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Issue 137 - 3 June 2010

Hot off the press

Advance copies of the newly released book 
"Freed to Care, Proud to Nurse: 100 years of the New Zealand
Nurses Organisation "
are available for purchase

More information about this book:
To order a copy of this book, email:

New NHS Website
NHS Evidence provides free access to clinical and non-clinical information - local, regional, national and international. Information includes evidence, guidance and Government policy
NHS Evidence allows everyone working in health and social care to access a wide range of health information to help them deliver quality patient care. Launched in April 2009, NHS Evidence:
- has a fast, free and easy to use search engine to help users search for the information they want
- ranks search results from credible medical sources according to relevance and quality
- allows users – through My Evidence - to personalise a search and register to receive the latest health information
- awards an Accreditation Mark to organisations who meet high quality standards in developing health information


1. Role for International Tobacco Control in Peacebuilding?
By Skinner, Harvey et al. Journal of Smoking Cessation, 1/05/2009, Vol. 4 Issue 1: p1-2
The article addresses the importance of international tobacco control (ITC) to peace-building. In answer to the growing health and economic effects of tobacco use, ITC has recruited a group of researchers, health practitioners and policy makers who promote the Framework Convention on Tobacco Control (FCTC). The Canada International Scientific Exchange Program (CISEPO) is similar to ITC, but is committed to promoting peace. One of the activities of CISEPO is the medical screening and habilitation of nearly 200,000 newborns for hearing loss.

2. Smoking Cessation Program Targeting Adolescents: Saudi Arabia
By Al-Lehiany, Obaidullah & Stanley, David. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p3-9
While developed countries have enjoyed a decreasing incidence of smoking over the last 30 years, in the developing world there are still reports of rapid smoking take-up. It seems that in developing countries tobacco smoking remains the number one cause of preventable death well into the future. To combat this costly habit, many governments have employed smoking cessation strategies since the 1960s. These programs have involved advertising the negative health impacts of smoking, increased taxation, targeted legislation, and even clinical counselling. This project aimed to explore and critically review the body of literature related to smoking cessation strategies in Saudi Arabia and assess their effectiveness. The project also aimed to use the data gathered to recommend legislative changes to smoking cessation programs. For the Saudi Arabian context, the results of the project found that the smoking cessation strategies, despite being revolutionary in many regards, still lacked depth, and that both males and females, particularly adolescents, were adopting smoking in increasing numbers. The recommendations of the project were for Saudi Arabian authorities to review a number of the current initiatives, and initiate further approaches to smoking cessation, such as stringent requirements for health warnings on cigarette packets.

3. Psychological Factors and Long-Term Abstinence After Smoking Cessation Treatment
By Boudrez, Hedwig. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p10-17
This study evaluated the association between psychological variables, measured by questionnaire at the start of a smoking cessation treatment, and smoking abstinence, 8 years after treatment. A total of 124 patients presenting at the stop-smoking clinic of the University Hospital in Ghent, Belgium, were included. Besides the Reasons for Smoking Scale (RSS), Fagerstrom Test for Nicotine Dependence (FTND), and smoking status, a psychological questionnaire (NEO PI-R) was presented at baseline. A postal survey after 8 years was executed in order to assess smoking status and smoke-free survival. In 2008, 103/124 answered the postal survey. 66/103 (64.1%) had relapsed. More men then women were smoke-free (46.2% vs. 18.4%; p = .004). Several associations between psychological baseline characteristics and smoking status at follow-up were detected: lower abstinence at follow-up was associated with lower self-discipline ( p = .001), lower goal-directedness ( p = .03), higher score on symptoms of depression ( p = .03), higher anxiety score ( p = .01), higher score on the variable shame ( p = .02). Some of these associations are confirmed by Kaplan-Meier survival scores that show borderline significance in case of depression ( p = .06), statistically significance in case of self-discipline ( p = .05) and shame ( p = .05) and clear statistical significance in case of anxiety ( p = .007). An association between psychological variables at the start of a smoking cessation treatment and smoking abstinence, even after 8 years, can be accepted. [ABSTRACT FROM AUTHOR]

4. Water Pipe Smoking: Effects, Attitudes and Directions
By Watad, Waseem et al. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p18-25
Water pipe (WP) smoking is prevalent in several countries and is emerging as a major international public health issue. This article reviews the literature on WP smoking practices and its health effects. Water pipe smokingin the Middle East is more common in women compared to cigarette smoking. WP smoking has harmful effects similar to cigarette smoking, and the nicotine and tar content of WP smoke is higher than that of cigarettes. Still, many users believe that WP is less harmful than cigarettes and are unaware of the damage that WP can cause to their health.
There is limited literature on WP smoking, highlighting the need for research in several areas including: epidemiology of WP smoking, sociological dimensions and tobacco control. The unique social and traditional role of WP smoking renders forgiving, culture-sensitive and patient approach. [ABSTRACT FROM AUTHOR]

5. A Process Evaluation of E-Mail Counselling for Smoking Cessation in College Students: Feasibility, Acceptability and Cost
By Abroms, Lorien C. et al. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p26-33
Few smoking cessation interventions have made extensive use of e-mail. Objective: This study set out to document how the e-mail component of an e-mail-based smoking cessation program was received by college smokers.
Methods: Participants were randomised after enrolment to receive either a moderately intensive, e-mail-based intervention — the X-Pack Group — or a less intensive program based on a widely available smoking cessation guidebook. Participants were assessed at baseline and 3 months post-enrolment. This analysis is limited to those in the X-Pack Group ( n = 48).
Results: Twelve e-mails on average were sent out to each participant over the course of 6 months. Ninety-one per cent of participants reported reading all or most of the e-mails and 73% replied to at least one of the e-mails they received. On average, participants were positive about the e-mails received and most reported that they had liked the e-mails because of the social support and encouragement provided. The average time for counsellors to write and send each e-mail from the templates was 12 minutes, with a range from 2 to 60 minutes.
Conclusions: These findings offer evidence of feasibility of an e-mail-based smoking cessation intervention in a college population. [ABSTRACT FROM AUTHOR]

6. Effects of Feedback on Spirometry in Primary Care on Motivation for Smoking Cessation
By Walters, Julia A. et al. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p34-41
We evaluated the effect of feedback after opportunistic spirometry in general practice on motivation for smoking cessation using stage change in the transtheoretical model. A total of 328 smokers aged over 35 years were given immediate feedback on the presence or absence of lung damage due to smoking, plus brief standard cessation advice. At 3 months, 99 (30.2%) smokers reported making an attempt to quit and 17 (5.2%) smokers reported moving into action stage for cessation. Of 297 (80.5%) successfully followed up, 81 (27.3%) smokers demonstrated forward shift and 35 (11.8%) smokers demonstrated backward shift. Feedback on the presence of lung damage was not significantly associated with reporting a quit attempt ( p = .31) or moving into action stage for cessation ( p = .30). Odds of forward or backward shift were not independently associated with either feedback on the presence of lung damage or normal lung function. Odds of backward shift with feedback on lung damage depended on participants assessments of quit benefits, which were correlated with their prior self-assessment of lung damage. Our findings suggest that feedback to smokers after spirometry about the absence of lung damage is not harmful. However, eliciting personal health attitudes is also important so cessation advice can be tailored especially for smokers who believe they already have lung damage from smoking. [ABSTRACT FROM AUTHOR]

7. A Plan of Group Therapy for Smoking Cessation in Patients Suffering From Buerger's Disease: A Case Series Study in Northeast Iran
By Fazeli, Bahare & Arshadi, Hamidreza. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p42-47
Buerger's disease (BD) is a chronic peripheral vascular disease that affects the young smokers from low socioeconomic backgrounds. The only effective therapy for this disease is smoking cessation; otherwise the outcome of BD will be several amputations.
Aims & Methods: Via 12 sessions, an elective pattern of group therapy was designed and tried with six volunteer patients. The therapy commenced with motivation, mixed with a behavioural and
cognitive model appropriate to the patients' socioeconomic and educational status. Two extra training sessions of apposite and supporting behaviour were allocated for their family members. Urine cotinine level was measured before and after the group therapy. The aim of study was to lead the patients towards a self-help group. Results: A partial remission of the disease in one patient and a complete remission in four patients were the consequences of the
present study. The average decline of urine cotinine level was about two ranks. One patient was not helped.
Conclusion: Although the study faced major loss of subjects, in regards to dramatic changes in urine cotinine level, this plan of group therapy seems to be an effective and cost-effective option for clinical improvement in patients with BD, as a chronic and smoking-related disease. [ABSTRACT FROM AUTHOR]

8. Time Spent With Urges to Smoke and Strength of Urges as Independent Predictors of Self-Rated Difficulty Not Smoking During Abstinence
By Georgiades, Chrissa & West, Robert. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p48-51
Self-perceived difficulty not smoking during a quit attempts is potentially an important factor mediating ability to remain abstinent during quit attempts. We investigated how far this could be explained by specific withdrawal symptoms (e.g., irritability, depressed mood, hunger etc.), strength of the urges to smoke and the time spent with urges to smoke. Thirty-five male and female smokers, who smoked at least 15 cigarettes per day were required to abstain overnight and attended the laboratory the next day and completed the Mood and Physical Symptoms Scale (MPSS), a validated questionnaire assessing cigarette withdrawal symptoms and urges to smoke. They also rated how difficult they had found it not smoking. Difficulty not smoking was independently and strongly predicted by both strength of urges to smoke and time spent with urges, but not by other withdrawal symptoms. The results support the idea that both time spent with urges and strength of urges to smoke are what primarily makes it difficult for smokers to abstain early in a quit attempt and that other withdrawal symptoms play a more modest role. Further research is needed to confirm this finding and examine how far difficulty not smoking mediates failure of quit attempts. [ABSTRACT FROM AUTHOR]

9. How to Measure Client Satisfaction With Stop Smoking Services: A Pilot Project in the UK National Health Service
By May, Sylvia et al. Journal of Smoking Cessation, 01/05/2009, Vol. 4 Issue 1: p52-58
This pilot study aimed to develop a tool and methodology for measuring client satisfaction in UK National Health (NHS) Stop Smoking Services (SSS). A brief postcard questionnaire (measuring overall satisfaction with the service, willingness to recommend the service to others and smoking status) and a complete questionnaire (with 20 additional items measuring satisfaction with specific elements of the service) were developed. An NHS SSS mailed the postcard to 298 clients who had set a quit date in the previous quarter, they mailed the complete questionnaire to a subsample of 99 clients. Overall 34% (100/298) of those surveyed responded: 30% (90/298) for the card and 25% (25/99) for the questionnaire (15 people responded to both). Intraclass correlation coefficients (ICC) were found to be acceptable for both the overall service satisfaction item (ICC value = .43, p = .05) and the item regarding recommending the service to others (ICC-value = .83, p < .001). Hence the tool had reliability and at least face validity and the survey methodology proved practicable. The small modifications made to service delivery and the need for future research are discussed. [ABSTRACT FROM AUTHOR]


10. AAPM Exerts Leadership in Public Policy: The AMA Summit, the Pain Research Database, and Opioid Safety
bY Gallagher, Rollin M. Pain Medicine, May 2009, Vol. 10 Issue 4: p605-606
The article presents several initiatives offered by the American Academy of Pain Medicine (AAPM) for pain care improvement. One of the initiatives includes the pain summit that would address various issues including pain medicine, exploring certification and accreditation, and the creation of the state of the art comprehensive textbook It also calls for the advocacy on pain-related issues which is critically important to pain care practitioners such as the opioid safety.

11. Hubert Rosomoff, MD, DMedSc: Pioneer in Neurosurgery and Pain Medicine
By Lippe, Philipp al. Pain Medicine, May 2009, Vol. 10 Issue 4: p607-610
An obituary for Hubert Rosomoff, pioneer in neurosurgery and pain medicine is presented.

12. Acupuncture Research Is Part of My Life
By Ji-Sheng Han. Pain Medicine, May 2009, Vol. 10 Issue 4: p611-618
Acupuncture has been used in China for more than 3,000 years. Although the clinical application of acupuncture is very popular, its mechanisms of action are still unclear. Beginning in the middle of the 20th century a boost of research on acupuncture emerged in China, and I was one of the researchers involved in this episode. With the help of modern neuroscience, the mechanisms of acupuncture for pain management have been unraveled at least
partly. This article describes my decision as a young medical graduate to devote my life to research on acupuncture and pain medicine; it has since been my life's journey—one full of challenges and happiness, pitfalls and achievements. [ABSTRACT FROM AUTHOR]

13. An Investigation of Pain Self-Efficacy Beliefs in Iranian Chronic Pain Patients: A Preliminary Validation of a Translated English-Language Scale
By Asghari, Ali & Nicholas, Michael K. Pain Medicine, May 2009, Vol. 10 Issue 4: p619-632
1) To determine the psychometric properties of a Persian-language version of the Pain Self-Efficacy Questionnaire (P-PSEQ) in Iranian chronic pain patients; and 2) to evaluate the validity of the P-PSEQ in another Iranian chronic pain sample.
 Design. Cross-sectional designs. Setting. Two medical centers and a large industrial company.
Method. In Study 1 , the P-PSEQ was administered to 348 chronic pain patients. In Study 2 , 169 males with chronic pain who were working completed the P-PSEQ, Beck Depression Inventory, Roland–Morris Disability Questionnaire, Short Form Health Survey, and a pain scale.
Results. The psychometric properties (internal consistency, test–retest reliability, construct validity, and concurrent validity) of the P-PSEQ were found to be strong. Multiple hierarchical regression analyses indicated that pain self-efficacy scores accounted for a significant proportion of the variance in scores on measures of disability, depression, and general health even after controlling for the possible confounding effects of pain severity and education.
Conclusion. The psychometric properties of the P-PSEQ were confirmed. Consistent with findings in other countries with other language versions of the same scale, pain self-efficacy beliefs are associated with levels of physical disability, depression and general health status of chronic pain patients, over and above the influence of pain severity in this sample of Iranians with chronic pain. [ABSTRACT FROM AUTHOR]

14. Rapid Responders to Frovatriptan in Acute Migraine Treatment: Results from a Long-Term, Open-Label Study
By Spierings, Egilius L & Keywood, Charlotte. Pain Medicine, May 2009, Vol. 10 Issue 4: p633-638
The chronic nature of migraine and the reliance on acute treatment constitute the basis of the present long-term, open-label study.
Objectives. First, assessment of the tolerability and safety of frovatriptan, 2.5–7.5mg taken orally over 24 hours, for the acute treatment of migraine, repeatedly over a 12-month period.Second,
assessment of the efficacy and tolerability of a second, double-blind dose of 2.5-mg frovatriptan, compared with placebo, for nonresponse at 2 hours after treatment of moderate or severe headache with 2.5-mg frovatriptan.
Results. With regard to the first attack treated, 173 (36%) of the 486 subjects in the study did not take a second dose at 2 hours for nonresponse. At 2 hours and 4 hours, these “rapid responders” experienced a decrease in headache intensity from moderate or severe to mild or no pain in 84% and 98%, respectively (“headache response”). Six percent of them experienced recurrence of moderate or severe headache within 24 hours following a response at 4 hours and 12% took rescue medication. The response, measured in terms of median time to “complete migraine relief,” was maintained over 30 subsequent migraine attacks, treated from attack 2 onwards over the course of 12 months.
Conclusion. Frovatriptan provides a remarkably fast and high headache response in a subgroup of more than one-third of migraineurs, with a very low 24-hour headache recurrence and low rescue medication intake. [ABSTRACT FROM AUTHOR]

15. Pretreatment Psychosocial Variables as Predictors of Outcomes Following Lumbar Surgery and Spinal Cord Stimulation: A Systematic Review and Literature Synthesis
By Celestin, James et al. Pain Medicine, May 2009, Vol. 10 Issue 4: p639-653
In the multimodal treatment approach to chronic back pain, interventional back procedures are often reserved for those who do not improve after more conservative management. Psychological screening prior to lumbar surgery or spinal cord stimulation (SCS) has been widely recommended to help identify suitable candidates and to predict possible complications or poor outcome from treatment. However, it remains unclear which, if any, variables are most predictive of pain-related treatment outcomes.
Objective. The intent of this article is to perform a systematic review to examine the relationship between presurgical predictor variables and treatment outcomes, to review the existing evidence for the benefit of psychological screening prior to lumbar surgery or SCS, and to make treatment recommendations for the use of psychological screening.
Results. Out of 753 study titles, 25 studies were identified, of which none were randomized controlled trials and only four SCS studies met inclusion criteria. The methodological quality of the studies varied and some important shortcomings were identified. A positive
relationship was found between one or more psychological factors and poor treatment outcome in 92.0% of the studies reviewed. In particular, presurgical somatization, depression, anxiety, and poor coping were most useful in helping to predict poor response (i.e., less treatment-related benefit) to lumbar surgery and SCS. Older age and longer pain duration were also predictive of poorer outcome in some studies, while pretreatment physical findings, activity interference, and presurgical pain intensity were minimally predictive.
Conclusions. At present, while there is insufficient empirical evidence that psychological screening before surgery or device implantation helps to improve treatment outcomes, the current literature suggests that psychological factors such as somatization, depression, anxiety, and poor coping, are important predictors of poor outcome. More research is needed to show if early identification and treatment of these factors through psychological screening will enhance treatment outcome.

16. Nausea and Vomiting Side Effects with Opioid Analgesics during Treatment of Chronic Pain: Mechanisms, Implications, and Management Options
By Porreca, Frank & Ossipov, Michael H. Pain Medicine, May 2009, Vol. 10 Issue 4: p654-662
Gastrointestinal (GI) side effects such as nausea and vomiting are common following opioid analgesia and represent a significant cause of patient discomfort and treatment dissatisfaction. This review examines the mechanisms that produce these side effects, their impact on treatment outcomes in chronic pain patients, and counteractive strategies.
Results. A number of mechanisms by which opioids produce nausea and vomiting have been identified. These involve both central and peripheral sites including the vomiting center, chemoreceptor trigger zones, cerebral cortex, and the vestibular apparatus of the brain, as well as the GI tract itself. Nausea and vomiting have a negative impact on treatment efficacy and successful patient management because they limit the effective analgesic dosage that can be achieved and are frequently reported as the reason for discontinuation of opioid pain medication or missed doses. While various strategies such as antiemetic agents or opioid switching can be employed to control these side effects, neither option is ideal because they are not always effective and incur additional costs and inconvenience. Opioid-sparing analgesic agents may provide a further alternative to avoid nausea and vomiting due to their reduced reliance on mu-opioid signalling pathways to induce analgesia.
Conclusions. Nausea and vomiting side effects limit the analgesic efficiency of current opioid therapies. There is a clear need for the development of improved opioid-based analgesics that mitigate these intolerable effects.

17. Fibromyalgia Symptoms Are Reduced by Low-Dose Naltrexone: A Pilot Study
By Younger, Jarred & Mackey, Sean. Pain Medicine, May 2009, Vol. 10 Issue 4: p663-672
Fibromyalgia is a chronic pain disorder that is characterized by diffuse musculoskeletal pain and sensitivity to mechanical stimulation. In this pilot clinical trial, we tested the effectiveness of low-dose naltrexone in treating the symptoms of fibromyalgia.
Design. Participants completed a single-blind, crossover trial with the following time line: baseline (2 weeks), placebo (2 weeks), drug (8 weeks), and washout (2 weeks). Patients Ten women meeting criteria for fibromyalgia and not taking an opioid medication. Interventions. Naltrexone, in addition to antagonizing opioid receptors on neurons, also inhibits microglia activity in the central nervous system At low doses (4.5 mg), naltrexone may inhibit the activity of microglia and reverse central and peripheral
Outcome Measures. Participants completed reports of symptom severity everyday, using a handheld computer. In addition, participants visited the lab every 2 weeks for tests of mechanical, heat, and cold pain sensitivity.
Results. Low-dose naltrexone reduced fibromyalgia symptoms in the entire cohort, with a greater than 30% reduction of symptoms over placebo. In addition, laboratory visits showed that mechanical and heat pain thresholds were improved by the drug. Side effects (including insomnia and vivid dreams) were rare, and described as minor and transient. Baseline erythrocyte sedimentation rate predicted over 80% of the variance in drug response. Individuals with higher sedimentation rates (indicating general inflammatory processes) had the greatest reduction of symptoms in response to low-dose naltrexone.
Conclusions. We conclude that low-dose naltrexone may be an
effective, highly tolerable, and inexpensive treatment for fibromyalgia. [ABSTRACT FROM AUTHOR]

18. Pulsed Radiofrequency for Chronic Testicular Pain—A Preliminary Report
By Misra, Saumya et al. Pain Medicine, May 2009, Vol. 10 Issue 4: p673-678
To evaluate the effectiveness of pulsed radiofrequency (PRF) of spermatic cord in the treatment of chronic testicular pain.
Design. Ten patients with chronic testicular pain were treated with PRF stimulation of the spermatic cord. A radiofrequency probe placed percutaneously into the spermatic cord was used to deliver four 120-second cycles of 20-millisecond pulses at 2 Hz. Test stimulation was first used to confirm the precise placement
of the probe. The short-form McGill Pain Questionnaire was used to assess pain before treatment and at 3 months. Patients who had experienced improvement were followed up by telephone, to determine whether pain relief was sustained.
Results. Ten patients were entered into the study but one was lost to follow-up. Of the nine patients evaluated, four had complete resolution of pain, while one had partial pain relief. Three patients experienced no change and one reported that his pain was worse. All patients who experienced complete and partial pain relief continued to do so at a mean long-term follow-up of 9.6 months (range 3–14 months). There were no complications observed immediately or during the follow-up period.
Conclusion. In this pilot study, pain scores improved in five out of nine patients. PRF of spermatic cord appears to be a safe minimally invasive outpatient procedure that should be investigated further with placebo-controlled trials. [ABSTRACT FROM AUTHOR]

19. The Ability of Multi-Site, Multi-Depth Sacral Lateral Branch Blocks to Anesthetize the Sacroiliac Joint Complex
By Dreyfuss, Paul et al. Pain Medicine, May 2009, Vol. 10 Issue 4: p679-688
To determine the physiologic effectiveness of multi-site, multi-depth sacral lateral branch injections.
Design. Double-blind, randomized, placebo-controlled study.
Setting. Outpatient pain management center.
Patients.Twenty asymptomatic volunteers.
Background. The dorsal innervation to the sacroiliac joint (SIJ) is from the L5 dorsal ramus and the S1-3 lateral branches. Multi-site, multi-depth lateral branch blocks were developed to compensate for the complex regional anatomy that limited the effectiveness of single-site, single-depth lateral branch injections. Interventions. Bilateral multi-site, multi-depth lateral branch green dye injections and subsequent dissection on two cadavers revealed a 91% accuracy with this technique. Session 1: 20 asymptomatic subjects had a 25- g spinal needle probe their interosseous (IO) and dorsal sacroiliac (DSI) ligaments. The inferior dorsal SIJ was entered and
capsular distension with contrast medium was performed. Discomfort had to occur with each provocation maneuver and a contained arthrogram was necessary to continue in the study. Session 2: 1 week later; computer randomized, double-blind multi-site, multi-depth lateral branch blocks injections were performed. Ten subjects received active (bupivicaine 0.75%

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