Search

Background The Accreditation Council for Graduate Medical Education (ACGME) requires all emergency medicine (EM) training programs to evaluate resident performance and also requires core faculty to attend didactic conference. Assuring faculty participation in these activities can be challenging. Previously, our institution did not have a formal tracking program nor financial incentive for participation in these activities. In 2017, we initiated an educational dashboard which tracked and published all full-time university faculty conference attendance and participation in resident evaluations and other educational activities. Objectives We sought to determine if the implementation of a financially-incentivized educational dashboard would lead to an increase in faculty conference attendance and the number of completed resident evaluations. Methods We conducted a pre- and post-intervention observational study at our EM residency training program between July 2017 and July 2019. Participants were 17 full-time EM attendings at one training site. We compared the number of completed online resident evaluations (MedHub) and number of conference days attended (call-in verification) before and after the introduction of our financial incentive in June 2018. The incentive required 100% completion of resident evaluations and at least 25% attendance at eligible didactic conference days. We calculated pre- and post-intervention averages, and comparisons were made using a chi-square test. Results Prior to implementation of the intervention, the 90-day resident evaluation completion rate was 71.8%. This increased to 100% after implementation (p < 0.001). Conference attendance prior to implementation was 43.8%, which remained unchanged at 41.3% after implementation of the financial incentive (p = 0.920). Conclusions Attaching a financial incentive to a tracked educational dashboard increased faculty participation in resident evaluations but did not change conference attendance. This difference likely reflects the minimum thresholds required to obtain the financial incentive.

Emergency departments (ED) have proposed utilizing a Web-based format to distribute patient satisfaction surveys, but the potential for bias in this distribution method has not been assessed.The aim of this study was to evaluate the characteristics of ED patients who have access to the Internet to better understand potential bias in Web-based patient satisfaction surveys.We distributed a 20-question survey to consenting, English-speaking adult patients presenting to the ED from December 2010 to March 2012. Patients reported demographic information and answered questions related to their access and use of the Internet.Seven hundred four patients participated in the study; 90% of Whites reported Internet access, vs. 82% of Hispanics (p = 0.034). Ninety-two percent of patients with at least some college education had Internet access, compared to 79% of those with a high school education level or lower (p ≤ 0.001). Of households reporting an income of$22,000/year, 95% had Internet access, compared to 77% of those reporting a household income$22,000/year (p ≤ 0.001). Ninety-four percent of participants40 years of age had Internet access, compared to 83% between the ages of 40 and 56 years, and 77% for those over 56 years of age (p0.001).A Web-based distribution of ED patient satisfaction surveys may underrepresent minorities, patients without college education, those with lower income, and patients older than 40 years. This information may provide guidance in interpreting results of Web-based patient satisfaction surveys and may suggest the need for multiple sampling methods.

Background: In emergency medicine, the ability to provide rapid, adequate pain control without high resource utilization is ideal. In this study, the efficacy of intranasal sufentanil in emergency department (ED) patients with acute distal extremity injury was evaluated. Methods: A nonrandomized, open-label dose trial to determine safety and efficacy of intranasal sufentanil in patients with a distal extremity injury who presented to the ED with moderate to severe pain was conducted. Vital signs, pain scores, Ramsay sedation score, and any side effects during a 30-minute observation period after medication administration were recorded. Patients, nurses, and physicians completed satisfaction surveys. Results: Fifteen ED patients with acute extremity injuries agreed to participate in the study and received a dose of 0.5 µ g/kg of sufentanil intranasally. The average pain score decreased 4.3 points (from 7.8 to 3.5). Eight patients reported a final pain score of ≤ 3. The most common side effect was mild dysphoria. Patients, physicians, and nurses reported high average satisfaction scores. Conclusion: Intranasal sufentanil resulted in a significant clinical reduction in patients’ reported pain without serious side effects. This medication and administration route demonstrated promise for potential use in the ED.

A subcutaneous peritoneal catheter (SCPC) developed at the University of Utah has been used for chronic peritoneal dialysis in this center during the last 2% years. Fifty-six SCPC's were implanted in 48 patients for a total of 11, 260 days (30.8 patient years). The SCPC's were used for peritoneal dialysis for 7831 days (21.4 patient years) for 3356 peritoneal dialyses, the longest for 778 days (2.1 years). The SCPC remained functioning in ten patients during periods of nonuse, e. g., successful renal transplant, for 1908 days (5.2 patient years). The functional status of the SCPC was unknown in five patients lost to follow-up for 809 days. Functional outflow obstruction episodes occurred 39 times during peritoneal dialysis (1 per 6.6 patient months); 29 of these episodes were corrected by either bedside maneuvers or minor surgical procedures. Five out of ten SCPC's removed for obstruction were successfully replaced. Twenty-nine infections occurred (0.80% of peritoneal dialyses), resulting in nine SCPC removals (three successfully replaced). In spite of the necessary insertion of a 14-g needle for each peritoneal dialysis, the SCPC was well accepted by the patients, mostly because of the reduced care required and the increased personal freedom gained during the interdialytic interval. The long periods of patency during nonuse (up to 397 days) further indicated the possible usefulness of the SCPC as a back-up device for hemodialysis patients. This could greatly reduce the problems associated with temporary loss of blood access in patients on hemodialysis.

Purpose: It is often difficult to determine the functional status of the detrusor muscle in patients with detrusor areflexia. We performed a clinical study to establish a test defining residual detrusor capacity in such patients.Materials and Methods: In phase 1, 5 controls with detrusor areflexia were tested with an intravesical instillation of 20 mg. bethanechol in 150 cc of sodium chloride 0.3% with and without 20 mA. of pulsed current applied via an electrode catheter through the saline. Cystometry simultaneously recorded intravesical pressure changes. In phase 2, 45 patients with detrusor areflexia were tested with electromotive administration of intravesical bethanechol. In phase 3, 25 mg. bethanechol given orally once daily were prescribed for 15 patients and voiding control was assessed after 6 weeks of therapy.Results: Neither bethanechol without current nor current through saline only led to increased intravesical pressure. However, we noted a mean pressure increase of 34 cm. water during the el...

Purpose: The discomfort caused by intravesical capsaicin during instillation may restrict its use in some patients. We studied the effectiveness of using electromotive drug administration (EMDA) of lidocaine to anesthetize the bladder before capsaicin.Materials and Methods: EMDA of lidocaine and epinephrine was performed in 8 patients with detrusor hyperreflexia using catheters, electrodes and an electrical current generator (20 mA., 15 minutes) followed immediately by intravesical capsaicin (2 mmol./l.) for 30 minutes under urodynamic monitoring. The patients scored suprapubic pain at 5 minutes and at the end of the capsaicin instillations on a scale of 0 to 10. Of the 8 patients 5 had had previous capsaicin treatments and the scores were compared to previous scores when intravesical lidocaine without EMDA had been used as local anesthesia before capsaicin.Results: The pain scores during capsaicin instillations after EMDA of lidocaine were much lower than those during capsaicin instillations afte...

Two formulations of morphine citrate were synthesized: trimorphine citrate, 3(MH)+(C6H5O7)3- and morphine sodium citrate, 3(MH)+3Na+2(C6H5O7)3-. Four healthy individuals volunteered to undergo electromotive administration of the two formulations. Application of electric current (2 mA) to solutions of trimorphine citrate for 1 h resulted in iontophoretic transcutaneous administration of therapeutic quantities of morphine, without deleterious reduction in the pH of the drug solutions. Application of a 2-mA current to solutions of morphine sodium citrate for 2 h resulted in combined iontophoretic and electrophoretic delivery of morphine with increased administration rates and an improved buffering capacity of the drug solutions.

Introduction Painful extremity injuries are common patient complaints in resort clinics, urgent care clinics, and emergency departments. We hypothesized that intranasal (IN) sufentanil could provide rapid, noninvasive, effective pain relief to patients presenting with acute extremity injuries. Methods This was an unblinded, nonrandomized, observational study that enrolled a convenience sample of patients presenting to a university-affiliated ski clinic with acute moderate to severe pain associated with a traumatic injury between the months of January and March 2011. Patients were excluded if they reported an allergy to sufentanil or had hypoxia, significant head injury, or hypotension. Nurses administered IN sufentanil using an IN atomizer device. The nurse recorded patient-reported pain scores (0-10 scale) on arrival and at 10, 20, and 30 minutes after administration of sufentanil. Results During the study period, 40 patients were enrolled; 75% were men. The average age was 32 years (range, 16-60 years). The average dose of sufentanil was 37.7 μ g. Five patients (12.5%) were given additional IN analgesia. Average pain on arrival was 9 (on a 10-point scale), and the mean reduction in pain scores was 4.7 (95% confidence interval [CI], 3.67-5.57) at 10 minutes, 5.79 (95% CI, 4.81-6.77) at 20 minutes, and 5.74 (95% CI, 4.72-6.76) at 30 minutes. Conclusion In this limited observational trial, IN sufentanil provided rapid, safe, and noninvasive pain relief to patients presenting with acute traumatic extremity injuries. Given the ease of administration, this may serve as a viable option for use in other settings, such as urgent care clinics and emergency departments.

background : Obtaining anesthesia for dermatologic, office-based surgeries often involves the pain of needle stick and burning upon injection of local anesthetic agents. No truly effective method for obtaining painless anesthesia is well accepted in the United States. objective : A study was carried out using iontophoresis of lidocaine with epinephrine to determine the practicality of this method of delivering local anesthesia prior to invasive procedures in dermatology offices. methods : A two-center, open-label study was undertaken using iontophoretic administration of 4% lidocaine with epinephrine 1:50,000 before painful procedures occurring in the dermatologists’office. results : Ninety-four procedures in 64 patients were evaluated. Both patients and physicians recorded 51% of procedures as painless, 36% as minor (partial), and 14% causing moderate to severe pain. Iontophoretic local anesthesia was 80 to 100% effective for pain relief for injections, abrasions, laser surgery, and cautery; it was significantly less effective in effecting pain relief for dermal excisions. conclusions : Iontophoretic administration of anesthesia is a useful adjunct to the armamentarium of dermatologists performing surgical procedures in their office. J Dermatol Surg Oncol 1992;18:937–940.

We have demonstrated that dexamethasone sodium phosphate (DmNaP) is delivered most efficiently from the negative electrode by iontophoresis, but, under certain conditions, the delivery from the positive electrode by electroosmosis can be accomplished. The laboratory data indicate that more dexamethasone is delivered per mAmin by iontophoresis than by electroosmosis, thus the same amount of drug can be administered in a shorter time from the negative electrode. Electrodes containing a hydrogel material, which restricts bulk water transport, delivered DmNaP most efficiently from the electrode of negative polarity. When DmNaP is to be delivered in a mixture with another drug such as lidocaine, selection of the clinical treatment protocol depends on the desired therapeutic effect and on the iontophoretic electrode which is to be used. When minimization of total treatment time is not critical, switching polarity of the electrode during the treatment can be used to administer drugs of opposite polarity from a mixture. Since co-iontophoresis of different compounds is often necessary for fully effective therapy, further research to understand the mechanism of simultaneous transport of various drugs is required.

Iontophoresis is a method of transdermal administration of ionized drugs in which electrically charged molecules are propelled through the skin by an external electrical field. This was a prospective, randomized, single-blind study to determine the effectiveness of iontophoretically delivered morphine HCl for the control of postoperative pain. Thirty-eight patients who underwent total knee or hip replacement completed this clinical trial. Informed consent was obtained before surgery and patients were instructed on the use of a patient-controlled analgesia (PCA) device. Postoperatively, pain in the recovery room was initially controlled with IV meperidine, and thereafter with PCA therapy using meperidine, 2 mg/cc, with a dose of 10 mg IV and a lock-out period of 15 min. The dose was adjusted as necessary and the lock-out period remained the same. The number of patient requests and the dose (mg) administered was recorded hourly. On the morning following surgery, iontophoresis devices were attached for 6 hr to patients who received either morphine HCl or lactated ringers solution. During this period and for 12 hr following completion of iontophoresis, PCA analgesia remained available to patients. Venous blood samples for determination of morphine levels were obtained every 30 min during iontophoresis, then every 60 min for 2 hr following iontophoresis. Of the 38 patients, 17 received iontophoresed morphine, and 21 received iontophoresed lactated ringers. The morphine group utilized the PCA device more than the control group during the baseline period. However, following the institution of iontophoresis and continuing up to 12 hr following completion of iontophoresis, the morphine group used significantly less PCA meperidine to maintain analgesia than the control group (p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Summary Background The rationale for combining anticancer drugs has not been applied consistently to use of intravesical agents for treatment of superficial bladder cancer, for which immunotherapeutic BCG and chemotherapeutic mitomycin seem to be a potentially effective combination. We aimed to do a prospective, randomised comparison of BCG alone with that of sequential BCG and electromotive mitomycin in patients with stage pT1 bladder cancer. Methods After transurethral resection and multiple biopsies, 212 patients with stage pT1 bladder cancer were randomly assigned to: 81 mg BCG infused over 120 min once a week for 6 weeks (n=105); or to 81 mg BCG infused over 120 min once a week for 2 weeks, followed by 40 mg electromotive mitomycin (intravesical electric current 20 mA for 30 min) once a week as one cycle for three cycles (n=107). Complete responders underwent maintenance treatment: those assigned BCG alone had one infusion of 81 mg BCG once a month for 10 months, and those assigned BCG and mitomycin had 40 mg electromotive mitomycin once a month for 2 months, followed by 81 mg BCG once a month as one cycle for three cycles. The primary endpoint was disease-free interval; secondary endpoints were time to progression; overall survival; and disease-specific survival. Analyses were done by intention to treat. This trial has been submitted for registration at the US National Cancer Institute website http://clinicaltrials.gov. Findings Median follow-up was 88 months (IQR 63–110). Patients assigned sequential BCG and electromotive mitomycin had higher disease-free interval than did those assigned BCG alone (69 months [95% CI 55–86] vs 21 months [15–54]; difference between groups 48 months [42–54], log-rank p=0·0012). Patients assigned sequential BCG and electromotive mitomycin also had lower recurrence (41·9% [32·7–51·5] vs 57·9% [48·7–67·5]; difference between groups 16·0% [2·7–29·3], log-rank p=0·0012); progression (9·3% [3·8–14·8] vs 21·9% [17·9–25·9]; difference between groups 12·6% [3·0–22·2], log-rank p=0·004); overall mortality (21·5% [13·5–29·5] vs 32·4% [23·4–41·4], difference between groups 10·9% [0·6–21·2], log-rank p=0·045); and disease-specific mortality (5·6% [1·2–10·0] vs 16·2% [6·1–23·3], difference between groups 10·6% [2·5–18·7], log-rank p=0·01). Side-effects were mainly localised to the bladder. Interpretation BCG-induced inflammation might increase the permeability of the bladder mucosa such that mitomycin can reach the target tissue more easily and exert its anticancer effect.

We investigated the effectiveness and safety of intravesical resiniferatoxin (Sigma Chemical Co., St. Louis, Missouri) and botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients with neurogenic detrusor overactivity unresponsive to conventional anticholinergic therapy.A total of 25 patients were randomly assigned to receive intravesically 0.6 microM resiniferatoxin in 50 ml of 0.9% NaCl or injections into the detrusor muscle of 300 units botulinum A-toxin diluted in 30 ml 0.9% NaCl. Clinical evaluation and urodynamics were performed at baseline, and at 6, 12 and 18 months after treatment.In both arms there was a significant decrease in catheterization and incontinent episodes, and a significant increase in first detrusor contraction and maximum bladder capacity at 6, 12 and 18-month followup. There were no local side effects with either treatment. Botulinum-A toxin induced a significant decrease in the frequency of daily incontinence episodes (p0.05), a significant increase in first uninhibited detrusor contraction (p0.01) in maximum bladder capacity (p0.01), and a significant decrease in maximum pressure of uninhibited detrusor contractions (p0.01) compared to resiniferatoxin at 6, 12 and 18-month followup.In spinal cord injured patients with refractory neurogenic detrusor overactivity, intravesical resiniferatoxin and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with decreases in detrusor overactivity and restoration of urinary continence in a large proportion of patients. Botulinum-A toxin injections provided superior clinical and urodynamic benefits compared to those of intravesical resiniferatoxin.

Purpose: Uncontrolled studies with intraplaque electromotive administration of verapamil and dexamethasone have demonstrated objective improvements in Peyronie’s disease. We performed a prospective controlled study to assess the efficacy of intraplaque electromotive verapamil/dexamethasone vs electromotive lidocaine.Materials and Methods: Patients with Peyronie’s disease were randomized into a study group (47 patients) and a control group (49 patients). For each treatment session an electrode receptacle was sited over the plaque and filled with either 5 mg verapamil and 8 mg dexamethasone (study group) or 2% lidocaine (control group), and a 2.4 mA electric current was applied for 20 minutes. All patients were scheduled for 4 sessions per week for 6 weeks. Assessment before and after treatment included measurements of plaque volume and penile curvature, and pain on erection (from questionnaire).Results: A total of 37 patients in the study group and 36 in the control group completed treatment course...

In laboratory studies electromotive mitomycin C (MMC) demonstrated markedly increased transport rates compared with passive transport. We performed a prospective study in patients with high risk superficial bladder cancer to assess the efficacy of intravesical electromotive vs passive MMC using bacillus Calmette-Guerin (BCG) as a comparative treatment.Following transurethral resection and multiple biopsies 108 patients with multifocal Tis, including 98 with T1 tumors, were randomized into 3 equal groups of 36 each who underwent 40 mg electromotive MMC instillation with 20 mA electric current for 30 minutes, 40 mg passive MMC with a dwell time of 60 minutes or 81 mg BCG with a dwell time of 120 minutes. Patients were scheduled for an initial 6 weekly treatments, a further 6 weekly treatments for nonresponders and a followup 10 monthly treatments for responders. Primary end points were the complete response rate at 3 and 6 months. MMC pharmacokinetics were assessed.The complete response for electromotive vs passive MMC at 3 and 6 months was 53% versus 28% (p = 0.036) and 58% versus 31% (p = 0.012). For BCG the responses were 56% and 64%. Median time to recurrence was 35 vs 19.5 months (p = 0.013) and for BCG it was 26 months. Peak plasma MMC was significantly higher following electromotive MMC than after MMC (43 vs 8 ng/ml), consistent with bladder content absorption.Intravesical electromotive administration increases bladder uptake of MMC, resulting in an improved response rate in cases of high risk superficial bladder cancer.

Intravesical electromotive administration of local anesthetics is clinically successful but electrochemistry, cost and effectiveness limit the choice of drugs to diluted lidocaine HCl 4% mixed with epinephrine. These studies address the stability of lidocaine and epinephrine both over time and when exposed to electric current, i.e. transport rates with passive diffusion and electromotive administration. The drug mixture used was 50 ml lidocaine 4%, 50 ml H2O and 1 ml epinephrine 1/1000. For stability, the solution was placed either in bowls for 7 days or in a two chamber cell with the donor compartment (drugs) separated from the receptor compartment (NaCl solution) by a viable pig bladder wall. This was subjected to 30 mA for 45 min. Stability was measured with mass spectrometry. The cell was also used to determine transport rates with passive diffusion and currents of 20 mA and 30 mA, over 20, 30 and 45 min. Drug measurements in both compartments and bladder were made with HPLC. Lidocaine remained stable throughout the 7 days, epinephrine on day 1 only and both drugs were stable with 30 mA for 45 min. Comparing 20 mA and 30 mA with passive diffusion, there were significant differences in 6/6 donor compartment lidocaine levels, 4/6 receptor compartment levels and 6/6 bladder tissue levels and also in 6/6 epinephrine donor levels and 6/6 tissue levels. The combination lidocaine and epinephrine remains stable for 1 day and when exposed to 30 mA for 45 min. Electric current accelerates the transport of lidocaine and epinephrine.

Capsaicin and resiniferatoxin (Sigma Chemical Co., St. Louis, Missouri) administered intravesically are attractive options for treating detrusor hyperreflexia. Because the 2 agents differ in chemical structure and relative potency, possible differences in their clinical and urodynamic effects were investigated in this prospective comparative study.A group of 24 spinal cord injured patients with refractory detrusor hyperreflexia were randomly assigned to receive a single dose of 2 mM. capsaicin in 30 ml. ethanol plus 70 ml. 0.9% sodium chloride or 100 nM. resiniferatoxin in 100 ml. 0.9% sodium chloride. Dwell time was 40 minutes with urodynamic monitoring. Urodynamics were performed at baseline before treatment, and after followups of 30 and 60 days. The frequency of daily catheterizations, incontinence episodes and side effects was recorded.There was no significant urodynamic or clinical improvement in the capsaicin arm at 30 and 60 days of followup. In the resiniferatoxin arm the mean uninhibited detrusor contraction threshold plus or minus standard deviation increased from 176 +/- 54 to 250 +/- 107 ml. at 30 days (p0.05) and to 275 +/- 98 ml. at 60 days (p0.01). Mean maximum bladder capacity increased from 196 +/- 75 to 365 +/- 113 ml. at 30 days (p0.001) and to 357 +/- 101 ml. at 60 days (p0.001). Daily catheterizations and incontinent episodes were significantly decreased at 30 and 60 days of followup. Autonomic dysreflexia, limb spasms, suprapubic discomfort and hematuria developed in most patients who received capsaicin but in none who received resiniferatoxin.Intravesical administration of resiniferatoxin is superior to that of capsaicin in terms of urodynamic results and clinical benefits in spinal cord injured patients and it does not cause the inflammatory side effects associated with capsaicin.

Scurvy, caused by a lack of Vitamin C in the diet, is thought to occur only sporadically in developed countries. The signs and symptoms are diverse but generally follow a predictable progression most striking for their hemorrhagic component, particularly of the skin, gums, and joints. We report a case of scurvy in an elderly, alcoholic woman. The diagnosis was contemplated based on dermatologic findings and a dietary history. All symptoms resolved within 10 days of oral ascorbic acid supplementation. Patients most at risk for developing scurvy include food faddists, the isolated elderly, and the mentally ill.

A proportion of patients with detrusor hyperreflexia who are unresponsive to oral oxybutynin often benefit from intravesical oxybutynin instillation. To our knowledge the precise mode of action of this method is obscure.In 12 patients with detrusor hyperreflexia who were previously unresponsive to oral and intravesical passive diffusion of 5 mg. oxybutynin we administered 5 mg. oxybutynin orally as well as increased doses of 15 mg. oxybutynin intravesically with passive diffusion and with 15 mA. associated electric current. Each administration mode per patient was associated with an 8-hour urodynamic monitoring session during which oxybutynin and N-desethyl oxybutynin plasma levels, and intravesical oxybutynin uptake were measured.A dose of 5 mg. oxybutynin orally induced no urodynamic improvement with an area under the plasma concentration time curve of combined N-desethyl oxybutynin plus oxybutynin of 16,297 ng./8 hours and an area under the curve ratio of N-desethyl oxybutynin-to-oxybutynin of 11:1. Passive diffusion oxybutynin resulted in 12 mg. oxybutynin intravesical uptake and significant improvement in 3 of 8 urodynamic measurements, although the area under the curve of combined N-desethyl oxybutynin plus oxybutynin was only 2,123 ng./8 hours and the N-desethyl oxybutynin-to-oxybutynin ratio was 1.1:1.0. Electromotive administration of oxybutynin resulted in almost complete intravesical uptake of the 15 mg. dose, significant improvement in all 8 urodynamic measurements and an increased oxybutynin level versus oral and passive diffusion, although the area under the curve of combined N-desethyl oxybutynin plus oxybutynin was 4,574 ng./8 hours and the N-desethyl oxybutynin-to-oxybutynin ratio was inverted at 1.0:1.4. The oral dose of 5 mg. oxybutynin caused anticholinergic side effects in 8 of the 12 patients. Neither intravesical passive diffusion nor electromotive administration caused side effects with an uptake of 12 and 15 mg., respectively.A large proportion of intravesical oxybutynin is sequestered, probably in the urothelium. Intravesical oxybutynin administration confers therapeutic benefits via localized direct action within the bladder wall.

Study objective: To determine the effect of topical anesthetics on visual acuity (VA). Methods: We studied 66 consecutive patients (73 afflicted eyes) who presented to a university hospital emergency department with the complaint of eye pain. VA was measured before and after patients were treated with proparacaine, a topical ocular anesthetic. Results: After proparacaine instillation, VA was improved in 33 patients (45%), unchanged in 34 (47%), and worse in 6 (8%). Conclusion: Patients with eye pain often demonstrate improved VA after the instillation of a topical anesthetic. [Bossart PJ, Stephen RL, Herr RD, Berndt D: Visual acuity after topical application of proparacaine. Ann Emerg Med January 1997;29:158-160.]

Persistent neuropathic pain is associated with, diagnostic and therapeutic challenges that may be very difficult to resolve. This report describes eight patients with incapacitating, posttraumatic neuropathic pain characteristic of reflex sympathetic dystrophy (RSD) who were treated by electromotive administration of guanethidine into affected areas of skin. Following 1–5 treatments, six patients experienced complete resolution of all superficial symptoms of hyperalgesia, pain, pallor, coolness, and sweating of the affected areas. One patient demonstrated partial relief of these symptoms, and one patient failed to respond. The results of this preliminary study suggest that electromotive administration of the sympatholytic agent, guanethidine, may be useful in the treatment of some types of neuropathic pain. These findings justify the implementation of further controlled studies.

Iontophoresis is the active transport of ions into tissues by means of an electric current: Ji = -D(i)delta Ci/delta chi + DizeECi/kT. Where Ji is the total ionic flux, D(i) the diffusion coefficient, Ci the concentration, z the valency, and E the electric field. The first expression on the right side of the equation is Fick's law of diffusion and approaches zero for bladder mucosa, which leads to uncertain results following intravesical administration of various therapeutic agents. The application of an electric field will potentially accelerate drug administration into the bladder wall in a controllable manner. To evaluate this concept, an appropriate source of electric current and electrodes was fabricated; then, studies were conducted in human cadaveric bladders and clinical trials in human subjects. Ionized dyes were applied in duplicate to 10 fresh cadaveric bladders. Electric currents (3.5-5.0 mA) were applied for 20 min to 10 solutions, and no current was used in 10 controls. Twenty-eight patients had 100 ml solutions of 1% mepivacaine or lidocaine with epinephrine infused into their bladders prior to endoscopic resections. Twenty-two patients received currents of 10-20 mA for 10-20 min, and 6 controls had either no drugs or a current of reverse polarity applied. Visually and on microscopy, the 10 control cadaveric bladder surfaces demonstrated only faint staining of the surface mucosa whereas the experimental surfaces showed full-thickness staining of the mucosa extending into the muscularis. The 6 control patients required supplemental anesthesia or abandonment of the operative procedure. Of the 22 experimental subjects, 16 tolerated procedures with up to 25 g of tissue removed by diathermic resection.