Sunday, June 28, 2009

How or When to Listen to Your Body When Pain Strikes -

A colleagueE of mine at The Times who is a triathlete had a question: Everyone tells you to listen to your body, but what are you supposed to listen to?

Turns out it's not so obvious.

Deena Kastor, the American record holder for the marathon, interprets the advice selectively.

"Running isn't always comfortable," she said. "I remember running through a lot of discomfort and pain."

And, Ms. Kastor added, she also runs when she does not feel like it.

"So many times the alarm goes off in the morning and you tell yourself you are too tired," she said. "There are times when you are unmotivated, you don't feel your best and most accomplished."

But if you ignore those messages from your body and just go out and run or do your sport, she said, "those are the days when we have the most pride."

"The trick in listening to your body is to know what you can run through," she said. "If you have a sharp pain you should take care of it."

So does listening to your body mean learning to understand the difference between a pain that signals a serious injury and one that can be ignored? And if it does, why do athletes like Ms. Kastor become seriously injured, anyway?

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Monday, June 22, 2009

BBC NEWS - Painkiller ban 'has cut suicides'

A gradual phase-out of co-proxamol led to 350 fewer suicides and accidental deaths in England and Wales, a study in the British Medical Journal reports.

Regulators removed the drug's licence in 2007 after fears about the risk of overdose but the move proved unpopular with some patients and doctors.

Arthritis Care says some patients now struggle to control their pain.

The Medicines and Healthcare Products Regulatory Agency announced the withdrawal in 2005.

GPs were encouraged to move patients to other painkillers before the drug's licence was revoked in 2007.

After that time doctors could prescribe the drug on a "named patient basis" for those who could not manage their pain with alternatives but as it is unlicensed they did so at their own risk.

Study leader Professor Keith Hawton, director of the Centre for Suicide Research at Oxford University, said before the restrictions co-proxamol was responsible for a fifth of all drug-related suicides.

By the 2007 deadline, prescribing of the drug had fallen by 59%, his analysis showed.

Over the two-year period, deaths from co-proxamol fell by 62%.

Specifically there were 295 fewer suicides and 349 fewer deaths from the drug including accidental overdoses.

The research also showed that had been no increase in deaths from other painkillers, despite large increases in their use.

Professor Hawton said authorities in the US were now considering withdrawing co-proxamol, which is a mixture of paracetamol and an opioid drug.

"This marked reduction in suicides and accidental poisonings involving co-proxamol during this period, with no evidence of an increase in deaths involving other analgesics, suggests the initiative has been effective," he added.

In 2008, there were 380,831 prescription items for co-proxamol, showing some GPs are still prescribing the drug.

A spokesman for the Medicines and Healthcare Products Regulatory Agency (MHRA) said prior to its withdrawal co-proxamol was involved in 300-400 self-poisoning deaths each year, of which around a fifth were accidental.

"Co-proxamol is extremely dangerous in overdose - only a small overdose can be fatal, and death can occur very rapidly - before medical attention can be sought."

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Thursday, June 18, 2009

Chronic Pain and Depression Linked to Gender, Age, Ethnicity

The association between chronic pain and clinical depression is well established; now, a new study shows the connection between pain and depression is strongest in middle-aged women and African-Americans.

Researchers at Wayne State University studied a representative community sample of 1,100 Michigan residents and found that the incidence of chronic pain, defined as pain persisting for six months, was 22 percent. Approximately 35 percent of those with chronic pain said they had depression, but mood problems were not associated with a particular pain condition or pain site.

Researchers evaluated several demographic factors and found that older age was generally related to chronic pain but with comorbid depression. They noted that depression tends to decrease with age while pain tends to increase.

From the data, the authors concluded that in middle-aged women chronic pain might not be the cause of depression but preexisting mood problems could be associated with development of chronic pain. They further concluded that depression can increase vulnerability to experiencing persistent pain.

The study also showed that African-Americans were more likely to have chronic pain with depression than Caucasians. Further analysis showed that racial differences were not attributable to possible socioeconomic factors but might be associated with differences in the use of pain coping strategies.

Though income was not a significant risk factor for the study, the authors indicated that occupational factors, such as physically demanding work and poor or no health insurance coverage, may account for the link between lower socioeconomic status and pain, and that financial strain and stress are closely linked with depression.

Saturday, June 13, 2009

The day pain died: What really happened during the most famous moment in Boston medicine - The Boston Globe

The date of the first operation under anesthetic, Oct. 16, 1846, ranks among the most iconic in the history of medicine. It was the moment when Boston, and indeed the United States, first emerged as a world-class center of medical innovation. The room at the heart of Massachusetts General Hospital where the operation took place has been known ever since as the Ether Dome, and the word "anesthesia" itself was coined by the Boston physician and poet Oliver Wendell Holmes to denote the strange new state of suspended consciousness that the city's physicians had witnessed. The news from Boston swept around the world, and it was recognized within weeks as a moment that had changed medicine forever.

But what precisely was invented that day? Not a chemical - the mysterious substance used by William Morton, the local dentist who performed the procedure, turned out to be simply ether, a volatile solvent that had been in common use for decades. And not the idea of anesthesia - ether, and the anesthetic gas nitrous oxide, had both been thoroughly inhaled and explored. As far back as 1525, the Renaissance physician Paracelsus had recorded that it made chickens "fall asleep, but wake up again after some time without any bad effect," and that it "extinguishes pain" for the duration.

What the great moment in the Ether Dome really marked was something less tangible but far more significant: a huge cultural shift in the idea of pain. Operating under anesthetic would transform medicine, dramatically expanding the scope of what doctors were able to accomplish. What needed to change first wasn't the technology - that was long since established - but medicine's readiness to use it.

Before 1846, the vast majority of religious and medical opinion held that pain was inseparable from sensation in general, and thus from life itself. Though the idea of pain as necessary may seem primitive and brutal to us today, it lingers in certain corners of healthcare, such as obstetrics and childbirth, where epidurals and caesarean sections still carry the taint of moral opprobrium. In the early 19th century, doctors interested in the pain-relieving properties of ether and nitrous oxide were characterized as cranks and profiteers. The case against them was not merely practical, but moral: They were seen as seeking to exploit their patients' base and cowardly instincts. Furthermore, by whipping up the fear of operations, they were frightening others away from surgery and damaging public health.

The "eureka moment" of anesthesia, like the seemingly sudden arrival of many new technologies, was not so much a moment of discovery as a moment of recognition: a tipping point when society decided that old attitudes needed to be overthrown. It was a social revolution as much as a medical one: a crucial breakthrough not only for modern medicine, but for modernity itself. It required not simply new science, but a radical change in how we saw ourselves.

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Understanding Your Central Post-Stroke Pain - Émilie McMahon

CAHR - Community Alliances for Health Research and Knowledge Exchange on Pain - Canada

Message from the Director, Dr. James L. Henry. 

CAHR-pain is a Canadian research network funded by the Canadian Institutes of Health Research to provide knowledge translation to receptor communities in the area of pain.  The six themes are each led by internationally-recognized leaders in the field, and you are invited to learn about what each theme has as its research objectives, who the participants are in each research theme, what the respective receptor communities are, what the long-term objectives are and how these will be carried out.  This information is available by clicking on the respective section of this web site.
Studies have shown that one in five Canadians suffers some form of persistent or chronic pain.  The impact on individual lives, on families and friends, on the health services sector and on the economy is huge.  CAHR-pain has been created to develop, disseminate and evaluate innovation in knowledge translation.  Bridging the quality chasm between chronic pain and the care process will come from this unique confluence of opinion from all stakeholders committed within this focussed community of practice to address the impact of pain.
Pain has traditionally been seen as secondary to something else – the result is under-treated or untreated pain, unnecessary suffering, heavier reliance on the health care system, loss of productivity in the workforce, absenteeism, increased comorbidity, and a cycle of illness that overall exacts a heavy toll on Canadians and the Canadian economy. Reliable evidence is available that these burdens can be markedly reduced when available knowledge is applied.  Various levels of success in this regard have been demonstrated when there is exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users.  The objectives of this initiative are to accelerate the capture of the benefits of research for Canadians through improved health, more effective and responsive services and products, and a strengthened health care system through promoting and integrating six internationally-recognized success stories to bring about health reform and health care reform across Canada as it pertains to the one in five Canadians living with chronic, disabling pain.  Demonstration will be initiated in one jurisdiction as a model.
Partnership development will be an on-going program.  As research initiatives evolve, new opportunities for partnership will announce themselves. A mobilizing plan for action has been developed and will be pursued based on shared vision and common values, which builds commitment, engages participants and uses participants' time well.
The overarching impact from the outputs of this CAHR is to promote and sustain a balanced portfolio of curiosity-based and needs-based research, which along with existing knowledge will be mobilized and applied for the benefit of Canadians, the health system and the economy.
The value-added of the CAHR is as follows:

  • Creation of a unified stakeholder voice to make recommendations for public and voluntary sector policy development to address the huge burden of chronic pain
  • Creation of the defensible case for research-community interactions in this domain to ensure that reliable knowledge addresses burden by being socially robust
  • Enhancement of the funding base supporting operations and, on this basis, potential for leverage from the public purse, for incremental funding

Gout, the Ailment of Kings, Now Afflicts the Middle Class -

Disease of Rich Extends Its Pain to Middle Class

Lonnie Matthews, a retired building maintenance engineer in Burlington, N.C., has something in common with King Henry VIII, Sir Isaac Newton and Benjamin Franklin. He has gout.

Often called the "disease of kings" because of its association with the rich foods and copious alcohol once available only to aristocrats, gout is staging a middle-class comeback as American society grows older and heavier.

The rising tide of gout — an extremely painful arthritis of the big toe and other joints — is leading the pharmaceutical industry to rediscover what it had considered a disease of the past. Companies are now racing to improve upon decades-old generic drugs that do not work well for everyone.

Already this year the Food and Drug Administration has approved the first new gout drug in more than 40 years, a product called Uloric from Takeda Pharmaceutical.

Another new drug, Krystexxa, made by Savient Pharmaceuticals of East Brunswick, N.J., will be reviewed for possible approval by an F.D.A. advisory committee on Tuesday.

And several other companies are testing drugs in clinical trials.

"It's kind of like the forgotten disease," said Barry D. Quart, chief executive of one of those companies, Ardea Biosciences of San Diego.

Ardea discovered accidentally that an AIDS drug it was developing might work against gout. Now the company has shifted its focus to gout, envisioning annual sales of $1 billion if its drug is successful.

That would mean a huge increase in spending on gout medicines, which had sales of only $53.4 million last year, according to IMS Health, a health care information company. Uloric, the drug from Takeda, sells a daily pill for at least $4.50 compared with 10 to 50 cents for the most commonly used generic, allopurinol.

It is estimated that two million to six million Americans have gout. Although the disease becomes more common as people age, some men develop gout in their 40s and 50s, or even younger. It is three to four times as common in men as in women, in part because estrogen is thought to protect premenopausal women from the illness.

Various studies suggest that the number of cases in this country has as much as doubled in the last three decades.

"We have accumulated a lot of people with severe disease," said Dr. Robert A. Terkeltaub, section chief of rheumatology at the Veterans Affairs Medical Center in San Diego and a consultant to some of the companies developing gout drugs. And the typical case these days, is "not going to be someone who looks like Henry VIII," he said. "Now it's going to be some 80-year-old lady with congestive heart failure."

One of the severe cases is Mr. Matthews, who had controlled his disease for many years with the generic allopurinol. But when he developed renal problems in 2006, he stopped taking allopurinol because it can be harmful to those with bad kidneys. After that, Mr. Matthews was bedridden or in a wheelchair and in such excruciating pain in many of his joints that he said he contemplated suicide.

"It was like having a toothache so bad you can't stand it, all over your body," he said.

Mr. Matthews, 76, says he found relief as a participant in a clinical trial of Savient's Krystexxa, the drug now up for review by the F.D.A.

Gout is caused by the buildup of a chemical called uric acid in the blood. Uric acid is formed by the breakdown of purines, which are components of DNA, RNA and some other important molecules in the body.

Some types of meat and fish, as well as beer, are particularly rich in purines and can raise the risk of gout. There is also evidence that sugary soft drinks raise the risk.

When uric acid levels get too high, the chemical can form needlelike crystals that accumulate in joints.

In the early stages of the disease, gout attacks, which can last several days and are excruciating, occur only rarely. But over time, the frequency increases and people can develop disfiguring and disabling lumps of the chalky white crystals, called tophi. Michael Clayton of Atlanta, who has severe gout, said he had to quit a job as general manager of a restaurant after customers complained about the tophi on his hands, which sometimes oozed liquid resembling Wite-Out.

Many doctors and patients treat only gout attacks. They use either pain relievers like naproxen, steroids or colchicine — a crocus plant derivative that has been used for centuries.

Many of the new drugs lower uric acid levels in the blood, meaning they can prevent gout attacks and keep the disease under control.

A problem in getting doctors to prescribe chronic treatment for gout is that many patients are reluctant to admit they have the disease because of its association with gluttony.

"It's part of society's view of gout that this is something self-inflicted," said Dr. N. Lawrence Edwards, professor of medicine at the University of Florida.

So the industry is trying to spread the word that genetics and other factors, not just diet, contribute to gout. Takeda and Savient bankroll the Gout and Uric Acid Education Society, which is led by Dr. Edwards and was formed in 2005 to raise awareness of the disease.

Another reason that gout is shedding its image as a disease of the past is preliminary evidence — though still far from proof — that high uric acid levels might also contribute to modern-day ills like hypertension, obesity, heart disease, kidney impairment and diabetes.

In one small study published last year, treatment with allopurinol reduced high blood pressure in adolescents.

Right now, it is estimated that 15 million to 20 million Americans have elevated uric acid levels, known as hyperuricemia. But they do not have gout symptoms and are therefore not treated.

If further studies prove that high uric acid levels contribute to other diseases, though, then "hyperuricemia" could be defined as a disease in its own right and millions of people might one day take drugs to lower uric acid levels, much as they now do to lower cholesterol.

Paul Hamelin, president of Savient, said, "There's a huge amount of ground that nobody's ever plowed yet."

Monday, June 01, 2009

New developments in the diagnosis of fibromyalgia syndrome: Say goodbye to tender points? — Cleveland Clinic Journal of Medicine

The Symptom Intensity Scale score can be used to identify and quantify fibromyalgia syndrome from information supplied by a simple questionnaire. In this paper, the author describes how this test was developed and argues in favor of its use in clinical practice in diagnosing fibromyalgia syndrome.

Hip Injuries Bringing More Athletes to Their Knees -

The quest to build ever more proficient athletes keeps hitting unexpected snags, and perhaps nowhere is this more vivid than in Major League Baseball. Several top players have been hampered by a hip ailment that was unheard of in the sport a decade ago.

Knee injuries to countless recreational and professional athletes in recent years made anterior cruciate ligament a household phrase and compelled trainers to emphasize building leg strength. Sports medicine experts now say that approach, while mitigating knee injuries, may be making hips vulnerable.

"No matter what we do, as complex as we try and make workouts and training methods, we lose sight of other things," said Mackie Shilstone, a trainer based in New Orleans, who works with baseball, football and hockey players who are rehabilitating injuries. "We tend to concentrate on what is directly in front of us.

"In all my years as a trainer, I have not seen anything like the increase in hip injuries that I have seen over the past two years."

No studies have been published to confirm this phenomenon. But many trainers and orthopedists say the anecdotal evidence is jarring, and medical staffs for Major League Baseball teams and franchises in other sports are scrambling to understand why athletes' hips suddenly seem so fragile.

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Do fish feel pain? - By Michael Agger - Slate Magazine

Here we go again. There is a new study out that contends fish feel
pain. A professor at Purdue and his Norwegian graduate student
attached small foil heaters to goldfish. Half of the goldfish were
injected with morphine, half with saline, and then the researchers
turned on the attached micro-toasters. After the heat was gone, the
fish without painkillers "acted with defensive behaviors, indicating
wariness, or fear and anxiety." They had also developed a lovely
brown crust. These results echo a 2003 study by researchers from the
University of Edinburgh who shot bee venom into the lips of trout.
The bee-stung fish rubbed their lips in the gravel of their tank and
generally seemed pissed off.

Whenever one of these studies about fish pain appears, animal lovers
start glaring at me and my fellow fishermen. If fish can experience
pain, then angling must be a cruel sport, right up there with deer
hunting, bear baiting, and eating hot dogs. Why can't we just leave
fish alone and do something else?

The online reaction to the goldfish pain study was both typical and
funny—especially in the United Kingdom, where they seem to take
animal news more personally. The assembled mob at the Daily Mail got
very rowdy. In one corner, you have comments like this: "Every time I
see an angler, I say a little prayer that he will get his fishing
hook lodged in his body, and then perhaps he will give some thought
to the barbaric 'sport' he is pursuing." In the other corner,
comments like this: "I'm a trout fisherman and I can tell you all
with 100% accuracy that the trout I catch feel absolutely no pain
after I've smacked them over the head with a cosh." The pro-angling
side rattled off some good jokes about whether or not carrots feel
pain when they are peeled. They also directed a surprising amount of
vitriol toward lentils and those who eat them.

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