Studies of midazolam should evaluate the contribution of 1-OHMDZ to the overall PD effect. The metabolite 1-OHMDZ has approximately half the activity of the parent drug and can compensate for at least part of the decreased effect due to increased midazolam metabolism.
The Lidocaine 5% plaster is licensed for the symptomatic relief of neuropathic pain associated with post-herpetic neuralgia in adult patients over 18 years of age. Studies in adults also demonstrate efficacy of Lidocaine 5% plasters in other neuropathic pain conditions. Case reports and experience suggested efficacy of Lidocaine 5% plasters in children and adolescents with localised neuropathic pain. Initiated by the Pain in Children Special Interest Group (PICSIG) of the British Pain Society, a 3-year prospective multicentre service evaluation was undertaken to document the usage and efficacy of the Lidocaine 5% plaster in paediatric patients being managed by paediatric pain teams in the United Kingdom. Five paediatric pain teams provided anonymised data pre-treatment and 3-6 months after commencing Lidocaine 5% plaster. Changes in pain score, function, sleep and continuing use were evaluated. Data were obtained for 115 patients; age range 5-18 years (mean: 12 years). Diagnosis and site of application varied. Benefit from use of a Lidocaine 5% plaster in an individual was deemed if two or more of the following were reported: reduction in pain score, functional improvement, sleep improvement and continuing use of Lidocaine 5% plaster. Benefit was recorded for 79 patients (69%); 32 patients were recorded as receiving no benefit and data were unavailable for 4 patients, and 7 patients reported minor skin reactions. This prospective service evaluation supports the efficacy of the Lidocaine 5% plaster in children and adolescents with localised neuropathic pain and confirms tolerability and safety. It is the opinion of the PICSIG of the British Pain Society that the Lidocaine 5% plaster should be considered early in the multidisciplinary management of localised neuropathic pain in children and adolescents.
The aim of the present study was to review the history, clinical course, treatment, and outcome of movement disorders in children and young people with complex regional pain syndrome (CRPS). Case notes were reviewed retrospectively of children and young people who presented with movement disorders in CRPS to our tertiary paediatric pain service over a period of 13 years. Ten children with CRPS presented with movement disorders (eight females, two males). The age at first presentation with symptoms of CRPS ranged from 8 to 15 years (mean 11y 2mo, median 13y). The most common movement disorder was dystonia (n=8), followed by tremors (n=3) and myoclonus (n=3); two patients had all three movement disorders. The movement disorder affected mainly the lower limb (n=9) with a predilection for the foot (n=7) and was frequently initiated by minor trauma (n=7). Follow‐up ranged from 6 months to 14 years. The outcome was variable, with good prognosis in nearly half of the cases: four children experienced complete resolution of symptoms. Two children showed a slight improvement. Four children showed no improvement. Movement disorders in CRPS are under‐recognized in children. The management has to be multidisciplinary with an expertize in paediatric pain.
The effectiveness of patient-controlled intravenous morphine with and without a supplementary fixed rate infusion was studied in 40 children after orthopaedic surgery and 40 children after abdominal surgery. The use of a background infusion after orthopaedic surgery, where the majority of children received intra-operative regional blockade, resulted in a higher total dose of morphine (P < 0.05) without evidence of improved analgesia, compared to PCA alone. Children receiving a background infusion after abdominal surgery showed evidence of improved sleeping patterns post-operatively compared with those receiving PCA alone, despite similar overall morphine consumption. There were no episodes of excessive sedation, or respiratory depression with the use of either regimen, and over 90% of the children studied were assessed as experiencing either no pain or mild pain. The suitability and efficacy of patient controlled analgesia for management of post-operative pain for children aged between 5 and 17 years appears to be confirmed. The use of a supplementary background infusion may be of value in children.
SummaryThis study investigated the effect of diclofenac on the lung function of 70 children aged 6±15 years with a diagnosis of asthma, recruited from a hospital respiratory clinic. Peak¯ow and a forced expiratory¯ow-volume loop were measured and the patients were then given 1±1.5 mg.kg À1 effervescent diclofenac orally. Spirometry was repeated at 10, 20 and 30 min, a 15% decrease in results being considered a signi®cant reduction in lung function. No patient demonstrated a consistent reduction in lung function of > 15% during the study and there were no reports of wheezing or increased bronchodilator use after completion of the spirometry. In conclusion, we studied a group of genuine asthmatics and found no clinically signi®cant incidence of bronchospasm with the use of a single therapeutic dose of diclofenac. Attempts to provide adequate postoperative analgesia, particularly after day case surgery, are hampered in children with asthma by the recommendation to avoid nonsteroidal anti-in¯ammatory drugs (NSAIDs) [1]. The avoidance of this class of drugs is based on the risk of NSAID-induced bronchospasm, a complication with a 5±10% incidence in adult-onset asthmatics [2]. Because the incidence of childhood asthma is estimated at 13.1% in Great Britain [3], a large number of children undergoing surgery are denied a class of drugs that would otherwise form a major part of their pain management. Diclofenac has been used cautiously for postoperative pain relief in asthmatic children for some years in this hospital. We are unaware of any signi®cant episodes of bronchospasm associated with its use in this group of patients. We therefore formed the impression that diclofenac-induced bronchospasm has a considerably lower incidence in children than that reported in adult asthmatics. This study was carried out to test this hypothesis. MethodsLocal research ethics committee approval was granted for the study and participants and parents gave informed consent. Children aged 6±15 years with a diagnosis of asthma and taking regular prophylactic medication were recruited on attendance at a hospital respiratory clinic (90%) or at presentation for day case surgery (10%). Exclusion criteria included: a previous adverse reaction to NSAIDs, known renal disease or risk of gastro-intestinal bleeding, current deterioration in lung function (FEV 1 < 80% predicted) and medication with theophyllines or leukotriene receptor antagonists. Patients taking longacting b 2 agonists were asked to omit the medication for 12 h before the study.A questionnaire, based on the International Study of Asthma and Allergies in Childhood (ISAAC) [4], allowed assessment of the type and severity of asthma, the incidence of atopy and a review of current medication. Asthma was categorised as`severe' if there were more than 12 episodes of wheezing in the last year or if speech had been limited to only one or two words between breaths, and`moderate' if there were fewer than 12 episodes of wheezing in the last year, but wheezing occurred in the absence of viral sy...
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