Study Evaluates Electroacupuncture for Carpal Tunnel Pain

MedicalResearch.com Interview with:

Dr Vincent Chung Assistant Professor, Jockey Club School of Public Health and Primary Care Associate Director (Education), Hong Kong Institute of Integrative Medicine Registered Chinese Medicine Practitioner The Chinese University of Hong Kong

Dr. Vincent Chung

Dr Vincent Chung
Assistant Professor, Jockey Club School of Public Health and Primary Care
Associate Director (Education), Hong Kong Institute of Integrative Medicine
Registered Chinese Medicine Practitioner
The Chinese University of Hong Kong

MedicalResearch.com: What is the background for this study?

Response: Primary carpal tunnel syndrome (CTS) is one of the most common forms of peripheral entrapment neuropathy. It is a major cause of disability on the upper extremity incurring considerable limitation on daily activities among patients. Currently, there is no consensus on appropriate treatment for patients with chronic (≥6 months) mild to moderate symptoms [Archives of physical medicine and rehabilitation. 2014;95(12):2253-63].

Electroacupuncture is a common technique for managing pain and neuropathy in Chinese medicine. Current CTS treatment guidelines from the UK National Institute for Health and Care Excellence (NICE), American Academy of Orthopaedic Surgeons (AAOS) and the American College of Occupational and Environmental Medicine (ACOEM) made no specific recommendations for or against electroacupuncture.

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Opioid-Free Approach To Breast Cancer Surgery Explored

MedicalResearch.com Interview with:
Dr. Sarah Saxena
Université Libre de Bruxelles

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Saxena: Opioids are well known analgesics, but like every drug, they do not come without side-effects. Recently, certain studies have been published about an opioid-free approach in bariatric patients. An opioid free approach is possible combining ketamine, lidocaine and clonidine.

We studied this type of approach in breast cancer patients and looked at several factors such as patient comfort pain quality after an opioid free approach vs after an opioid approach. The study showed patients requiring less analgesics after an opioid free approach.

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Anger and Stonewalling Lead To Different Medical Vulnerabilities

MedicalResearch.com Interview with:

Robert W. Levenson, Ph.D. Professor, Department of Psychology Director, Institute of Personality and Social Research (IPSR) University of California Berkeley, CA

Dr. Robert Levenson

Robert W. Levenson, Ph.D.
Professor, Department of Psychology
Director, Institute of Personality
and Social Research (IPSR)
University of California
Berkeley, CA

MedicalResearch.com: What is the background for this study?

Dr. Levenson: This study comes from a 20-year longitudinal study of Bay Area married couples that we began in the late 1980s. The main purpose of the study was to understand the emotional qualities of successful marriages. Couples came to our laboratory every five years so that we could get a snapshot of the way they interacted with each. We also measured their psychological and physical health. This new paper connects the emotional behaviors we observed when couples discussed a problem in their marriage at the start of the study with the kinds of illnesses they developed over the ensuing decades.
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New Drug Candidate Aims To Treat Both Pain and Opioid Addiction

MedicalResearch.com Interview with:

Richard M. Mangano, PhD Chief Scientific Officer at Relmada Therapeutics

Dr. Richard Mangano

Richard M. Mangano, PhD
Chief Scientific Officer at Relmada Therapeutics

Dr. Mangano has extensive experience leading global R&D programs in both large and small pharmaceutical companies including positions in discovery and clinical research at Hoffmann-La Roche, Lederle Laboratories, Wyeth Research and Adolor Corporation. He served as acting Therapeutic Area Director for Neuroscience at Wyeth before joining Adolor as Vice President of Clinical Research and Development. Dr. Mangano’s expertise includes multiple IND/CTC submissions and NDA/MAA approvals in psychiatry, neurology and gastrointestinal therapeutic areas. Dr. Mangano is also an adjunct professor in the Department of Pharmacology and Physiology at the Drexel University School of Medicine. He lectures in the Drug Discovery and Development Program and in the Psychiatry Department’s Resident Training Program.  He has authored 30 peer reviewed publications and over 120 abstracts and presentations. Dr. Mangano holds a B.S degree in Chemistry from Iona College and a PhD degree in Biochemistry from Fordham University. Prior to joining the pharmaceutical industry, he was a research faculty member of the Maryland Psychiatric Research Institute at the University of Maryland School of Medicine.

Dr. Mangano discusses the opioid addiction and the development of abuse-resistant medications.

MedicalResearch.com: What is the background for the development of abuse-resistant medications? How extensive is the problem of opioid addiction?

Dr. Mangano: Recognizing the growing incidence of opioid abuse, misuse, and overdose in the United States, pharmaceutical companies, with the guidance of the FDA, are developing products that can mitigate abuse, while recognizing the importance of maintaining the availability of opioid analgesics for the millions of patients in this country who suffer from pain.

Approximately two million people in the U.S. are addicted to opioids. The market for products that treat opioid dependence has grown significantly due to the rapidly escalating problem of prescription opioid misuse and abuse, a recent resurgence of heroin use, and the growing number of physicians treating opioid dependence.

One of our product candidates, REL-1028 (BuTab), is a proprietary formulation of buprenorphine designed to treat both opioid addiction and moderate to severe chronic pain. Although there is the potential for addiction to buprenorphine, the risk is lower because it is a “partial agonist” of the mu opioid receptor compared with “full agonist” opioids like heroin, morphine, oxycodone, and hydrocodone. As a result, products containing buprenorphine, such as BuTab, should have reduced risk of abuse and physical dependence and would be controlled in Schedule III of the Controlled Substances Act (as opposed to the more restrictive Schedule II). We are also considering a formulation that would include an opioid antagonist that would not interfere with analgesia when taken orally as prescribed but would block the action of buprenorphine if it were to be inhaled or injected.

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Taking Acetaminophen Reduces Empathy For Others

MedicalResearch.com Interview with:

Dominik Mischkowski, co-author of the study Former Ph.D. student at Ohio State Now at the National Institutes of Health

Dr. Dominik Mischkowski

Dominik Mischkowski, co-author of the study
Former Ph.D. student at Ohio State
Now at the National Institutes of Health

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Mischkowski: We tested in two double blind experiments whether the popular physical painkiller acetaminophen reduces empathy for the pain of other people. In the first experiment (N=80), participants completed measures of empathy (i.e., perceived pain and personal distress) while reading hypothetical about the physical and social mishaps of other people. We found that acetaminophen reduced empathy for pain in these scenarios. In Study 2 (N=114), we replicated and extending these findings, showing that acetaminophen also decreased empathy (i.e., perceived pain, personal distress, and empathic concern) for another study participant experiencing ostracism or painful noise blasts. Furthermore, noise unpleasantness accounted for the effect of acetaminophen on empathy for noise pain.

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Gene Therapy to Spinal Cord Offers Potential Hope to Peripheral Nerve Pain Patients

MedicalResearch.com Interview with:

Hui-Lin Pan, MD, PhD Helen T. Hawkins Distinguished Professor  and Deputy Division Head for Research Division of Anesthesiology and Critical Care, Unit 110 The University of Texas MD Anderson Cancer Center Houston, TX

Dr. Hui-Lin Pan

Hui-Lin Pan, MD, PhD
Helen T. Hawkins Distinguished Professor
and Deputy Division Head for Research
Division of Anesthesiology and Critical Care, Unit 110
The University of Texas MD Anderson Cancer Center
Houston, TX

MedicalResearch.com: What is the background for this study?

Dr. Hui-Lin Pan: Chronic nerve pain caused by damage to the peripheral nerve is a debilitating health problem and remains very difficult to treat. Sensory neurons in the spinal cord are normally inhibited by inhibitory neurotransmitters (GABA and glycine) to regulate transmission of painful information. A major feature of nerve injury-induced chronic pain is reduced spinal cord inhibition, resulting from diminished activity of a chloride transporter called KCC2. In this study, we investigated whether increasing KCC2 expression at the spinal level using a lentiviral vector can restore KCC2 activity, thereby reducing chronic nerve pain.

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Adding Lumbar Fusion to Laminectomy Improves Long-Term Quality of Life

MedicalResearch.com Interview with:

Zoher Ghogawala MD FACS Department of Neurosurgery Lahey Hospital and Medical Center Burlington, MA 01805

Dr. Zoher Ghogawala

Zoher Ghogawala MD FACS
Department of Neurosurgery
Lahey Hospital and Medical Center
Burlington, MA 01805

MedicalResearch.com: What is the background for this study?

Dr. Ghogawala: There is enormous practice variation around the utilization of lumbar spinal fusion in the United States and across the world.  In the United States, lumbar spinal fusion utilization has increased to 465,000 hospital-based procedures in 2011 according to a report from the AHRQ (published in 2014).  Spinal fusion accounts now for the highest aggregate hospital cost (12.8 billion dollars in 2011) of any surgical procedure performed in US hospitals.  What is problematic is that there are no top tier studies that address the question of whether or not adding a lumbar spinal fusion when performing a simple decompression is necessary or helpful.  The question is whether we perform too many fusions in the United States.

The SLIP study is the first class I study that demonstrates that the addition of a lumbar fusion when performing a lumbar laminectomy to decompress spinal nerves improves health-related quality of life for patients suffering from low back pain and sciatica from lumbar stenosis with spondylolisthesis – a very common cause of low back pain caused by nerve compression associated with one spinal bone being slightly out of alignment. 

MedicalResearch.com: What are the main findings?

Dr. Ghogawala:

1)  Adding a lumbar fusion when performing a lumbar laminectomy results in superior health-related quality of life at 2,3, and 4 years after surgery.

2)  Patients with fusion obtained durable results but 14% required re-operation for problems adjacent to their fusion over the 4 year study period.

3)  Lumbar laminectomy alone provided good results for 70% of patients.  There was less blood loss and faster recovery for these patients.  On the other hand, the outcomes were less durable.  One in three patients who underwent a lumbar laminectomy alone required re-operation within 4 years because their back became unstable.  These patients underwent fusion and their health-related quality of life improved.

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Joint Pain and Physical Function Commonly Improve after Bariatric Surgery

MedicalResearch.com Interview with:

Wendy King, PhD Associate Professor of Epidemiology Epidemiology Data Center, Room 105 University of Pittsburgh Pittsburgh, PA 15213

Dr. Wendy King

Wendy King, PhD
Associate Professor of Epidemiology
Epidemiology Data Center, Room 105
University of Pittsburgh
Pittsburgh, PA 15213

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. King: Severe obesity is associated with significant joint pain and impaired physical function, such as difficulty bending, lifting carrying and walking. Excess weight can lead to joint damage and accompanying pain, resulting in activity restriction and walking limitations. Obesity can also contribute to pain and physical limitations through factors such as impaired cardiorespiratory function, systematic inflammation, reduced flexibility, low strength per body mass, and depression.  Previous studies have reported significant improvements in mean values of bodily and joint specific pain, physical function, and walking capacity in the first 3-12 months following RYGB or LAGB. However, very few studies have examined the variability in response to surgery or reported on longer-term follow-up of these procedures.

My colleagues and I followed 2,221 patients participating in the Longitudinal Assessment of Bariatric Surgery-2, a large NIH-funded prospective study of adults with severe obesity undergoing weight-loss surgery at one of 10 hospitals across the U.S. Through three years of follow-up, approximately 50 to 70 % of patients who underwent bariatric surgery reported clinically important improvements in bodily pain, physical function and usual walking speed. About three-quarters of the participants with symptoms indicative of osteoarthritis before surgery experienced improvements in knee and hip pain and function. In addition, over half of participants who had a mobility deficit prior to surgery did not post-surgery. Several baseline characteristics such as younger age, male sex, higher household income, lower body mass index, fewer depressive symptoms and no history of diabetes or venous edema with ulcerations, were associated with a higher chance of improvement in pain and physical function following surgery. In addition, pre- to post-surgery reductions in weight and depressive symptoms, and remission of diabetes and venous edema with ulcerations were associated with pre- to post-surgery improvements. Thus, our findings reinforce results from shorter-term studies by addressing the durability or response and expand our understanding of the variability in response, and what factors are related to chance of improvement.

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Fentanyl Patch Prescribing Still Not Safe in 50% of Prescriptions

MedicalResearch.com Interview with:

Shawn Bugden B.Sc. (Pharm), M.Sc., Pharm.D. Associate Professor College of Pharmacy, Faculty of Health Sciences University of Manitoba Winnipeg, Manitoba, Canada R3E 0T5

Dr. Bugden

Shawn Bugden B.Sc. (Pharm), M.Sc., Pharm.D.
Associate Professor
College of Pharmacy, Faculty of Health Sciences
University of Manitoba
Winnipeg, Manitoba, Canada

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Bugden: Fentanyl is 100 times more potent than morphine.  While there has been a great deal of attention to fentanyl deaths associated with substance abuse, our study focused on the safety of fentanyl use in standard medical practice.   Fentanyl is most commonly prescribed as a transdermal (skin) patch that delivers the medication over 3 days. The product monograph and numerous safety warnings (FDA, Health Canada…) make it clear that fentanyl patches should not be used unless the patient has had considerable previous opioid exposure (more than 60mg morphine per day for more than 1 week).  Failure to heed these warnings may result in opioid overdose, respiratory depression and death.

This study examined over 11 000 first prescriptions for fentanyl patches over a 12-year period to determine if patients had received adequate exposure to opioids.  Overall 74.1% of first prescriptions were filled by patients who had not received adequate prior opioid exposure. An improvement was seen over the study period but even at the end of the study, 50% of prescriptions would be classed as unsafe.  More than a quarter (26.3%) of fentanyl prescriptions were given to patients who were completely opioid naïve and had no exposure to opioids of any kind in the previous 60 days.  Older adults, who may be more sensitive to the effects of fentanyl overdose, were more likely to receive unsafe prescriptions than younger adults.

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Mindfulness Training May Be Effective For Some Chronic Low Back Pain

MedicalResearch.com Interview with:

Dr. Daniel C. Cherkin PhD Senior Investigator Group Health Research Institute Seattle, WA

Dr. Daniel Cherkin

Dr. Daniel C. Cherkin PhD
Senior Investigator
Group Health Research Institute
Seattle, WA

MedicalResearch.com: What is the background for this study?

Dr. Cherkin: Chronic low back pain is a widespread, costly, and potentially disabling problem. It’s the most common cause of pain of any kind. It affects eight in 10 Americans at some point in their lives. In recent years, the United States has been spending more on back pain treatments—but unfortunately with worse results in how much pain bothers people and interferes with their lives. Group Health is addressing the problem in several ways, including this innovative research.

MedicalResearch.com: What are the main findings?

Dr. Cherkin: In a randomized controlled trial involving more than 300 patients at Group Health, we found that training in a kind of mindfulness meditation—mindfulness-based stress reduction (MBSR)—led to meaningful improvements in functioning and chronic low back pain at six months and one year. MBSR, which is becoming increasingly popular and available in the United States, involves training in observing, acknowledging, and accepting thoughts and feelings including pain. The training also includes some easy yoga poses to help participants become more aware of their bodies. Results with  mindfulness-based stress reduction were significantly better than with usual care (whatever patients would be doing for their back pain if they weren’t in the study, including medications and physical therapy—but not mindfulness meditation or cognitive behavioral therapy). And results with  mindfulness-based stress reduction were very similar to those with cognitive behavioral therapy (CBT). CBT includes education about chronic pain, relationships between thoughts and emotional and physical reactions, instruction and practice in changing dysfunctional thoughts, setting and working towards behavioral goals, relaxation skills, activity pacing, and pain coping strategies. Prior studies had already proven that CBT helped adults of various ages with back pain.

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Epidural Steroid Injections May Reduce Costs As Well As Pain

MedicalResearch.com Interview with:

Eric Sun, MD/PhD Instructor Department of Anesthesiology, Perioperative and Pain Medicine Stanford University

Dr. Eric Sun

Eric Sun, MD/PhD
Instructor
Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University

MedicalResearch.com: What is the background for this study? 

Dr. Sun: Epidural steroid injections are frequently used to treat chronic low back pain.  While previous studies have shown they are effective at improving symptoms, whether they reduce spending is unknown.  These concerns are particularly salient because insurers are worried that epidural steroid injections are being overused.

MedicalResearch.com: What are the main findings?

Dr. Sun: Overall, we find that epidural steroid injections were associated with decreases in spending ranging from five to fifteen percent, depending on the specific indication.  These differences were largely driven by decreases in outpatient spending (e.g., spending on outpatient physician visits).

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Botulinum Toxin A Injections Helpful For Some Patients With Peripheral Neuropathic Pain

MedicalResearch.com Interview with:
Nadine Attal, MD PhD
Professeur associée de l’UVSQ
INSERM U 987 et CETD
CHU Ambroise Paré
92100 Boulogne-Billancourt

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Attal: The background for this study is based on the findings of experimental studies in animals and healthy subjects indicating that botulinum toxin type A  (BTX-A) may have analgesic activity independent of its effect on muscle tone.

BTX-A has been reported to have analgesic effects against peripheral neuropathic pain in prior trials, but the quality of the evidence was generally low, as it was derived mostly from small pilot studies and no study has evaluated the relevance of repeated administrations for the treatment of NP. Furthermore, the clinical profiles of the patients responding to BTX-A have not been fully characterized.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Attal: They should take away that two repeated subcutaneous administrations of botulinum toxin type A are effective in peripheral  neuropathic pain but mostly in patients with allodynia and/or limited thermal deficits. BTX-A also appears to be particularly effective on paroxysmal pain (ie electric shock like pain).

Finally, the efficacy of a second administration of BTX-A is enhanced over the first injection.

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Pregnant Women With Severe Migraine Should Be Considered High Risk

MedicalResearch.com Interview with:

Matthew S. Robbins, MD, FAHS Associate Professor of Clinical Neurology, Albert Einstein College of Medicine Chief of Neurology, Jack D. Weiler Hospital, Montefiore Medical Center Director of Inpatient Services, Montefiore Headache Center Associate Program Director, Neurology Residency

Dr. Matthew Robbins

Matthew S. Robbins, MD, FAHS
Associate Professor of Clinical Neurology, Albert Einstein College of Medicine
Chief of Neurology, Jack D. Weiler Hospital
Montefiore Medical Center
Director of Inpatient Services, Montefiore Headache Center
Associate Program Director, Neurology Residency

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Robbins: It is now well-established that having a history of migraine increases the risk of having vascular and obstetrical complications for pregnant women.  What is not known is if having active migraine during pregnancy would increase complications later on in that very same pregnancy.  Having severe migraine attacks during pregnancy may indicate particularly severe and active disease.  We evaluated pregnant women who presented to the hospital setting with acute, severe migraine attacks, and then reviewed their records for what happened during the same pregnancy when they delivered.  We found that compared to local and national rates, pregnant women with severe migraine attacks presenting to the hospital have increased rates of preeclampsia, preterm delivery, and low birthweight.  This risk was particularly elevated in pregnant women age 35 years or older.

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Blacks and White Patients Perceive and Cope With Pain Differently

MedicalResearch.com Interview with:

Adam T. Hirsh PhD Assistant Professor, Psychology Indiana University Indianapolis, IN

Dr. Adam T. Hirsh

Adam T. Hirsh PhD
Assistant Professor, Psychology
Indiana University
Indianapolis, IN 

Medical Research: What is the background for this study? What are the main findings?

Dr. Hirsh: Pain is highly prevalent and is a major cause of disability. How patients cope with pain affects how much pain they feel and how much that pain interferes with their lives. Compared to White individuals, Black individuals experience greater pain across a number of clinical conditions, as well as in response to experimentally-delivered stimuli. These race differences may be due to differences in pain-related coping. We conducted a meta-analysis of clinical and experimental studies (including 2,719 Black and 3,770 White adults) to quantify race differences in the overall use of pain coping strategies as well as specific coping strategies. The results indicated that, compared to White individuals, Black individuals used pain coping strategies more frequently overall. In particular, Black individuals more frequently used strategies that involved praying and catastrophizing, whereas White individuals more frequently used strategies that involved task persistence. These results suggest that Black individuals use coping strategies more frequently, specifically strategies associated with poorer pain outcomes.

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Depression Can Recur After Opioids Initiated For Non-Cancer Pain

MedicalResearch.com Interview with:

Dr-Jeffrey-ScherrerJeffrey F. Scherrer, PhD
Associate Professor
Research Director
Department of Family and Community Medicine
Saint Louis University School of Medicine
St. Louis, MO 63104 

Medical Research: What is the background for this study? What are the main findings?

Dr. Scherrer: We initiated a series of studies on chronic opioid use and risk of depression about 3 years ago and obtained an NIH R21 to study prescription opioid use and risk of new onset depression, depression recurrence and transition to treatment resistant depression.  The rationale comes partly from clinical observations of the research team (I am not a clinician, just a epidemiologist).  We also observed the large field demonstrating patients with depression are more likely to get opioids for pain, take them longer and develop abuse.  We wanted to switch the direction of effect to determine if the reverse exists.  After publishing two papers demonstrating longer use of opioid was associated with increasing risk of depression, our next step was to look at recurrence among patients with a recent history of depression.

Medical Research: What should clinicians and patients take away from your report?

Dr. Scherrer: Our main recommendation is clinicians should repeatedly screen patients for depression.  While screening at time of starting opioids is common, repeated screening is worth consideration.  Patients with depression who may experience temporary euphoria should not expect opioids to cure depression and they may increase risk for worsening mood and or recurrence after long term use.

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Migraine with Aura Linked To Increased Risk of Stroke

MedicalResearch.com Interview with:

Souvik Sen, MD, MS, MPH, FAHA Professor and Chair, Neurology Department, South Carolina Smart State Endowed Stroke Chair University of South Carolina School of Medicine

Dr. Souvik Sen

Souvik Sen, MD, MS, MPH, FAHA
Professor and Chair,  Neurology Department,
South Carolina Smart State Endowed Stroke Chair
University of South Carolina School of Medicine 

Medical Research: What was the catalyst for conducting this study examining the association between migraine with aura and ischemic stroke subtypes?

Dr. Souvik Sen: South Carolina, North Carolina, and Georgia are located in the “buckle” of the stroke belt, with one of the highest stroke related death rates in the country. An unfortunate trend is that younger patients are having strokes leading to death and disability. As a part of the workup for young stroke we are interested in migraine with aura and the type of stroke associated with this condition.

Medical Research: What did you conclude as a result of the findings and how did they compare with your expectations at the beginning of the study?

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For Many Women, Migraines Worsen During Menopause

Dr. Vincent Martin, MD Professor of Internal Medicine University of Cincinnati College of Medicine Cincinnati OH

Dr. Martin

MedicalResearch.com Interview with:
Dr. Vincent Martin, MD
Professor of Internal Medicine
University of Cincinnati College of Medicine
Cincinnati OH

Medical Research: What is the background for this study? What are the main findings?

Dr. Martin: Past studies have found that the perimenopause is associated with an increased prevalence of migraine headache, but there have been no studies to determine if the frequency of migraine attacks is increased during this time period.  In our study we reported that high frequency headache (≥10 days per month with headache) was increased by 62% during perimenopause (irregular menstrual cycles) as compared to premenopause (regular menstrual cycles).  We later divided the perimenopause into early and late stages.  During the early perimenopause women experience irregular menstrual bleeding while during the late perimenopause women begin skipping menstrual periods for 2-11 months.  Of the two stages the late perimenopause in particular had the greatest likelihood for high frequency headache increasing its risk by 86%.  This could suggest that low estrogen and progesterone levels, which occur when menstrual periods are skipped, might account for the increased probability of headache attacks in women with migraine.

The common belief in the medical field is that migraine attacks improve in women during menopause.  To the contrary we found that high frequency migraine increased by 76% during menopause compared to premenopause.  This indicates that a subgroup of women with frequent headaches tend to worsen with menopause.  The increased probability of high frequency headache appeared to be secondary to an increased intake of pain medications occurring during this time period, which could result in “rebound headaches”.  Rebound headaches occur from overuse of pain medications.

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Acupuncture No Better Than Placebo For Hot Flashes

Acupuncture-Wikipedia-Image

Acupuncture Presure

MedicalResearch.com Interview with:
Carolyn Ee
MBBS
Department of General Practice
University of Melbourne
Carlton, Victoria, Australia

Medical Research: What is the background for this study? What are the main findings?

Response: Hot flushes affect up to 90% of women during the menopause and beyond, and women are turning to complementary therapies. Our randomised sham-controlled trial found no difference between real and sham acupuncture (given with a blunt needle) for hot flushes, with both groups improving by around 40% at the end of treatment.

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Comorbid Psychiatric Conditions Can Increase Migraine Disability

Dr. Mia T. Minen, MD, MPH Director, Headache Services at NYU Langone Medical Center Assistant professor, Department of Neurology

Dr. Mia T. Minen

More on Mental Health Research on MedicalResearch.com

MedicalResearch.com Interview with:
Dr Mia Tova Minen
Department of Neurology
NYU Langone Medical Center
New York, NY 10016

Medical Research: What is the background for this study? What are the main findings?

Dr. Minen: Migraine affects 12% of adults in the United States, and is thus a very common condition. There are effective treatments for migraine patients, but we also know that if patients and their doctors do not consider the psychiatric disorders that can co-occur with migraine, migraines can worsen, a term called migraine chronification. Thus, we felt that it was important to discuss the various psychiatric disorders associated with migraine, the screening tools available to assess for them, and various treatment considerations for patients with migraine and psychiatric conditions.

We also discussed potential explanations for the relationship between migraine and these psychiatric conditions.

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Irritable Bowel Symptoms Reduced By Antihistamine

Prof. Guy Boeckxstaens Translational Research in GastroIntestinal Disorders KU Leuven, Belgium

Prof. Guy Boeckxstaens

More on Gastroenterology on MedicalResearch.com

MedicalResearch.com Interview with:
Prof. Guy Boeckxstaens
Translational Research in GastroIntestinal Disorders
KU Leuven, Belgium

Medical Research: What is the background for this study? What are the main findings?

Prof. Boeckxstaens: Patients with IBS have increased abdominal pain for which no efficient therapy is available, mainly as the underlying cause is unclear. In our study, we checked the hypothesis that pain receptors (in particular TRPV1) in the gut wall of IBS patients are more sensitive (sensitized) than those of control subjects. Based on previous work, we focused on histamine, mainly as we had indications that mast cells releasing histamine may be involved in IBS. Interestingly, we noticed that neurons in rectal biopsies were indeed more sensitive to capsaicin, a substance of which we know it selectively acts on the pain receptors of interest. We could demonstrate that histamine sensitizes TRPV1 via interaction with its histamine 1 receptor (H1R). We next showed that treatment with a H1R blocker was able to prevent TRPV1 sensitization. Based on this observation, we decided to start a pilot study evaluating the effect of a H1R blocker, ebastine, in patients suffering from IBS. This study showed that 12 weeks treatment with ebastine indeed improved abdominal symptoms, in particular pain.

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Exercise and Education Prevent Back Pain, Devices Do Not

Daniel Steffens, Ph.D. The George Institute for Global Health The University of SydneyMedicalResearch.com Interview with:
Daniel Steffens, Ph.D.
The George Institute for Global Health
The University of Sydney

Medical Research: What is the background for this study?

Dr. Steffens: Back pain is a leading cause of disease burden globally. At present, a variety of interventions, such as exercise, education, back belts and shoe insoles, are commonly prescribed to prevent an episode of low back pain. Guidelines lack clear recommendations for prevention of low back pain and the effectiveness of the range of possible prevention strategies for low back pain is not clear. Our study aimed to investigate the effectiveness of these interventions for prevention of low back pain.
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Most Patients Receive Another Opioid Prescription After Overdose

Dr. Marc LaRochelle MD MPH

Dr. LaRochelle

MedicalResearch.com Interview with:
Marc R. Larochelle, MD, MPH
Assistant Professor of Medicine
Boston Medical Center
Boston, MA 

Medical Research: What is the background for this study? What are the main findings?

Dr. Larochelle: More than 16 thousand people in the United States die from prescription opioid overdose each year. However, morbidity extends well beyond fatal overdose – nearly half a million emergency department visits each year are related to prescription opioid-related harms. Emergency department visits for misuse of opioids represent an opportunity to identify and intervene on opioid use disorders, particularly for patients who receive prescriptions for opioids to treat pain. We examined a cohort of nearly 3000 commercially insured individuals prescribed opioids for chronic pain who were treated for a nonfatal opioid overdose in an emergency department or inpatient setting. We were interested in examining rates of continued prescribing after the overdose and the association of that prescribing with risk of repeated overdose. We found that 91% of individuals received another prescription for opioids after the overdose. Those continuing to receive opioids at high dosages were twice as likely as those whose opioids were discontinued to experience repeated overdose.

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ER Trial of Inhaling Isopropyl Alcohol From Pads Reduced Nausea

Michael D. April, MD, DPhil Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio, TX

Dr. April

MedicalResearch.com Interview with:
Michael D. April, MD, DPhil
Department of Emergency Medicine
San Antonio Uniformed Services Health Education Consortium
San Antonio, TX 

Medical Research: What is the background for this study? What are the main findings?

Dr. April: Anesthesia research studies have found that nasal inhalation of isopropyl
alcohol has efficacy in treating nausea among post-operative patients. We
sought to study this agent among Emergency Department patients with nausea or
vomiting. We found that patients randomized to inhale isopropyl alcohol had
improved self-reported nausea scores compared to patients randomized to inhale
saline (placebo).

MedicalEditor’s note:  Do Not Do This Without Medical Supervision!

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Soothing Words Do More Than Pills To Decrease Patient Anxiety

Dr Emmanuel Boselli, MD, PhD Anesthesiology and Intensive Care University Claude Bernard Lyon I University of Lyon Lyon, France

Dr. Boselli

MedicalResearch.com Interview with:
Dr Emmanuel Boselli, MD, PhD
Anesthesiology and Intensive Care
University Claude Bernard Lyon I
University of Lyon
Lyon, France

Medical Research: What is the background for this study? What are the main findings?

Dr. Boselli: We hypothesized that the use of conversational hypnosis in patients undergoing regional anesthesia procedures for ambulatory upper limb surgery might provide better comfort than the use of oral premedication during the regional anesthesia procedure. We assessed the subjective effect of conversational hypnosis on a patient self-reported comfort scale ranging from 0 (no comfort) to 10 (maximal comfort), and the objective effect was assessed using the Analgesia/Nociception Index (ANI), a 0-100 index derived from heart rate variability reflecting the relative parasympathetic tone. In our study of 100 patients undergoing hand surgery in two different centers, 50 had conversational hypnosis while being given regional anesthesia (Saint-Grégoire hospital), and 50 were given of oral hydroxyzine 30 minutes to an hour before the regional anesthesia procedure (Lyon hospital). Patients having hypnosis measured an average ANI of 51 before and 78 after hypnosis, whereas those who had premedication averaged 63 before and 70 after. The average comfort scale of those who had received hypnosis was 6.7 before and 9.3 after, while patients who had medication averaged 7.8 before and 8.3 after. The main finding of this study is that conversational hypnosis induced greater increase in comfort scales and ANI values than oral premedication.

Medical Research: What is conversational hypnosis? What does it consist of?

Dr. Boselli: Conversational hypnosis consists of matching the patient’s behavioral communication patterns, reflective listening, avoiding any negative suggestion (e.g. “Keep calm and quiet” instead of “Please don’t move!”) and focalizing the patient’s attention on something else than the regional anesthesia procedure, such as the ultrasound machine screen.

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FDA Approves Belbuca Opioid Delivery Film For Chronic Severe Pain

Richard L. Rauck, M.D. Director of Carolinas Pain Institute Winston Salem, NC

Dr. Richard Rauck

MedicalResearch.com Interview with:
Richard L. Rauck, M.D.
Director of Carolinas Pain Institute
Winston Salem, NC

Medical Research: How large is the problem of chronic pain severe enough to require daily, around-the-clock, long-term opioid treatment and for whom alternative treatment options are inadequate?

Dr. Rauck: Chronic pain affects more than 100 million Americans – more than diabetes, heart disease and cancer combined. It is the most common cause of long-term disability, costing the U.S. billions of dollars annually in medical costs and lost wages and productivity.  

Medical Research: What are the main medical conditions associated with this type of pain? 

Dr. Rauck: A National Institute of Health Statistics survey indicated that low back pain is the most common cause of chronic pain (27%), followed by severe headache or migraine pain (15%), neck pain (15%) and facial ache or pain (4%).

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Low Back Pain Remains Frustrating Problem For Emergency Rooms and Patients

Benjamin W. Friedman MD, MS Department of Emergency Medicine Montefiore Medical Center Albert Einstein College of Medicine Bronx, New YorkMedicalResearch.com Interview with:
Benjamin W. Friedman MD, MS
Department of Emergency Medicine
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, New York

Medical Research: What is the background for this study? What are the main findings?

Dr. Friedman: Low back pain is responsible for 2.4% of visits to emergency departments resulting in 2.7 million visits annually. Pain outcomes for these patients are generally poor. One week after an ED visit in an unselected low back pain population, 70% of patients report persistent back-pain related functional impairment and 69% report analgesic use. Three months later, 48% report functional impairment and 46% report persistent analgesic use. Treatment of  Low back pain with multiple concurrent medications is common in the ED setting. Data from a national sample show that emergency physicians often prescribe NSAIDs, skeletal muscle relaxants, and opioids in combination—26% of patients receive a NSAID combined with a skeletal muscle relaxant and 26% also receive an NSAID combined with an opioid. Sixteen percent of patients receive all three classes of medication. Several clinical trials have compared combination therapy with NSAIDS + skeletal muscle relaxants to monotherapy with just one of these agents. These trials have reported heterogeneous results. The combination of opioids + NSAIDS has not been well evaluated in patients with acute low back pain. Given the poor pain and functional outcomes that persist beyond an ED visit for musculoskeletal LBP and the heterogeneity in clinical care, we conducted a randomized comparative efficacy study with the following objective. To compare pain and functional outcomes one week and three months after ED discharge among patients randomized to a ten day course of:

1) naproxen + placebo

2) naproxen + cyclobenzaprine or

3) naproxen + oxycodone/acetaminophen.

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Physical Therapy Has A Small Beneficial Effect In New Onset Back Pain

MedicalResearch.com Interview with:
Julie M. Fritz, PT, PhD, FAPTA

Professor, Department of Physical Therapy
Associate Dean for Research, College of Health
University of Utah
Salt Lake City, UT  84106

Medical Research: What is the background for this study? What are the main findings?

Dr. Fritz: Low back pain affects up to 80% of adults at some point in their lives and back pain is among the most common reasons why someone visits their primary care provider.  Despite how common back pain is, the health care system does a surprisingly poor job of managing patients with the condition. There are many things that can happen at the initial primary care visit for back pain that are unhelpful or may even delay recovery such as ordering an MRI or prescribing opioids. Most practice guidelines recommend that primary care providers avoid ordering an MRI or opioid pain medication, reassure the patient that they will begin to feel better quickly and then wait a few weeks before considering referral to physical therapy.  Others have suggested that earlier use of physical therapy may be more beneficial to patients.  We conducted this study to compare early physical therapy with a wait-and-see approach.

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Psoriasis Elevates Risk of Migraines

psoriasis foundationMedicalResearch.com Interview with:
Alexander Egeberg, MD
Department of Cardiology
Herlev and Gentofte Hospital
Hellerup, Denmark

Medical Research: What is the background for this study? What are the main findings?

Dr. Egeberg: Psoriasis is a common chronic skin disease, with a strong inflammatory component. Within the last decade, our understanding of psoriasis have advanced significantly, and psoriasis is now widely regarded as a systemic disease, where the skin is a direct marker of disease activity. The inflammatory pathways in psoriasis have also been implicated in several central nervous system diseases such as depression, uveitis, and multiple sclerosis. Moreover, pain generation and sensitization can occur as a result of the pro-inflammatory mediators which are upregulated in psoriasis.

In the present study, we investigated the association between psoriasis and psoriatic arthritis, and the risk of new-onset migraine. The main finding was a psoriasis-severity dependent increased risk of new-onset migraine, and patients with severe skin psoriasis, and psoriatic arthritis appeared to have the highest risk.

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Changing Delivery Method Reduces Pain of Neuroblastoma Treatment

Prof. Dr. Holger Lode Clinical Immunology, Pediatrics University of Greifswald, GreifswaldMedicalResearch.com Interview with:
Prof. Dr. Holger Lode

Clinical Immunology, Pediatrics
University of Greifswald, Greifswald

Medical Research: What is the background for this study?

Response: Neuroblastoma is a cancer in childhood with one of the highest death rates.  Standard treatment is already very intensive. It includes chemotherapy, surgery, radiation, high dose chemotherapy followed by autologous stem cell transplantation. However, the progress made in improving survival rates is still poor.

The use of an immune-modulatory treatment with a neuroblastoma specific monoclonal antibody ch14.18 (100 mg/m2 /cycle) in combination with cytokines and 13cis retinoic acid (13 cis RA) has shown benefit for patients with this disease [1].  This antibody targets ganglioside GD2 abundantly expressed on neuroblastoma with limited to no expression on healthy tissue. Low expression of GD2 on pain fibers is associated with an on-target side effect of the treatment, which is the induction of neuropathic pain. Approval of ch14.18 (dinutuximab) for the treatment of children with neuroblastoma has been provided by FDA.

In Europe, ch14.18 was not available for a long time. There were several reasons why the antibody in the US could not be given to children in Europe. Therefore a new development of this side of the Atlantic was initiated following the remanufacturing of the antibody in CHO cells [2] (dinutuximab beta) and was made available within clinical trials of the SIOPEN group. The SIOPEN group is a network of leading European pediatric oncology centers to improve outcome for children with neuroblastoma (http://www.siopen.org), similar to the COG (children`s oncology group in the USA; https://www.childrensoncologygroup.org).

Following the recloning procedure, ch14.18/CHO was first evaluated for safety in a Phase I study [3], which confirmed the tolerability and showed activity at a dosing regimen of 20 mg/m2 given by 8 hour infusions on 5 consecutive days. Dinutuximab beta is further developed by Apeiron Biologics.

The current way to apply 100 mg /m2 / cycle is by 4 short term infusions of 25 mg/m2/day each over 8 hrs on 4 consecutive days. The entire treatment consists of 5 cycles. The drawback is that STI is associated with a high amount of intravenous morphine required to make this treatment tolerable for patients. Also the rate of inflammatory side effects observed is substantial.

Clinical observation indicates that if patients treated by STI suffer from pain despite analgesic treatments, a decrease in speed of antibody infusion improves this on target toxicity. Therefore, we hypothesized that significant prolongation of the time of antibody infusion will improve tolerability of that treatment, but at the same time maintains clinical activity and efficacy in high risk neuroblastoma patients.

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Racial Disparities in Pain Medications For Pediatric Appendicitis

Monika Goyal, MD Pediatric emergency medicine Children’s National Hospital Washington, DC

MedicalResearch.com Interview with:
Monika Goyal, MD
Pediatric emergency medicine
Children’s National Hospital
Washington, DC

Medical Research: What is the background for this study? What are the main findings?

Dr. Goyal: Appendicitis is a painful surgical condition and adequate analgesia, particularly with opioids, are considered one of the mainstays of management. We found that almost half of all children diagnosed with appendicitis did not receive any analgesia. Furthermore, among the patients that did receive analgesia, there were marked racial differences with black children having lower rates of opioid medication receipt than white children, even after we took pain scores or acuity level into account.

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Opioid Buccal Delivery System May Enhance Relief of Chronic Pain

Lynn Webster, M.D. Vice President of Scientific Affairs PRA Health Sciences (lead study investigator, and former President of the American Academy of Pain Medicine) photo: WikipediaMedicalResearch.com Interview with:
Lynn Webster, M.D.

Vice President of Scientific Affairs
PRA Health Sciences
(lead study investigator, and former President of the American Academy of Pain Medicine)

Medical Research: What is the background for this study? What are the main advantages of the buccal film?

Dr. Webster: Because of its partial agonist activity and high affinity for mu-opioid receptors, buprenorphine has the potential to precipitate withdrawal in patients who are already on mu-opioid full agonists.  As a result, the current practice is to taper patients who are on around-the-clock (ATC) opioid therapy to a morphine sulfate equivalent (MSE) dose before switching to buprenorphine.  But tapering can result in a loss of pain control for patients.  For this study, we wanted to determine if patients on around-the-clock opioid full agonist therapy could be safely transitioned to buprenorphine HCl buccal film – an opioid partial agonist administered through the buccal mucosa – without the need for an opioid taper, and without inducing opioid withdrawal or sacrificing pain control.  Buprenorphine HCl buccal film is the first pain product in development to combine the efficacy of buprenorphine with this unique delivery system, which allows for efficient and convenient delivery of buprenorphine into the bloodstream.

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Fentanyl Buccal Tablet May Provide More Rapid Relief of Cancer Pain

Dr. Sebastiano Mercadante MD Director, Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit La Maddalena Cancer Center, Palermo, ItalyMedicalResearch.com Interview with:
Dr. Sebastiano Mercadante MD

Director, Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit
La Maddalena Cancer Center, Palermo, Italy

Medical Research: What is the background for this study? What are the main findings?

Dr. Mercadante:  Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background (1). Breakthrough cancer pain is a common problem in patients with cancer and is associated with significant morbidity. In a recent report in which a pragmatic definition of breakthrough cancer pain was used (2), the prevalence of BTcP was 75% (3).

Oral morphine (OM) has been traditionally offered as a breakthrough cancer pain medication in doses of about 1/6 of the daily opioid regimen for years, although this approach has never been supported by any evidence. Different technologies have been developed to provide a rapid onset of effect with potent opioid drugs such as fentanyl (rapid onset opioids, ROOs) delivered by non-invasive routes. Fentanyl products have been shown to be significantly superior to oral opioids, but it has been suggested that the dose of fentanyl should be individually titrated in order to enable effective analgesia to be delivered while minimizing the risk of clinically significant adverse effects. The need of dose titration with rapid onset opioids has never been appropriately assessed and this statement is derived by a series of weaknesses of papers published for regulatory issues. Indeed, the only existing study comparing dose titration and proportional doses, reported that proportional doses of (Fentanyl buccal tablet) FBT are more effective and safe over dose titration method. NICE guidelines did not provide evidence for that, at least at certain time intervals after administration.

To scientifically compare rapid onset opioids and oral morphine, we used a similar approach and made a strict selection of patients, according to a more specific algorithm for a diagnosis o fbreakthrough cancer pain. Thus, patients were randomized to receive in a crossover design Fentanyl buccal tablet and oral morphine, both given in doses proportional to opioid daily doses, for the management of breakthrough cancer pain.

This comparative study has shown that, when giving the drugs for breakthrough cancer pain in doses proportional to the opioid regimen for background pain, Fentanyl was clearly superior for efficacy and rapidity in comparison with oral morphine. The analgesic effect was more intense either at 15 and 30 minutes after study medications were given. A larger number of episodes treated with Fentanyl buccal tablet  presented a decrease in pain intensity of ≥33% and ≥50% in comparison with episodes treated with oral morphine, and a relevant difference in SPID30 was reported. Of interest, adverse effects commonly observed in patients receiving opioids were not severe and did not differ between the treatments, suggesting that the use of proportional doses of both drugs are safe, reflecting what is derived by the long-lasting experience with oral morphine.   Continue reading

Music Reduces Need For Pain Medications After Surgery

Dr Martin Hirsch  Clinical Research Fellow Women’s Health Research Unit Queen Mary University of LondoMedicalResearch.com Interview with:
Dr Martin Hirsch
Clinical Research Fellow
Women’s Health Research Unit
Queen Mary University of London and
Dr Jenny Hole Foundation Year 1 Doctor Kettering University Hospital

Dr Jenny Hole
Foundation Year 1 Doctor
Kettering University Hospital

 

MedicalResearch: What is the background for this study? What are the main findings?

Response: As doctors we see medicines being prescribed on a daily basis and the benefit but also harm that they can cause. We wanted to assess the role of non pharmaceutical interventions which can benefit patients with a low or minimal potential for harm. We all have an interest in music of different genres and we agreed that we didn’t know anybody who did not like music of one sort or another. On the basis that we all have gained pleasure from music, we wanted to see if this pleasurable experience at the time of a difficult and painful stimulus could reduce the problems encountered as people recover from surgery.

We searched all published medical literature and found 73 of the highest quality studies (randomised controlled trials) to compare and combine their findings in a meta-analysis. This technique aims to strengthen the validity by producing a combined result.

We found that using music before during or after surgery reduced pain, reduced the requirement for pain killers, reduced anxiety, and improved satisfaction.

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Over 10% US Adults Live With Pain Every Day

Richard L. Nahin, Ph.D., M.P.H National Center for Complementary and Integrative Health National Institutes of Health, Bethesda, MarylandMedicalResearch.com Interview with:
Richard L. Nahin, Ph.D., M.P.H
National Center for Complementary and Integrative Health
National Institutes of Health, Bethesda, Maryland

Medical Research: What is the background for this study?

Dr. Nahin: In 2011 the Institute of Medicine published a blueprint for transforming pain care in the United States.  In this report the IOM noted the lack of a comprehensive picture of pain’s prevalence and severity in the U.S., and especially noted that lack of data examining racial and ethnic groups. The current analysis of data from the 2012 National Health Interview survey is a step toward addressing these deficiencies. 

Medical Research: What are the main findings?

Dr. Nahin: The analyses found that an estimated 25.3 million adults (11.2 percent) had pain every day for the preceding 3 months. Nearly 40 million adults (17.6 percent) experience severe levels of pain.  Those with severe pain are also likely to have worse health status.  There were associations between pain severity and race, ethnicity, language preference, gender, and age. Women, older individuals, and non-Hispanics were more likely to report any pain, while Asians were less likely.  Minorities who did not choose to be interviewed in English are markedly less likely to report pain.

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Botulinum Toxin Reduces Pain of Skin Leiomyomas

Edward W. Cowen, MD, MHSc Dermatology Branch, Center for Cancer Research National Cancer Institute Bethesda, MarylandMedicalResearch.com Interview with:
Edward W. Cowen, MD, MHSc
Dermatology Branch, Center for Cancer Research
National Cancer Institute
Bethesda, Maryland

Medical Research: What is the background for this study?

Dr. Cowen: Cutaneous leiomyomas are benign smooth muscle proliferations that are associated with pain that is typically not well-controlled by topical remedies or systemic pain medication. Hereditary leiomyomatosis and renal cell cancer is a rare syndrome in which patients may have dozens or even hundreds of these painful tumors. We sought to determine if botulinum toxin injected directly into leiomyomas may ameliorate discomfort and improve quality of life in patients who experience significant pain from cutaneous leiomyomas.

Medical Research: What are the main findings?

Dr. Cowen: In a double-blinded placebo-controlled study, we found that injection of botulinum toxin was associated with improved skin-related quality of life (p = 0.007) and decreased skin-specific pain (p = 0.048) on the Dermatology Life Quality Index. A trend for decreased pain (p = 0.06) by visual analog score was reported in the botulinum toxin treated group compared to the placebo group.

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NSAIDS Work For Menses Pain But Carry Risk of Side Effects

MedicalResearch.com Interview with:
Jane Marjoribanks
Obstetrics and Gynaecology
University of Auckland, National Women’s Hospital,
Auckland, New Zealand

MedicalResearch: What is the background for this study?

Response: This study is a systematic review of all randomised evidence published up to January 2015 on the effectiveness and safety of non-steroidal inflamatory drugs (NSAIDs) used to treat primary dysmenorrhoea (period pain). It includes 80 randomised controlled trials (total 5820 participants), which compare 20 different NSAIDs versus placebo, other NSAIDs or paracetamol.

The review was prepared by researchers from the Cochrane Collaboration, which is a global independent network of contributors (37,000 from more than 130 countries) who gather and summarize the best evidence from research to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest.

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Topical and Injected Placebos More Effective Than Pills

MedicalResearch.com Interview with:
Raveendhara R Bannuru MD, PhD, FAGE
Director, Center for Treatment Comparison and Integrative Analysis (CTCIA)
Asst Professor of Medicine, Tufts University School of Medicine
Special & Scientific Staff, Center for Arthritis and Rheumatic Diseases
Tufts Medical Center Boston, MA

Medical Research: What is the background for this study?

Dr. Bannuru: Placebos are used to determine the efficacy of a wide variety of treatments for medical conditions such as osteoarthritis. A sound understanding of potential differences among placebos is essential for determining the relative efficacy of such treatments.

Medical Research: What are the main findings?

Dr. Bannuru: Our results indicate that different types of placebos do in fact differ in efficacy. Placebo injections and topical placebos were both found to be more effective than orally administered placebos for reducing knee osteoarthritis pain.

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Study Evaluates Cannabis For Pain From Diabetic Neuropathy

Mark S. Wallace MD Department of Anesthesiology School of Medicine University of California, San Diego, CaliforniaMedicalResearch.com Interview with:
Mark S. Wallace MD
Department of Anesthesiology
School of Medicine
University of California, San Diego, California

Medical Research: What is the background for this study? What are the main findings?

Dr. Wallace: The study was funded by the center for medicinal cannabis research at the University of California San Diego.  The center was funded by the state of California.  The center was the first to fund a series of double-blind randomized controlled trials with inhaled cannabis for neuropathic pain.  My trial is the first in diabetic peripheral neuropathy pain which is one of the most prevalent pain syndromes in our society with limited treatments.  We found a dose dependent reduction in pain.  However there was also a dose dependent increase in euphoria and sedation which may limit clinical use.  Effects on neurocognitive functioning were minimal.

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Study Compares Two Surgical Techniques To Relieve Migraine Headaches

MedicalResearch.com Interview with:
Dr. Bahman Guyuron MD

Cleveland and Lyndhurst, Ohio From the Department of Plastic Surgery, University Hospital Case Medical Center; and the American Migraine Center

Medical Research: What is the background for this study?

Dr. Guyuron: Through several studies including retrospective, prospective pilot, prospective randomized, prospective randomized study with sham surgery, prospective randomized study with 5 year follow up, basic science analysis comparing the nerves of the patients who do not have migraine to those who do not have migraine headaches we have demonstrated efficacy of migraine surgery and the rational for effectiveness of this operation. The later study demonstrated that the patients who experience migraine headaches may have deficiency in myelin membrane protecting the peripheral nerves. Four other centers have reported similar experience independently.

Medical Research: What are the main findings?

Dr. Guyuron: Most of the surgical procedures that the I have developed for migraine surgery in the forehead, occipital area and the nose focus on decompression of the nerves. However, in dealing with some of the temporal migraine headaches involving the zygomticotemporal branch of the trigeminal nerve we perform neurectomy for years. The nature of the this procedure which involves removing a small segment this 1 mm nerve, is unsettling to us, the patients and the neurologist. The purpose of this study was to compare the outcome of the neurectomy to decompression for the patients with temporal headaches.

Medical Research: What should clinicians and patients take away from your report?

Dr. Guyuron: The study demonstrated the there is no statistical difference between the outcome migraine surgery in temple area using neurectomy or nerve decompression. Based this study the clinician can use either technique having the some level of confidence. Should the decompression fail it would offer an opportunity for a plan B which would be removing a segment of the nerve.

Citation:

A Prospective Randomized Outcomes Comparison of Two Temple Migraine Trigger Site Deactivation Techniques

Guyuron B1, Harvey D, Reed D.

Plast Reconstr Surg. 2015 Jul;136(1):159-65. doi: 10.1097/PRS.0000000000001322.

Dr. Bahman Guyuron MD, & Cleveland and Lyndhurst (2015). Study Compares Two Surgical Techniques To Relieve Migraine Headaches

Patient Controlled Medication Found Effective For Abdominal Pain In ER

MedicalResearch.com Interview with:
Prof. Jason Smith
Consultant in Emergency Medicine, Derriford Hospital, Plymouth, UK
Royal College of Emergency Medicine Professor
Defence Professor of Emergency Medicine, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, UK
Honorary Professor in Emergency Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, UK

Medical Research: What is the background for this study?

Prof. Smith: Patients commonly present to emergency departments in pain. When patients are asked about their emergency department experience, they often say that more could have been done to manage their pain.

Routine care for patients in moderate or severe pain who present to emergency departments usually involves intravenous (IV) morphine, delivered by a nurse. There may be a delay when patients are admitted to a hospital ward before they are reviewed by the admitting medical team, when their pain needs are reassessed.

Patient controlled analgesia (PCA) is used to good effect elsewhere in the hospital.
The aim of this study was to compare PCA with routine care in patients presenting to emergency departments with either traumatic injuries or non-traumatic abdominal pain, who require admission to hospital.

Medical Research: What are the main findings?

Prof. Smith: We found that significant reductions in pain were possible using patient controlled analgesia in patients with abdominal pain. Patients spent significantly less time in moderate or severe pain, and were more likely to be very or perfectly satisfied with their pain management.

In patients with traumatic injuries, a modest (but non-significant) reduction in pain was seen in patients allocated to the PCA group compared with the routine care group. Patients in the PCA group were more likely to be very or perfectly satisfied with their pain management. Continue reading

Opioids and Barbituates Commonly Prescribed For Headaches

Dr. Mia T. Minen, MD, MPH Director, Headache Services at NYU Langone Medical Center Assistant professor, Department of Neurology
MedicalResearch.com Interview with:
Dr. Mia T. Minen, MD, MPH
Director, Headache Services
NYU Langone Medical Center
Assistant professor, Department of Neurology

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Minen: We conducted a survey on opioid and barbiturate use among patients visiting a headache center to find out which medications they were receiving for treatment. There’s limited evidence that long-term use of these medications can help treat headaches or migraines, and even short-term use in small quantities can cause medication overuse headache. It is important to determine which providers start these medications so that educational interventions can be tailored to these physician specialties to try to prevent situations such as incorrect prescribing practices and medication overuse.

In this sample of patients from a specialty headache center, approximately 20 percent of patients — or 1 in 5 — were using opioids or barbiturates, and about half had been prescribed these medications at some point in the past for their headaches. These findings show that opioids and barbiturates are commonly prescribed to patients with headaches. While two-thirds of patients found opioids or barbiturates helpful, many did not like them, were limited by side effects or did not find them to be helpful. Emergency department physicians were reported to be the most frequent first prescribers of opioids and general neurologists were the most frequent prescribers of barbiturate-containing medications. Primary care physicians were also identified as frequent first prescribers of these medications.
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Pain From Sciatica Not Helped By Oral Steroids

Harley Goldberg, DO Physical Medicine and Rehabilitation Kaiser PermanenteMedicalResearch.com Interview with:
Harley Goldberg, DO
Physical Medicine and Rehabilitation
Kaiser Permanente

Medical Research: What is the background for this study? What are the main findings?

Dr. Goldberg: This is the first large-scale randomized, double-blind, placebo-controlled clinical trial of oral steroids for acute radiculopathy, commonly called sciatica, associated with a herniated lumbar disk.

Lumbar radiculopathy (or pain down the leg in a lumbar nerve root distribution) is a common source of pain and disability for many adults. It is thought that inflammation from a disk herniation is responsible for many of the symptoms, so giving a powerful anti-inflammatory, such as steroid medication, might help relieve sciatica symptoms quickly. Prior research has shown that lumbar diskectomy does not affect the one year outcome for most patients, and epidural steroid injections do not have strong support by clinical trials. If the use of epidural steroids injections is based on application of steroid anti-inflammatory to the affected nerve root(s), perhaps an oral steroid can have affect. Although oral steroids are used by many physicians and have been included in some clinical guidelines, no large-scale clinical trials of oral steroids for sciatica have been conducted before.

Our study found that among patients with acute radiculopathy associated with a herniated lumbar disk, a short course of oral steroids resulted in only modest improvement in function and no significant improvement in pain.
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US Surgery Patients Report More Pain, Receive More Opioids

MedicalResearch.com Interview with:
Winfried Meissner, M.D.

Dep. of Anesthesiology and Intensive Care
Jena University Hospital
University Hospital Jena, Germany

Medical Research: What is the background for this study?

Dr. Meissner: Post-operative pain is managed inadequately worldwide. There are probably many reasons for this, one of which may be lack of evidence about outcomes of treatment in the clinical routine.

PAIN OUT was established  as a  multi-national research network and quality improvement project offering healthcare providers  validated tools to collect data about pain-related patient reported outcomes and management after surgery. Patients fill in a questionnaire asking for pain intensity, pain interference and side effects of pain management. The questionnaire has now been translated into 20 languages. Data are collected electronically and clinicians are provided with feedback about management of their own patients, compared to similar patients in other hospitals.  Furthermore, the findings are used for outcomes and comparative effectiveness research. PAIN OUT is unique in that  outcomes of postoperative pain management can be examined internationally.

PAIN OUT was created in 2009 with funds from the European Commission, within the FP7 framework and  has now been implemented in hospitals in Europe, USA, Africa and SE Asia. The findings allow us to gain insights as to how pain in managed in different settings and countries.

For this particular study, we compared management of pain in the US to other countries. We assessed a large group of patients who underwent different types of orthopedic surgery and compared their patient reported outcomes and management regimens. We included 1011 patients from 4 hospitals in the USA  and 28,510 patients from  45  hospitals in 14 countries (“INTERNATIONAL”).

Medical Research: What are the main findings?

Dr. Meissner: Postoperative pain intensity of US patients was higher than in INTERNATIONAL patients; they felt more often negatively affected by pain-associated anxiety and helplessness, and more US patients stated they wished to have received more pain treatment. However, other patient-reported outcomes like time in severe pain or the level of pain relief did not differ.

We found that treatment regiments of American patients differed compared to INTERNATIONAL patients. More US patients received opioids, and their opioid doses were higher compared to INTERNATIONAL patients. In contrast, INTERNATIONAL countries use more nonopioid medications intraoperatively and postoperatively. Thus, under-supply with opioids cannot explain our findings.

Mean BMI of US patients was 30.3 while for INTERNATIONAL it was 27.4. However, insufficient evidence exists that this finding might account for differences in pain intensity.

Routine pain assessment was performed in almost all US patients, in contrast to about 75% in the INTERNATIONAL group. Obviously, routine pain assessment, as practiced in the United States, fails to result in lower postoperative pain. Perhaps it has the opposite effect by directing patients’ attention to the pain.

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Orthopedic Patients and Their Families At Risk For Opioid Abuse

Hassan R. Mir, MD, MBA Associate professor of Orthopaedics and Rehabilitation Vanderbilt Orthopaedic InstituteMedicalResearch.com Interview with:
Hassan R. Mir, MD, MBA
Associate professor of Orthopaedics and Rehabilitation
Vanderbilt Orthopaedic Institute and

and

Brent J. Morris, M.D. Shoulder and Elbow Surgery Fellowship Texas Orthopaedic Hospital in affiliation with the University of Texas Houston Health Science Center, Houston, TexasDr. Brent J. Morris, M.D.
Shoulder and Elbow Surgery Fellowship
Texas Orthopaedic Hospital University of Texas Houston Health Science Center,
Houston, Texas

Medical Research: What is the background for this study? What are the main findings?

Dr. Mir: The past few decades have seen an alarming rise in opioid use in the United States, and the negative consequences are dramatically increasing. The US represents less than 5% of the world’s population, yet consumes 80% of the global opioid supply. Management of pain is an important part of patient care, however, the increased usage of opioids for the treatment of pain has led to several unanticipated aftereffects for individual patients and for society at large.

Orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States. Orthopaedic patients can experience a tremendous amount of pain with acute injuries and chronic conditions, and the treatment plan may involve opioid prescriptions for relief of discomfort. A significant number of orthopaedic patients and their families are at risk for repercussions from opioid use. We must work together to decrease the use of opioids for musculoskeletal pain.

Clinicians should aim to control pain and improve patient satisfaction while avoiding overprescribing opioids. A comprehensive strategy of risk assessment is needed to identify patients who may be at risk for opioid abuse. Objective measures including patient history, recognition of aberrant behavior, urine drug testing, state prescription drug–monitoring programs, and opioid risk-assessment screening tools may be necessary in select cases.

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Acetaminophen May Reduce Both Pain and Emotional Response

MedicalResearch.com Interview with:
Geoff Durso PhD Candidate
Department of Psychology
The Ohio State University

Medical Research: What is the background for this study? What are the main findings?

Response: Recent research has shown that acetaminophen blunts negative emotions beyond those arising from physical pain (e.g., social rejection). We hypothesized that this was the case because acetaminophen was having a broader effect on individuals’ evaluative and emotional processing, given past psychological theory (e.g., differential susceptibility, personality differences in emotionality, etc) and related neurological evidence (acetaminophen affects serotonin neurotransmission in the brain, reduces inflammatory signaling in the brain, and decreases activation in the brain areas responsible for emotion, for instance–any one or combination of these effects could be responsible for the psychological outcomes that we observe on individuals’ blunted negative and positive evaluations).

So we conducted two double-blind studies (neither participants nor experiments were aware of participants’ assignment to condition). What we found was that participants taking an acute dose of acetaminophen (compared to those taking an inert placebo control) reported diminished negative evaluations of displeasing stimuli (photographs of starving children, wartorn city blocks, disgusting toilets) as well as diminished positive evaluations of pleasing stimuli (photographs of children playing with kittens, a large pile of money, a couple in bed together). Participants taking acetaminophen also reported experiencing diminished emotional responses to the photographs overall. These findings supported our predictions that acetaminophen works to reduce pain in part because it has a broader blunting effect on individuals’ evaluations and emotional experience. Continue reading

Acetaminophen May Not Be Effective For Osteoarthritis, Low Back Pain

Gustavo C Machado, PhD student The George Institute for Global Health, Sydney Medical School University of Sydney Sydney AustraliaMedicalResearch.com Interview with:
Gustavo C Machado
, PhD student
The George Institute for Global Health, Sydney Medical School
University of Sydney Sydney Australia

(Editor’s note: Paracetamol isalso known as acetaminophen)

MedicalResearch: What is the background for this study? What are the main findings?

Response: Back pain and osteoarthritis are the two major musculoskeletal conditions affecting people worldwide, and paracetamol is the most used over the counter medicine to treat these conditions. Recent debates on the efficacy and safety of paracetamol prompted us to conduct a systematic review of literature on the efficacy of this medication. In our study we included all available clinical trials that compared paracetamol to placebo, and our conclusions are based on data from more than 5,300 patients with low back pain and hip or knee osteoarthritis. We found that paracetamol is ineffective for low back pain and provides small and not clinically important benefits to patients with osteoarthritis.
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Back Pain: Early Imaging Of Older Adults Results in More Costs, Not Better Outcomes

Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA  98104-2499MedicalResearch.com Interview with:
Jeffrey (Jerry) G. Jarvik MD MPH
Professor, Radiology, Neurological Surgery and Health Services
Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine
Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA

Medical Research: What is the background for this study?

Dr. Jarvik: 
When I arrived at the Univ of WA over 20 years ago, my mentor, Rick Deyo, had just finished leading a project that was responsible for developing one of the first set of guidelines for the diagnosis and treatment of acute low back pain. These guidelines, published in a booklet by AHRQ (then called AHCPR), recommended that patients with acute low back pain not undergo imaging for 4-6 weeks unless a red flag was present. One of the exceptions was that patients older than 50 could get imaged immediately, the rationale being that older adults had a higher prevalence of potentially serious conditions such as cancer, infections, etc, that would justify the early imaging. As a practicing neuroradiologist, it was clear that a potential problem with this strategy is that the prevalence of age-related changes, which may or may not be related to back pain, also increases with age. So earlier imaging of older adults would almost certainly reveal findings, and these could easily start a series of unfortunate events leading to potentially poor outcomes and more healthcare resource use. Thus this policy of early imaging of older adults didn’t entirely make sense.

About 5 years ago, these guidelines hit home when I developed acute low back pain and since I was over 50 (barely) my doctor recommended that I get an imaging study. Being a knowledgeable patient and having a reasonable doctor, we mutually agreed not to get the study. I improved but that wasn’t the end of it. When we had the chance to apply for one of the CHOICE ARRA awards funded by AHRQ, we made answering this question of early imaging in older adults one of our primary goals.

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ESCAPE Study Evaluates Stepped Care For Chronic Pain in Veterans

Matthew J. Bair, MD, MS Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication Richard L. Roudebush Veterans Affairs Medical Center, Department of Medicine, Indiana University School of Medicine, Health Services Research, Regenstrief Institute, Inc, Indianapolis, IndianaMedicalResearch.com Interview with:
Matthew J. Bair, MD, MS
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication
Richard L. Roudebush Veterans Affairs Medical Center,
Department of Medicine, Indiana University School of Medicine, Health Services Research, Regenstrief Institute, Inc, Indianapolis, Indiana

MedicalResearch.com: What is the background for this study?

Dr. Bair: Despite the prevalence and functional, psychological, and economic impact of chronic pain, there have been few intervention studies to treat chronic pain in Veterans.

MedicalResearch.com: What are the main findings?

Dr. Bair: A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain.

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Jyoti Meditation May Help Chronic Neck Pain

Prof. Dr. med. Andreas Michalsen Stiftungsprofessur für klinische Naturheilkunde Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie Charité - Universitätsmedizin Berlin Immanuel Krankenhaus BerlinMedicalResearch.com Interview with:
Prof. Dr. med. Andreas Michalsen
Stiftungsprofessur für klinische Naturheilkunde
Institut für Sozialmedizin, Epidemiologie und
Gesundheitsökonomie
Charité – Universitätsmedizin Berlin
Immanuel Krankenhaus Berlin

Medical Research: What is the background for this study? What are the main findings?

Response: Chronic neck and back pain is an increasing health care problem in Europe and the U.S.

Chronic neck pain is associated with distress and there is a need to evaluate methods of stress reduction in the management of chronic neck pain. The main findings of this trial were, that an 8-week meditation program teaching a traditional meditation technique, Jyoti meditation, leads to significant pain relief and reduced pain-related bothersomeness.
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NSAIDS After Heart Attack Increase Risk of Bleeding and Further Heart Attacks

MedicalResearch.com Interview with:
Anne-Marie Schjerning Olsen, MD, PhD Department of Cardiology Gentofte Hospital, University of Copenhagen DenmarkAnne-Marie Schjerning Olsen, MD, PhD
Department of Cardiology
Gentofte Hospital, University of Copenhagen
Denmark

MedicalResearch.com: What is the background for this study?

Dr. Olsen: The question addressed in the study was: Do people who have had a myocardial infarction (heart attack) and are who taking drugs (known as antithrombotics) to reduce their risk of further heart attacks have an increased risk of serious bleeding, especially gastrointestinal bleeding, and of further heart attacks if they also take painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs)?

We found that taking NSAIDs, even for periods of under one week (3-4 days for bleeding), was associated with increased risks of both bleeding and of further heart attacks.

Background: People who have suffered a heart attack are prescribed medicines afterwards to reduce their risk of another one. The medicines usually include two ’antithrombotic drugs’ which make platelets in the blood less sticky – the two most commonly used drugs are aspirin and clopidogrel. A side effect of antithrombotic treatment is that the drugs increase bleeding risk.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat pain and inflammation. They are very effective and are among the most widely used drugs in the world. Some NSAIDs can be bought across the counter without a prescription, for example, ibuprofen. NSAIDs have side effects too. All of them increase the risk of bleeding, especially gastro-intestinal bleeding arising from damage (ulcers) caused to the gut lining. Some NSAIDs, for example diclofenac, are also associated with a small increase in the risk of heart attack – this risk matters most for people already at risk of a heart attack. The medical advice is for these patients to avoid NSAIDs and for their doctors to avoid prescribing them if possible.

But pain is a common problem and very distressing for people – so in practice, NSAIDs are used quite often by patients who have had a heart attack. If NSAIDs are to be taken by heart attack patients, then it is important that both they and their doctors know the risks so that they can weigh up the benefits and downsides and make an informed decision.

What this study did: This was a cohort study that included everyone in Denmark aged 30 years or older who had had a first heart attack and who was taking antithrombotic medicines. Using hospital and dispensing registries, we examined patients who had suffered serious bleeding (causing admission to hospital and/or death) or who had another heart attack or cardiac event to see if they had been prescribed NSAIDs or not.

Dr. Olsen: The study findings: In this study of over 60,000 patients in Denmark taking antithrombotic medicines, one third of them had at least one prescription for NSAIDs, commonly ibuprofen or diclofenac, dispensed over a median study time of 3.5 years. In the same period, 8.5% (5,288 patients or 1 in 12 of the study group) had a gastrointestinal bleed (of whom 799 or 15% died) and 30% (18,568; 1 in 3) had a new cardiac event, mostly heart attack. While these events happened to patients who were prescribed NSAIDs and also to patients were not prescribed NSAIDs, we found that the risk of bleeding was doubled when patients were taking NSAIDs compared with not taking them. The risk occurred within 3 days of starting a NSAID. The risk of a cardiac event (mainly heart attack) was increased by 40% when taking NSAIDs compared with not taking them and also occurred within days of starting a NSAID.

In other words, the NSAIDs appeared 1) to increase the bleeding risk already existing with antithrombotics and 2) to diminish the cardiac protection that antithrombotics provided.

Limitations: This is just one study, although it is a big one. It was a ’real-life’ observational study not a randomised controlled clinical trial. More studies are needed to confirm what we have found.

MedicalResearch:  Why is this important information for patients and doctors to know?

Dr. Olsen: NSAIDs were used a lot by the patients in this study – pain is a common problem and can cause great suffering. There has been a tendency to think that short-term use of NSAIDs is safe – our study suggests this in not the case and that even a few days of use is associated with increased risks of both bleeding and cardiac events, mainly heart attacks. People may be happy to take these risks to have relief from pain but it is very important that they aware of the risks and can make an informed decision about taking NSAIDs for pain relief.

Citation:

Schjerning Olsen A, Gislason GH, McGettigan P, et al. Association of NSAID Use With Risk of Bleeding and Cardiovascular Events in Patients Receiving Antithrombotic Therapy After Myocardial Infarction. JAMA. 2015;313(8):805-814. doi:10.1001/jama.2015.0809.

Anne-Marie Schjerning Olsen, MD, PhD Department of Cardiology (2015). NSAIDS After Heart Attack Increase Risk of Bleeding and Further Heart Attacks