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M O Columb - One of the best experts on this subject based on the ideXlab platform.
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an isobolographic analysis of Diamorphine and levobupivacaine for epidural analgesia in early labour
BJA: British Journal of Anaesthesia, 2007Co-Authors: G A Mcleod, B Munishankar, M O ColumbAbstract:Background Few data describe the pharmacological interactions between local anaesthetics and opioids. The aim of this study was to measure the median effective concentration (MEC) of Diamorphine and levobupivacaine when given separately and as mixtures for epidural analgesia, and determine whether the combination is additive or synergistic. Methods One hundred and twenty patients were enrolled in this prospective randomized, two-phase, double-blind study. In the first phase, 60 women were randomized to receive a fixed 20 ml volume of either levobupivacaine or Diamorphine epidurally. Dosing was determined using up-down sequential allocation with testing intervals, respectively, of 0.01%w/v and 12.5 µg ml−1. After estimations of the MEC of levobupivacaine and Diamorphine, a further 60 patients were randomized in the second phase to one of the three mixtures: (a) Diamorphine 70 µg ml−1 (fixed) and levobupivacaine (testing interval 0.004%w/v, starting at 0.044%w/v); (b) levobupivacaine 0.044%w/v (fixed) and Diamorphine (testing interval 7 µg ml−1, starting at 70 µg ml−1); and (c) bivariate Diamorphine and levobupivacaine (testing intervals of 7 µg ml−1 and 0.004%w/v starting at 70 µg ml−1 and 0.044% w/v respectively). Results The MEC estimates from the first phase were 143.8 µg ml−1 (95% CI 122.2–165.3) for Diamorphine and 0.083%w/v (95% CI 0.071–0.095) for levobupivacaine. In the second phase, the MEC and interaction index (γ) of the three combinations were: Diamorphine 65.5 µg ml−1 (56.8–74.2), γ = 0.99; levobupivacaine 0.041%w/v (0.037–0.049), γ = 0.98; and for the fixed combination Diamorphine 69.5 µg ml−1 (60.5–78.5) and levobupivacaine 0.044%w/v (0.039–0.049), γ = 1.02. Conclusion The combination of Diamorphine and levobupivacaine is additive and not synergistic when used for epidural analgesia in the first stage of labour.
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effect of intrathecal Diamorphine on block height during spinal anaesthesia for caesarean section with bupivacaine
BJA: British Journal of Anaesthesia, 2005Co-Authors: N Akerman, M O Columb, S Saxena, R Wilson, G LyonsAbstract:Background Opioid analgesics are commonly added to intrathecal bupivacaine to improve patient comfort during Caesarean section under spinal anaesthesia, and provide post-operative pain relief. We sought to discover if the addition of Diamorphine influenced block height when given with 0.5% w/v hyperbaric bupivacaine. Method Eighty ASA I and II women of at least 37 weeks gestation and planned for elective Caesarean section under combined spinal–epidural anaesthesia were recruited. They were randomized into two groups to receive intrathecal hyperbaric bupivacaine 0.5% at an initial dose of 13 mg, with the next dose determined by the response of the previous patient (dose interval 1 mg). One group also received Diamorphine 400 μg intrathecally. If a block height of T5 to blunt light touch had been achieved after 20 min, the block was deemed effective. A difference in the ED 50 for hyperbaric bupivacaine between the groups would indicate that Diamorphine influenced block height. Intraoperative patient discomfort and need for analgesic supplementation was noted. Results The median effective dose (ED 50 ) to achieve a T5 block to light touch for Caesarean section using hyperbaric bupivacaine 0.5% was 9.95 mg [95% confidence interval (CI) 9.0–10.90] and with the addition of Diamorphine it was 9.3 mg (95% CI 8.15–10.40), while the ED 95 was 13.55 mg (95% CI 10.10–17.0) and 13.6 mg (95% CI 9.15–18.05), respectively. Five women who had received intrathecal Diamorphine and 13 who had not received Diamorphine needed intraoperative supplementation (not significant). Conclusion The addition of intrathecal Diamorphine does not appear to influence block height.
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is the clinical efficacy of epidural Diamorphine concentration dependent when used as analgesia for labour
BJA: British Journal of Anaesthesia, 2005Co-Authors: G A Mcleod, B Munishankar, M O ColumbAbstract:Background. The physicochemical properties of Diamorphine (3,6-diacetylmorphine) enhance its bioavailability compared with more lipid-soluble opioids when administered into the epidural space. However, the influence of concentration, volume or mass on the clinical efficacy of Diamorphine is not known. Method. In this double-blind, randomized, prospective study, 62 women in active labour and <5 cm cervical dilatation were recruited to determine whether the mode of action of Diamorphine in the epidural space is concentration-dependent. After insertion of a lumbar epidural catheter, patients received epidural Diamorphine 3 mg either as a high-volume, low-concentration solution (group A) or a low-volume, high-concentration solution (group B). The concentration of Diamorphine was determined by the response of the previous patient in the same group using up‐ down sequential allocation. Pain corresponding to the previous contraction was assessed using a 100-mm visual analogue score and effective analgesia was defined as <10 mm within 30 min of epidural injection. Results. There was no significant difference in EC50 for Diamorphine between the groups: the difference was 15.0 m gm l 1 (95% CI 40.3 to 10.3). The EC50 for group A was 237.5 m gm l 1 (95% CI221.2to253.8) andthe EC50forgroupB was252.5 mgml 1 (95%CI 232.2to272.8).The EC50 ratio was 0.95 (95% CI 0.87 to 1.06). The groups exhibited parallelism (P=0.98). The overall EC50 for all data was 244.2 m gm l 1 (95% CI 230.8 to 257.2). Conclusion. We conclude that Diamorphine provides analgesia in labour by a concentrationdependent effect. Br J Anaesth 2005; 94: 229‐33
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minimum dose of intrathecal Diamorphine required to prevent intraoperative supplementation of spinal anaesthesia for caesarean section
BJA: British Journal of Anaesthesia, 2003Co-Authors: S Saravanan, M O Columb, A P C Robinson, G LyonsAbstract:Background Intraoperative discomfort during spinal anaesthesia for Caesarean section is the commonest cited anaesthetic cause of litigation in obstetric practice. Intrathecal opioids are used to improve intraoperative comfort and postoperative analgesia for these operations. The minimum intrathecal Diamorphine dose that prevents intraoperative supplementation requires determination. Method After ethics committee approval, 200 ASA I, II women with ≥37 weeks gestation and planned for elective Caesarean section under combined spinal–epidural anaesthesia were recruited. They were randomized into four groups to receive hyperbaric bupivacaine 0.5% 12.5 mg with Diamorphine 0.2, 0.3, 0.4 or 0.5 mg by intrathecal injection. The need for intraoperative i.v. supplementation with alfentanil, time to first requests for postoperative analgesia, incidence of nausea and vomiting and requirement for antiemetic and antipruritic were noted. Results Intraoperative supplementation was inversely proportional to the dose of Diamorphine used (P=0.004). The ED95 value for intrathecal Diamorphine to prevent intraoperative supplementation was 0.39 mg. Mean time interval for request for postoperative analgesia was 446 min in the 0.2 mg group, 489 min in the 0.3 mg group, 601 min in the 0.4 mg group and 687 min in the 0.5 mg group (P=0.003 for trend). Incidence of nausea, vomiting and pruritus increased with dose of Diamorphine used (P values for trend: nausea, 0.04; vomiting, 0.008; pruritus, 0.004). Requests for antiemetic increased with dose but achieved significance only for requirement for second antiemetic (P=0.03). Request for antipruritic did not achieve significance. Conclusion The ED95 for the amount of intrathecal Diamorphine required to prevent intraoperative supplementation during spinal anaesthesia for Caesarean section is 0.4 mg in clinical terms. Times to first requests for analgesia, incidence of nausea, vomiting and pruritus increase with dose.
M H Hanna - One of the best experts on this subject based on the ideXlab platform.
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a comparative study of patient controlled epidural Diamorphine subcutaneous Diamorphine and an epidural Diamorphine bupivacaine combination for postoperative pain
European Journal of Anaesthesiology, 2000Co-Authors: C Gopinathan, I Sockalingham, M Fung, S Peat, M H HannaAbstract:Summary This randomized double blind study investigates the relative efficacies of controlled analgesia (PCA) regimens in three different patient groups: epidural Diamorphine 2.5 mg followed by PCA bolus 1 mg with a 20-min lockout (Gp1), subcutaneous Diamorphine 2.5 mg followed by PCA bolus with a 10-min lockout period (Gp2) and epidural Diamorphine 2.5 mg in 4 mL of 0.125% (w/v) bupivacaine followed by a PCA bolus of 1 mg Diamorphine in 4 mL 0.125% (w/v) bupivacaine with a 20-min lockout (Gp3). Patients were evaluated at 0, 1, 2, 3, 4, 8, 12, 16, 20, 24 and 48 h. Patients in Gp2 consumed significantly more Diamorphine than those in Gp1 or Gp3 (P < 0.05), but their pain scores were higher only at 1, 2 and 3 h (P < 0.05) with respect to Gp3 and at 1 h with respect to Gp1. Fewer side effects (sedation, pruritis and nausea as assessed by antiemetic requirements) occurred in Gp2 compared to Gp1 (P < 0.05). Fewer patients in Gp2 required catheterization than in Gp3 (P < 0.05). This study indicates that the use of PCA epidural Diamorphine, either alone or in combination with bupivacaine, reduces the dose requirement for analgesia but offers little clinical advantage over subcutaneous PCA Diamorphine.
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A comparative study of patient-controlled epidural Diamorphine, subcutaneous Diamorphine and an epidural Diamorphine/bupivacaine combination for postoperative pain
European Journal of Anaesthesiology, 2000Co-Authors: C Gopinathan, I Sockalingham, S Peat, M. A. Fung, M H HannaAbstract:Summary This randomized double blind study investigates the relative efficacies of controlled analgesia (PCA) regimens in three different patient groups: epidural Diamorphine 2.5 mg followed by PCA bolus 1 mg with a 20-min lockout (Gp1), subcutaneous Diamorphine 2.5 mg followed by PCA bolus with a 10-min lockout period (Gp2) and epidural Diamorphine 2.5 mg in 4 mL of 0.125% (w/v) bupivacaine followed by a PCA bolus of 1 mg Diamorphine in 4 mL 0.125% (w/v) bupivacaine with a 20-min lockout (Gp3). Patients were evaluated at 0, 1, 2, 3, 4, 8, 12, 16, 20, 24 and 48 h. Patients in Gp2 consumed significantly more Diamorphine than those in Gp1 or Gp3 (P < 0.05), but their pain scores were higher only at 1, 2 and 3 h (P < 0.05) with respect to Gp3 and at 1 h with respect to Gp1. Fewer side effects (sedation, pruritis and nausea as assessed by antiemetic requirements) occurred in Gp2 compared to Gp1 (P < 0.05). Fewer patients in Gp2 required catheterization than in Gp3 (P < 0.05). This study indicates that the use of PCA epidural Diamorphine, either alone or in combination with bupivacaine, reduces the dose requirement for analgesia but offers little clinical advantage over subcutaneous PCA Diamorphine.
Gabriele Bammer - One of the best experts on this subject based on the ideXlab platform.
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Provision of Diamorphine (Heroin) by Prescription for Drug Dependency
CNS Drugs, 1999Co-Authors: Gabriele BammerAbstract:Existing evidence for the efficacy of Diamorphine treatment of heroin dependence is presented, focusing first on ‘gold standard’ randomised controlled trials and then on other forms of evidence. The evidence strongly suggests that Diamorphine treatment may be of some value and that further trials are warranted. Nevertheless, there are a range of risks associated with Diamorphine trials and these are also discussed. It is recommended that: (i) extensive trialling of the efficacy, safety and cost-effectiveness of Diamorphine should be undertaken; (ii) trials should be conducted to the highest scientific standards, but the standards should be realistic; (iii) the risks associated with Diamorphine prescribing must be taken seriously and included in trial planning and evaluation; (iv) competing moral positions about Diamorphine prescribing should be spelt out and debated; and (v) Diamorphine prescription should be viewed as only one of a number of treatment options and should be investigated as part of a pluralist approach to the treatment of heroin dependence.
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provision of Diamorphine heroin by prescription for drug dependency issues and recommendations
CNS Drugs, 1999Co-Authors: Gabriele BammerAbstract:Existing evidence for the efficacy of Diamorphine treatment of heroin dependence is presented, focusing first on ‘gold standard’ randomised controlled trials and then on other forms of evidence. The evidence strongly suggests that Diamorphine treatment may be of some value and that further trials are warranted. Nevertheless, there are a range of risks associated with Diamorphine trials and these are also discussed. It is recommended that: (i) extensive trialling of the efficacy, safety and cost-effectiveness of Diamorphine should be undertaken; (ii) trials should be conducted to the highest scientific standards, but the standards should be realistic; (iii) the risks associated with Diamorphine prescribing must be taken seriously and included in trial planning and evaluation; (iv) competing moral positions about Diamorphine prescribing should be spelt out and debated; and (v) Diamorphine prescription should be viewed as only one of a number of treatment options and should be investigated as part of a pluralist approach to the treatment of heroin dependence.
R G Wheatley - One of the best experts on this subject based on the ideXlab platform.
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double blind comparison of epidural Diamorphine and intramuscular morphine after elective caesarean section with computerised analysis of continuous pulse oximetry
Anaesthesia, 1991Co-Authors: J D Stevens, P Braithwaite, C F Corke, T H Madej, R G WheatleyAbstract:: A randomised, double-blind comparison of the efficacy, duration of action and side effects of two analgesic regimens following elective epidural Caesarean section is described. Patients received epidural Diamorphine 3 mg or intramuscular morphine 10 mg in the immediate postoperative period. Time to next analgesia was longer after epidural Diamorphine (11.0 hours) compared to intramuscular morphine (6.5 hours) (p less than 0.05). In addition, a greater number of patients in the Diamorphine group had a pain score less than 2.5 cm at 5 hours (p less than 0.05). However, more patients in the Diamorphine group required catheterisation and suffered emetic sequelae, whereas more patients in the morphine group were sedated at 8 hours. Ten patients in each group had continuous pulse oximetry performed overnight after administration of the trial medications. Neither group demonstrated evidence of hypoxia.
Nicola Metrebian - One of the best experts on this subject based on the ideXlab platform.
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pathways into receiving a prescription for Diamorphine heroin for the treatment of opiate dependence in the united kingdom
European Addiction Research, 2007Co-Authors: Nicola Metrebian, Z Carnwath, J Mott, Tom Carnwath, Gerry V Stimson, L SellAbstract:In the UK, few doctors prescribe Diamorphine for the treatment of opiate dependence to a small number of patients. A retrospective case note review of patients receiving Diamorphine in 2000 was conduc
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patients receiving a prescription for Diamorphine heroin in the united kingdom
Drug and Alcohol Review, 2006Co-Authors: Nicola Metrebian, Z Carnwath, J Mott, Tom Carnwath, Gerry V Stimson, L SellAbstract:The United Kingdom is unusual internationally in that it is one of few countries able to prescribe Diamorphine for the treatment of opiate dependence. Prescribing Diamorphine has been part of the UK response to drug problems since the 1920s. Despite this, little is known about who receives Diamorphine and how treatment is delivered. This study aims to describe the characteristics and treatment regimes of opiate-dependent drug users receiving a prescription for Diamorphine in the United Kingdom in 2000, and report on their status in 2002. A retrospective case-note review was conducted in England and Wales. Two hundred and ten (72%; 210/292) patients' sets of case-notes were reviewed at 27 of the 42 (64%) drug clinics where Diamorphine was prescribed by the doctor. Patients had been receiving a prescription for Diamorphine for a median length of six years. The majority were unemployed white males, with a median age of 44 years. Illicit drug use and criminal activity, while low, had not been eliminated total...
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survey of doctors prescribing Diamorphine heroin to opiate dependent drug users in the united kingdom
Addiction, 2002Co-Authors: Nicola Metrebian, Tom Carnwath, Gerry V Stimson, Thomas StorzAbstract:ABSTRACT Aim To determine the scale and practice of Diamorphine (heroin) prescribing for opiate dependence in the United Kingdom in 2000. Design Postal survey. Setting England, Scotland and Wales. Participants One hundred and eleven of the 164 doctors in the United Kingdom on the Home Office record as holding a licence to prescribe Diamorphine (response rate 68%), and 59 of the 108 doctors in the United Kingdom eligible to hold a licence (working in drug clinics), but not doing so (response rate 54%). Measurements The characteristics of doctors (a) holding a licence and (b) currently prescribing; the number of opiate users receiving a prescription; current treatment delivery, clinical criteria for patient eligibility; and reasons for prescribing or not prescribing Diamorphine. Findings Seventy of the 111 doctors actually held a licence. While the majority were consultant psychiatrists, five were general practitioners. Forty-six were currently prescribing to 448 patients. The majority of prescribers reported that they had not initiated a prescription for Diamorphine but had inherited patients already receiving such a prescription. Most of those who prescribed considered that in selected cases it could produce clinical and social improvement. There were great variations in clinical criteria for patient eligibility, prescribing practice, daily dose prescribed (range 5–1500 mg) and the daily dose-equivalent of 100 mg methadone (range 50–900 mg). Many respondents cited lack of appropriate resources as a reason for not prescribing to more patients. Reasons for non-prescribing varied from lack of resources to little evidence of its effectiveness. Conclusions The prescribing of Diamorphine to opiate dependent drug users remains rare in the United Kingdom. Not all eligible doctors seek a licence to prescribe, and not all those with licences actually prescribe it. There is no clear consensus on who should be treated with Diamorphine and in what way.