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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2003


FROM THE EDITOR: NEWS FROM NBPA COUNCIL headache in which the pain is often unilateral,
pulsating in quality and usually accompanied by
Welcome to the spring edition of Threshold, Clinical Information Subgroup anorexia, nausea and vomiting.” In some cases, it
which, like the last issue, has kindly been sponsored may be preceded or accompanied by focal
by Janssen Cilag. The winter scientific meeting At the last NBPA Council Meeting, Dr. Robin neurological, especially visual, symptoms. The
seems a long time ago now. The long winter months McKinlay from Stirling floated the suggestion of lifetime risk of suffering from migraine is 25% and
are now at an end. Spring is here, heralded by sunny forming a Clinical Information Subgroup. The group the prevalence in the general population is 10% -
days, birds singing in the trees and the sound of would advise on information technology and audit 15%. It is 2 – 3 times more common in women than
Threshold dropping through your letter box. issues, including the maintenance of the NBPA men, especially during the reproductive years. The
Unfortunately, all is not rosy in the world and these website. We are all aware of the need to audit our commonest age of onset is in the second or third
are troubled times. Perhaps, by the time you read activities and outcomes. There is a general decade. A positive family history is present in 70%
this, the war in Iraq will be over with, we hope, as recognition that many centres have struggled to set of cases and other risk factors include female sex,
few casualties as possible. Current events make the up and utilise the PACS national database for a age, menstruation, early pregnancy, stress, diet,
subject of the Spring Meeting, ‘Pain in Conflict’ all variety of reasons. The importance of support for this sleep, travel, exercise, head injury, SLE and certain
the more relevant. project was recently highlighted in an Editorial in drugs.
‘Anaesthesia’. It was agreed that Robin would
As I was working on this issue of Threshold, the approach three other individual with an interest in
Pain Society newsletter arrived. The new Editor, these matters to form the group. If anyone has
Stephen Ward, has produced an excellent ‘new look’ expertise in this field and would like to be involved
first issue. Now, being of a competitive nature, I tried then please speak to Robin at the next meeting in
telling myself that we are not rivals but Edinburgh or contact him at Stirling Royal Infirmary.
complementary publications. I don’t feel pressured
at all, I don’t…. not at all….. absolutely not.
NBPA Website
I have, in fact formulated bold plans for
Threshold, but on consultation with my colleagues I There are ongoing discussions about the cost,
have been advised that it would not be proper at this location and future of the NBPA website which is
juncture to turn Threshold into the ‘Loaded’ currently located on the University of Newcastle
magazine of the pain world. Oh well, never mind. server. Dr. Semple is to investigate other options and
will report back to council.
The winner of last issue’s caption competition is Dr Roger Cull and Dr Charlotte Feinmann
announced over the page and for this issue, as well
as the caption competition, Mike Basler has provided Migraine can be sub-divided into different types.
us with an interesting anagram competition. The commonest is migraine without aura affecting
DATES FOR YOUR DIARY 80%-90% of sufferers, followed by migraine with
As ever, there is much to keep us busy, including aura affecting 10% - 20%. Migraine with aura can
the Pain Society meeting in Glasgow, the Spring NBPA Spring Scientific Meeting Friday 9th May be further subdivided into basilar artery migraine,
NBPA meeting and of course summer holidays to 2003 “Pain in Conflict” which causes double vision and speech slurring,
look forward to. hemi-plegic, dysphasic/dysmnesic and dysphoric.
NBPA Winter Scientific Meeting Friday 21st
The deadline for the NBPA essay competition has November 2003 “An Inflammatory View of Pain” Migraine without aura generally lasts between 4
come and gone. There has not exactly been a flood and 72 hours. The headache should have two of the
of entries but those submitted have been of the following four features: -
highest standard. The winner will be announced at - Unilateral
the Spring Scientific Meeting. Information on next - Throbbing
year’s competition will be given in the Autumn issue. - Moderate to severe intensity
REPORT FROM WINTER
- Exacerbation by physical activity
If you have an article you would like to submit, SCIENTIFIC MEETING
a topic you would like covered, or a news item you There may be associated symptoms of
Friday 22/11/02
would like to be included in the next issue, please photophobia, nausea and vomiting.
send it to the address below. Any photographs, “Hard nuts to crack”
embarrassing or otherwise, suitable for the caption Typical features of migraine with aura include
competition would be much appreciated. Post them The meeting was kindly sponsored by Merck
Sharp and Dohme, Napp Pharmaceuticals, Pfizer and those for migraine without aura with at least three
to: - of the following characteristics: -
Dr Colin P. Rae, Janssen Cilag.
- One or more fully reversible aura symptoms
Department of Anaesthesia, - Aura symptoms develop over more than four
Stobhill Hospital, The day started with an excellent lecture given
by Dr Roger E Cull, Consultant & Senior Lecturer minutes
133 Balornock Road, - Aura lasts less than 60 minutes
Glasgow, in Neurophysiology, Western General Hospital,
Edinburgh. The title of his lecture was “Diagnosis - Type of aura may change during attack
G21 3UW. - Headache follows within 60 minutes
Tel no: 0141 201 3005. of migraine and other headaches”.
- Visual prodomata including teichopsia and
Fax no: 0141 201 4167. scintillating scotoma
Email: colin.rae@northglasgow.scot.nhs.uk Migraine is defined as: - “A familial periodic
NBPA website www.nbpa.org.uk disorder characterised by recurrent attacks of
Various trigger factors for migraine have been Dr Cull concluded by emphasising the associated with a suppression or mis-attribution of
identified and include: importance of taking a detailed history, thoroughly mood”.
examining the patient and undertaking investigations The basis of treatment is to consider the
- Relief of stress if the history is suspicious, clinical signs are present functional somatic symptoms together. A
- Hormonal changes or the headache cannot be categorised. He advised psychosocial approach with an empathic interviewer
- Physical exertion extra caution when dealing with patients with a may help the patient to recognise the problem. Health
- Change of routine previous neoplasm and also older patients with a new beliefs can be explored and appropriate reassurance
- Visual glare, vivid patterns headache. given although premature reassurance may not have
- Weather and atmospheric pressure changes the desired effect. The aim of management is to
- Foods and alcoholic drinks Dr Charlotte Feinmann, Reader in Psychiatry, change the patient’s focus of attention.
Behavioural Sciences and Dentistry, Eastman Dental
The differential diagnosis of migraine include: Institute and Royal Free and University College The pain team at the Eastman Dental Institute
Medical School, gave the second lecture. The subject includes psychiatrists, psychologists, nursing
1. Tension type headache. These affect 70% - 80% of the talk was “Oro-facial Pain”. practitioners, restorative specialists, neurologists and
of the population, have a variable duration with an anaesthetist. Treatments include the use of
mild to moderate pain, often bilateral which is antidepressants, cognitive behavioural therapy,
tight, pressing or band-like. The headache is informed reassurance, hypnosis, relaxation and splint
often frontal, temporal or occipital, there is therapy. Clinicians must take a full history in an
usually no nausea, vomiting or photophobia and attempt to make a diagnosis. Investigations and
it is often triggered by stress and relieved by physical treatments, however, may make pain more
relaxing. difficult to treat, can exacerbate anxiety and
depression and frustrate both patient and clinician.
2. Cervicogenic headache. These are less well
established than tension type headache. They In conclusion, Dr Feinmann stressed the
tend to occur daily, with occipital headache importance of adequate assessment, informed
associated with neck pain that may radiate to the reassurance, team management, antidepressants, the
temporal region. The headache is worse with use of cognitive behavioural therapy and hypnosis.
certain postures and there are limited and painful
neck movements. There followed the usual high quality lunch in
the conservatory.
Dr Andrea Harvey and Dr Charlotte Feinmann
3. Cluster headache (Migrainous Neuralgia). This
affects men 5 – 8 times more commonly than
women. It is a rare disorder af fecting Dr Feinmann started by giving an overview of
approximately 1 in 1000 people. the complexity of pain. Melzack and Wall were the
Characteristically, there are clusters of one or first to describe pain as the result of afferent upstream
more daily headaches over a period of several processes within the spinal cord with downstream
weeks, followed by painfree periods. They are modulation. We are aware that the brain can generate
commoner in smokers. They are characterised pain in the absence of input from peripheral
by severe retro-orbital pain, lasting 15 – 90 nociceptors, for example in phantom limb pain. She
minutes. Attacks are often nocturnal and emphasised the cognitive model of pain which takes
associated with epiphora, nasal congestion and into account both physical and psychosocial aspects
Horner ’s syndrome. In contrast to migraine and described the common problem of being able to
sufferers, people with cluster headache tend to explain to a patient what is not wrong with them but
walk around and may be aggressive. not what is wrong with them.

4. Temporal arteritis. This condition should also be She then reported the results of a series of Drs Carlin Thomas, Tom McCubbin
considered in older patients with a new headache studies. In 1985, Bridges and Goldberg, found that and Joanne Wood enjoy lunch
whether uni or bilateral. There may be associated one in five new consultations in primary care are for
tenderness over the temporal region or in the medically unexplainable symptoms. One third of Dr Mike Basler from Glasgow Royal Infirmary
occipital area and there may be systemic these persist and cause distress and disability. chaired the afternoon session. Dr Tom Brown,
symptoms including malaise, weight loss, fever, In 2002, MacFarlane et al published a population Consultant Liaison Psychiatrist based at the Western
polymyalgia and visual loss. If there is a based cross sectional survey of 2504 adults aged and Gartnavel Hospitals in Glasgow started the
suspicion of temporal arteritis, an ESR should between 18 and 65 in the journal Pain. It reported afternoon. The title of his lecture was “Chronic
be taken to confirm or exclude the diagnosis. that 23% of patients questioned described oro-facial fatigue syndrome and its management”.
pain, 6% described widespread pain only and 4%
5. Raised intra-cranial pressure headache. This described both. There were high levels of
headache is characterised by diffuse pain that is psychosocial distress.
worse on bending. Vomiting may occur (without
nausea). There may be visual obscuration, Predictors of chronic facial pain are: -
seizures, focal neurological symptoms, optic disc 1. Widespread pain within the facial region.
swelling and daily morning headache. 2. Widespread pain outside the facial region.
3. Inactivity.
6. Sub-arachnoid haemorrhage. This is
characterised by sudden onset, blow-like pain An outpatient three year retrospective case note
often to the back of the head. It may radiate to review study published by Koenke and Mangelsdorf
the neck and be associated with collapse, in 1989 reported an incidence of 30% in women and
vomiting and neck stiffness. The latter sign may 21% in men of facial pain. The highest incidence
be absent early. Exertion is a trigger for sub- was in the 18 – 25 age group and the lowest in the
arachnoid haemorrhage and patients may have 56 – 65 age group. Only 46% of people sought help
alteration in their conscious level with with 17% taking time from work. Less than 2% of
Dr Tom Brown, Consultant Liaison
irritability, drowsiness and focal neurological patients received an organic diagnosis.
Psychiatrist, Glasgow
signs. Examination of the optic fundi may reveal
sub-hyaloid haemorrhages. Urgent CT scanning In patients with chronic temporo-mandibular
joint pain, there is no relationship between early The lecture started with a very entertaining
is indicated.
signs and symptoms and severity of physical Simpson’s video which nicely demonstrated people’s
7. Cranio-vertebral anomalies. There may be abnormalities in the joints. There is, however, a fear of being thought to be “at it”. One of the
congenital anomalous development at the base strong relationship with depression, anxiety and problems of patient doctor interaction is that patients
of the skull with descent of the inferior somatisation. Often there will be a history of high present to doctors with illness (behaviour) and
levels of health care use and of other chronically doctors diagnose and treat diseases. He discussed
cerebellum. This is associated with cough-
painful conditions. the classification of chronic fatigue syndrome and
induced headache and cerebellar, brain stem and
pyramidal signs. The diagnosis is confirmed by its relationship to other disorders such as irritable
MRI scan. Treatment is surgical decompression. Simon and Von Korff in 1991 demonstrated that bowel syndrome, atypical chest pain,
patients may misattribute normal bodily functions as hyperventilation syndrome, non-epileptic seizures.
pain. We are aware that experience of pain is There is also a marked overlap between chronic
8. Benign occipital epilepsy. This normally presents
influenced by childhood exposure to illness, possible fatigue syndrome and fibromyalgia.
in childhood with idiopathic focal seizures
accompanied by visual hallucinations that are recall of physical or sexual abuse, depression, anxiety
often described as being circular in shape and and phobias. The prevalence of chronic fatigue symptom is
multi-coloured. EEG demonstrates occipital 0.4% to 2.6% of the general population. It is twice
The definition of somatisation is: - as common in women than in men and is commonest
spike wave discharges and the condition responds
“An amplification of normal bodily sensations between the ages of 20 and 40. It has been suggested
well to treatment with anti-convulsants.
that disturbance of the hypothalamic pituitary axis renal capsule and cortex follow the same pathway In 1995 Bultitude first described the use of a
with associated low levels of cortisol and enhanced and most fibres terminate in the sympathetic system capsaicin solution for the treatment of LPHS. It
serotonin function is important in its with some following the vagus nerve. involved ureteric catheterization with instillation of
pathophysiology. This is in contrast to depression a capsaicin solution into the renal calyx and ureter,
where there is reduced serotonin function. Visceral renal pain may be experienced as aching performed under general anaesthesia and required
and non-specific in the area of the costovertebral prolonged epidural anaesthesia. In humans the nerve
Ef fective interventions in chronic fatigue angle and may be due to inflammation of the kidneys supply to the renal pelvis and ureter is proportionally
syndrome can be categorised into behavioural, or acute ischaemia due to thrombus in the renal rich in C fibres. Capsaicin is said to cause intense
immunological, antiviral, pharmacological and vasculature. Patients without this pathology may also stimulation of these nerves with release and
dietary. experience a similar type of pain and may in fact have subsequent depletion of substance P from the
loin pain haematuria syndrome. nociceptors of the urothelium. It has been reported
Of four randomised control trials of cognitive to give 65% of patients short to medium term pain
behavioural therapy, benefit was shown in three. Loin Pain Haematuria Syndrome relief. However questions have been raised over the
There was improvement in fatigue, physical Loin pain haematuria syndrome (LPHS) was first safety of its use. In one study two patients developed
functioning and global measures of well-being. described by Little et al in 1967. Patients often deterioration in their renal function following
There were no differences in depression. A five-year present with recurrent episodes of loin pain capsaicin treatment. Capsaicin could not be excluded
follow up in one study demonstrated that (unilateral or bilateral) and some degree of from contributing to this complication. Another
improvement was generally maintained. microscopic or gross haematuria, which may be patient suffered mucosal ulceration in the bladder
intermittent. The onset of pain may precede the after extravasation of the solution.
Other treatments used include graded exercise presence of haematuria. The pain is often severe and
programmes, immunological therapies such as IgG debilitating and may radiate to the abdomen, thigh Surgical interventions
and drug treatments such as Interferon, Acyclovir or groin. Although the majority of patients with Surgery is rarely appropriate for the management
and Gamcyclovir. There is no evidence for the LPHS are female and present between the ages of of chronic pain conditions. It can worsen the patient’s
beneficial effect of antidepressants or steroids. twenty and forty, it can also occur in children. symptoms and cause further chronic postoperative
pain. However, surgical techniques have now been
Lisa Manchanda, Specialist Registrar in LPHS is rare and unfortunately the syndrome developed for the treatment of LPHS and are aimed
Anaesthesia at the Western Infirmary, Glasgow, gave remains a diagnosis of exclusion reached when at denervating the kidney. They include renal nerve
the next talk. She presented her winning entry to urological investigations do not reveal adequate excision, surgical sympathectomy, removal of the
the North British Pain Association Essay pathology to account for the symptoms. As a result, renal capsule, nephrectomy and renal auto-
Competition, Spring 2002. patients should be assessed by a renal physician with transplantation. Renal nerve excision has provided
experience of LPHS and should have adequate temporary pain relief, however case studies report a
Below is a transcript of her winning essay. investigations including an ultrasound, intravenous higher incidence of pain recurrence compared to auto
pyelogram, cystoscopy and renal isotope transplantation. In an extreme example of a
successful outcome, a patient was able to return to
The North British Pain Association scintigraphy. Ureteroscopy, angiography and renal
employment following a bilateral nephrectomy
biopsy should also be considered.
Essay Competition Spring 2002 despite the need for dialysis.

Is Surgery The Answer? Abnormalities detected following a renal biopsy


Renal auto transplantation surgery was first
have included mesangial proliferation and immune
Dr Lisa Manchanda SpR, described by Aber and Higgins in 1982 and is
complementation C3 deposition in the arterioles. One
Western Infirmary, Glasgow series showed that nearly 50% of patients had thin extremely rare is this country. It is performed as a
form of nephron-sparing denervation therapy. This
glomerular basement membrane disease. Changes in
procedure involves removing the affected kidney
Introduction intrarenal arterioles, the presence of cortical infarcts
from the loin and retransplanting it in the iliac fossa.
During an evening of pre-assessments, I noticed and the occurrence of microaneursyms have been
Most of the available literature on renal auto
an unusual entry on the normally routine renal detected on renal angiography. Decreased heparin-
transplantations is from small case studies. In 1998
surgery list. As I was unfamiliar with the procedure thrombin clotting time and elevated plasma serotonin
Chin et al looked at the results of 26 patients who
– a renal auto-transplantation – I discussed the case concentration suggests evidence of a platelet or
had undergone renal auto transplantation for LPHS.
with the attending surgeon. coagulation disorder.
The mean follow-up time was 7 years with
approximately 70% of patients having sustained pain
The patient was a young female who had suffered These abnormalities provide evidence that
relief and returning to normal activities. The
chronic loin pain for over ten years. She was to suggests the presence of a vascular disorder. procedure however carries the significant risks of
undergo this surgical procedure in an attempt to However, surprisingly, these patients do not go on
major renal surgery including graft failure and acute
alleviate her pain, which mainly affected the left side to develop impaired renal function. Serum creatinine renal failure. Other complications include
but was occasionally bilateral. She also experienced and renal concentrating ability remain normal. recurrence of the pain in the graft site and are
spontaneous exacerbations of severe pain and nothing assumed to be due to renal reinnervation. This
would alleviate her symptoms. The pain greatly Psychological Factors theory is probably too simplistic to explain the
affected her daily activities and as a result she had In the original description of LPHS, some recurrence of pain. The procedure may be carried out
suffered psychological distress. After years of patients were described as anxious, demanding of bilaterally as new pain can develop on the
extensive negative investigations she was finally medical attention, and inclined to fabricate medical contralateral side years later.
diagnosed as having loin pain haematuria syndrome evidence. Furthermore, Lucas et al proposed as
(LPHS). recently as 1995 that LPHS was a psychogenic pain The risks of performing surgery as an isolated
and a form of somatisation. This idea has further treatment option for chronic pain are huge and may
perpetuated the belief that the syndrome had a actually worsen the patient’s symptoms and function.
primary psychological aetiology. This approach perpetuates a patient’s belief that the
doctor will alleviate chronic pain rather than assist
In contrast, Bultitude et al published a study in the patient in managing their symptoms in order to
Pain in 1998, showing that psychological disability improve their functions of daily living. It is therefore
improves as the pain symptoms improve. They critical to meticulously screen surgical candidates
assessed 26 patients before and after a recognised including a full psychological assessment. Ignoring
treatment option and found that the psychological the multifactorial biopsychosocial model of any
distress is secondary to the pain and the disability it patient with chronic pain will decrease the chances
causes. of successful management.

Pain Management Giving the varying long-term success together


Patients diagnosed with LPHS are often very with the risks and complications, the decision to
challenging to manage. They commonly experience perform surgery is often taken at a late stage in
Lisa Manchanda, Sarah Morris severe pain requiring high dose opioid medication. treatment and may be the last resort.
and Kenneth Pollock On review of our Pain Management Clinic database,
it was found that the management of patients, who Case History
Renal Pain presented with similar symptoms, included treatment Following diagnosis, the patient described in the
with opioid analgesics, tricyclic antidepressants, beginning, was managed with oral opioid analgesia
Pain due to a renal aetiology is often elusive and
TENS application and local anaesthetic nerve blocks. with little improvement in her symptoms. She was
difficult to explain. This is partly due to the complex
The success of treatment was usually of a limited referred to the Pain Management Team who treated
innervation of the renal system. The kidney is
duration and varied across the patient population. her with tricyclic antidepressant medication as an
innervated by the renal plexus that is situated behind
adjunct to her opioid medication. This unfortunately
the origin of each renal artery at the level of T12 to
Regional techniques used for the treatment of had no effect on her symptoms. Other management
L2. There is an autonomic contribution from the
LPHS include intercostal, interpleural, paravertebral included a trial of transcutaneous electrical nerve
coeliac ganglia, aorticorenal ganglion, the aortic
and epidural local anaesthetic nerve blocks. Lumbar stimulation, which had a beneficial effect for a
plexus and the first lumbar splanchnic nerve. These
sympathetic and splanchnic nerve blocks have also limited duration only. Over the years she had
fibres follow the renal artery into the kidney hilus
been described in case literature. Implant able devices numerous paravertebral nerve blocks with varying
supplying the vessels, glomerular structures and
releasing intrathecal opioids have also been used. degrees of success.
tubules. Afferent fibres arising in the region of the
Throughout the duration of management, the The aims of the pain management team in patients
patient had expressed a strong interest in surgical with addictive disease are prevention of withdrawal
intervention. As the previous treatments were and effective and safe analgesic treatment. Patient
unsuccessful in providing sustained pain relief, assessment may be more difficult with scoring
surgery was now a viable option. systems not being as reliable. It is important to
establish which drugs the patient is addicted to and
Outcome how much of these drugs they normally take and by
So did surgery improve the patient’s symptoms? what route. They may be on a Methadone
In the immediate postoperative period, she had maintenance programme or may be an ex-user. These
excellent pain relief provided by epidural analgesia. facts can be validated with their GP. Patients with
However, her symptoms of loin pain recurred several an addictive disease may at times be abusive, request
weeks after her operation. Fortunately, several analgesics by name or by injection, refuse oral
months on, her symptoms improved and she no longer analgesics and are well-known to be unreliable
required opioid analgesia. The long-term outcome attenders for out-patient appointments. Sandra Lee welcomes delegates
for this patient is, as yet, unknown. A scoring system has been developed for the at the reception desk
assessment of withdrawal in an individual and
Can her pain relief be attributed to a direct effect includes scores for pupil size, skin temperature and
from the surgery? No. Many factors were involved sweating, nasal congestion, agitation and cardio-
in this successful outcome. It was possible that the vascular and gastrointestinal symptoms. Withdrawal Caption Competition
patient perceived surgery to be a ‘cure’ for her is normally treated with Dihydrocodeine in a
The winning caption is ‘That’s another fine mess
symptoms. However, as illustrated by one case series, reducing dose and Diazepam. It is useful to limit
you’ve gotten me into Stanley’ submitted by Dr
nearly one third of patients show spontaneous the number of staff dealing with the patient. In
Martin Dunbar, Clinical Psychologist, Glasgow. Well
resolution of symptoms within four years. general, we must accept the patient’s report of pain
done, Martin. Many thanks to all who sent in entries.
and develop a management plan for them on an
Please try again, the odds of winning are quite high!!
Conclusion individual basis. There should be an open and honest
An integrated multidisciplinary approach at an discussion with the patient. No Pethidine or agonist/
early stage, involving both the renal specialists and antagonist drugs are prescribed and addiction
the Pain Management Team, is vital for successfully specialists may be consulted. If the patient is on a
managing patients with LPHS. In addition, a full Methadone programme, this is continued. A
biopsychosocial assessment is critical before a balanced analgesic approach which may include non-
decision is made to proceed to surgery. Although not steroidals and other simple analgesics is used and
always the answer, it can be concluded that surgery the least invasive options for each medication
was possibly the best option for this patient and, at utilised. TENS machine may be useful.
present, has significantly improved her quality of life. Acute pain strategies may include regional
techniques, patient controlled analgesia with
References background infusion. Patients are monitored for
1. Little P.J., Sloper J.S. and de Wardener H.E. A syndrome excessive analgesic intake and for symptoms of
of loin pain and haematuria associated with disease of withdrawal. Excessive sedation may occur when
peripheral renal arteries. Quart.J. Med (1967) 36:253. drug combinations are used. Patients are changed to
2. Burke J.R., Hardie I.R. Loin pain haematuria syndrome.
non-opioid analgesics as soon as possible.
Pediatr Nephrol (1996) Apr 10(2) 216-20.
3. Lucas P.A., Leaker B.R., Murphy M. and Neild GH. Loin Entries for this issue’s Geordie caption
pain and haematuria syndrome: a somatoform disorder In the chronic pain management setting, a move competition should be emailed or posted to me at
Q.J.Med 1995 88: 703 is made towards time contingent use of analgesics the address on the front cover.
4. Bultitiude M, Young J, Bultitude M, Allan J Loin pain with long-acting preparations. Agreement must be
haematuria syndrome: distress resolved by pain relief. reached between the patient, primary care and the
Pain 1998 May; 76(1-2): 209-13
pain management consultant for prescription and
5. Allan J.D.D., Bultitude M.I.B., Bultitude M.F., Wall P.D.
monitoring of compliance.
and McMahon S.B. The effect of capsaicin on renal pain Anagram Competition
signaling systems in humans and Wistar rats. Lancet 1995
345, 921-922 All correct entries to the anagrams below will
6. Chin J.L, Kloth D, Pautler S.E, Mulligan M. Renal be put into a hat and the winner announced in the
autotransplantation for the loin pain-hematuria syndrome: next issue. All anagrams are relevant to the world of
the long term followup of 26 cases J Urol 1998 Oct; 160
the NBPA.
(4): 1232-5
7. Sheil AG, Chui AK, Verran DJ, Boulas J, Ibels LS Thin conning maniacal porn
Evaluation of the loin pain/haematuria syndrome treated
by renal autotransplantation or radical renal neurectomy. This impotent rascal
Am J Kidney Dis 1998 Aug; 32(2): 1215-20 Leper creation
8. Aber GM, Higgins PM The natural history and
management of the loin pain/haematuria syndrome. B J
Urol 1982 Dec; 54(6): 613-5
9. T. Armstrong, A.D.McLean, M.Hayes, B.T. Morgans and
D.N. Tulloch Early experience of intraureteric capsaicin Pain News and Gossip
infusion in loin pain haematuria syndrome. BJU
International 2000, 85,233-237
Alice Ong, Mike Basler, Lisa Manchanda Gavin McCallum from the Southern General in
and Sarah Morris Glasgow is currently serving in the Gulf and we send
Sarah Morris, Clinical Nurse Specialist in Pain
him and any other friends and family of NBPA
Management at the Southern General Hospital in members involved in the conflict our very best
The final presentation of the day was given by
Glasgow then spoke on ‘Pain Management in
Alice Ong, Medical Student, University of Glasgow wishes.
Addictive Disease’.
on the Treatment of Neuropathic Pain with Ketamine On a completely different note, Glasgow has
and Lignocaine Infusions. recently received recognition from the Royal College
She first stated that there is no evidence that the
of Anaesthetists as a training centre in Pain
prevalence of addictive disease is any greater in Management.
She described a double blind, cross over, placebo
chronic pain patients than in the general population.
controlled study investigating the effects of drug Dr. Gail Gillespie, Specialist Registrar in
Drug addiction is a major problem in the Greater
infusions on the severity of pain. Six patients with a Anaesthesia in the West of Scotland has recently
Glasgow Health Board area, with 6,980 drug misuse
diagnosis of neuropathic pain where recruited to been appointed as the new Glasgow pain fellow. She
related emergency admissions between 1993 and
undergo three infusion sessions at weekly intervals. will follow in the footsteps of Lars Williams who
1999. has done an excellent job.
These lasted two hours each and during them, the
Addiction is defined as ‘A primary chronic
patient received Ketamine 0.4mg/kg, saline or Dr. Pauline Adair, Clinical Psychologist,
neurobiological disease with genetic, psychosocial
Lignocaine 5mg/kg. Immediate and long term effects originally in Dundee, then in Glasgow, has moved
and environmental factors influencing its
on spontaneous pain, mechanical allodynia and on to Belfast and we send her our very best wishes
development and its manifestations, characterised by
mechanical hyperalgesia were measured. for the future.
impaired control of drug use and impulsive Holly Daniel, physio at Glasgow Royal is
behaviour’. Risk factors for addictive disease are a
The VAS for spontaneous pain were reduced by returning to work in the states and will be greatly
family history of addiction, psychiatric history or a
lignocaine, approaching statistical significance at missed. Again, our best wishes go with her.
history of substance abuse.
p=0.059. Pain relief lasting over 12 hours occurred Dr. Ivan Marples has recently been appointed to
Tolerance is defined as ‘A state where an
in lignocaine 3/6, ketamine 2/5, placebo 0/5. a Consultant post in Anaesthesia and Pain
increased dose of a psycho-active substance is needed management at the Western General Hospital in
Ketamine and lignocaine showed a significant short
to produce the desired effect’. Cross-tolerance is
term reduction in VAS score for sensitive pain. Edinburgh.
where repeated administration of one psycho-active
Ketamine and lignocaine showed trends of increasing Finally, congratulations to Andrea Harvey and
substance induces tolerance manifested towards
sensory and pain threshold on the painful side and Lesley Colvin on the birth of their daughters. I think
another substance to which the individual has not
reduction in dynamic allodynia and hyperalgesia. No we’re going to have to start a bonny baby section in
been exposed. Threshold!
long-term benefit could be demonstrated.