice. Nursing is a practical profession requiring skills of safe management, particularly in the care of critically ill patients. Such management includes the ability to make effective assessments and initiate appropriate therapy, as well as a duty to understand and utilise supportive technology in a competent manner.

A fracture risk profile using single-site bone density assessment and clinical risk factors.

The Risk Factor Profile combines single-site bone density assessment and selected clinical risk factors to help estimate the risk of osteoporotic fracture for Caucasian postmenopausal women over the next 5 years. The bone density assessment uses T score cut-off values equivalent to the WHO definitions of osteoporosis and osteopenia at the hip that would identify 16-17% of women over 50 years of age as "high" risk. The clinical risk factors are defined as "major" producing about a doubling of fracture risk independent of bone density, and "minor" where the predictive power is less certain.