Nurses’ Opinions of Pain and the Assessed Need for Pain Medication for the Elderly

The undertreatment of pain in the elderly living in nursing homes is a significant problem. In Swedish nursing homes, the registered nurse on duty is often responsible for 20-40 patients during the day with no daily contact from attending physicians. The aim of this study was to investigate the opinions of registered nurses regarding pain and the assessed need for pain medication for elderly patients using patient scenarios. Two patient scenarios were used in this study; a questionnaire and background information was provided. The scenarios consisted of one smiling patient and one grimacing patient, both with the same numeric rating scale value of pain, blood pressure, pulse rate, and respiration rate. Three questions regarding pain assessment and management followed the scenarios. The questionnaire was sent to all 128 registered nurses working daytime in elderly care in both municipal nursing homes and municipal home care in the mid-Sweden region. A total of 56 nurses participated, providing an answering frequency of 45%. Results showed that registered nurses with more experience did not have the same opinion about pain as the smiling patient and gave inadequate medication, which was not in accordance with recommendations from the county hospital and the World Health Organization.     

Is the combination of remifentanil and propopfol suitable for transsphenoid resection of the hypophysis?

In a multi-center trial, the feasibility of combining remifentanil (RF) and target-controlled infusion of propofol (P) for patients undergoing transsphenoidal resection of the pituitary gland was tested. After IRB approval, 74 patients (29 male/45 female) were included in the study. The concentration of RF and the target concentration of P were recorded as were heart rate (HR) and mean arterial blood pressure (MAP). For intubation the RF dosage was 0.26 +/- 0.06 microgram.kg-1.min-1 and the target concentration of P was 3.16 +/- 0.63 micrograms.ml-1. After induction, HR and MAP decreased significantly. The painful events of the operation were preparation of the nasal mucous membrane and penetration of the sella turcica. By adjusting the RF dose to 0.31 +/- 0.09 microgram.kg-1. min-1 and the target concentration of P to 3.48 +/- 1.49 micrograms.ml-1, an increase of HR and MAP above initial values was avoided at this time. Hypotension and bardycardia were treated in eight patients (10.8%) with a vasopressor, in four patients (5.4%) with atropine and in four more patients (5.4%) with a combination of these drugs. Two patients (2.7%) needed antihypertensive therapy. The average time interval between the end of P-TCI and spontaneous breathing was 6 +/- 3 min (median 6 min) and till patients opened their eyes 9 +/- 4 min (median 9 min). After 13 +/- 4 min (median 13 min) the patients became orientated. The average doses of analgetics were 19.5 +/- 19.9 mg piritramide and 1.8 +/- 1.0 g metamizol during the first 12 hours postoperatively. Eight patients (10.8%) did not need any analgetics. We suggest that the combination of RF and P as a "fast track concept" can supplement the repertoire of anaesthetic managements used for transsphenoidal resection of the pituitary gland.     

Clinical analysis of daptomycin treatment for 21 cases of bloodstream infection caused by staphylococcus aureus北大核心CSCD

Objective To retrospectively analyze the efficacy and safety of daptomycin treatment in bloodstream infections caused by Staphylococcus aureus. Methods From August 2010 to October 2013, 21 patients received daptomycin for treatment of S. aureus bloodstream infections. We reviewed and analyzed the clinical data of these patients retrospectively. Results The clinical response rate was 81.3% for the 16 patients with uncomplicated bloodstream infection, including 10 cases of methicillin resistant S. aureus (MRSA) infection, all responding well to daptomycin. Another five patients were complicated with infective endocarditis. Of these five patients, one cured and the other four improved. The mean time to bacterial elimination was 8.5 days (3~19 days). Daptomycin-related adverse events included 1 (4.8%) case of mild increase of serum creatine phosphokinase (CPK) and 1 (4.8%) case of moderate skin rash and pruritus. No serious adverse event was reported. Conclusions Daptomycin is effective and safe in the treatment of bloodstream infections caused by S. aureus, including MRSA. The most common adverse drug reaction is mild elevation of CPK, which can recover to normal after discontinuation of daptomycin. © by Editorial Department of Chinese Journal of Infection and Chemotherapy.     

Test–retest reliability and comparability of paper and computer questionnaires for the Finnish version of the Tampa Scale of Kinesiophobia

Objectives

To estimate the internal consistency, test–retest reliability and comparability of paper and computer versions of the Finnish version of the Tampa Scale of Kinesiophobia (TSK-FIN) among patients with chronic pain. In addition, patients’ personal experiences of completing both versions of the TSK-FIN and preferences between these two methods of data collection were studied.

Design

Test–retest reliability study. Paper and computer versions of the TSK-FIN were completed twice on two consecutive days.

Participants

The sample comprised 94 consecutive patients with chronic musculoskeletal pain participating in a pain management or individual rehabilitation programme. The group rehabilitation design consisted of physical and functional exercises, evaluation of the social situation, psychological assessment of pain-related stress factors, and personal pain management training in order to regain overall function and mitigate the inconvenience of pain and fear-avoidance behaviour.

Results

The mean TSK-FIN score was 37.1 [standard deviation (SD) 8.1] for the computer version and 35.3 (SD 7.9) for the paper version. The mean difference between the two versions was 1.9 (95% confidence interval 0.8 to 2.9). Test–retest reliability was 0.89 for the paper version and 0.88 for the computer version. Internal consistency was considered to be good for both versions. The intraclass correlation coefficient for comparability was 0.77 (95% confidence interval 0.66 to 0.85), indicating substantial reliability between the two methods.

Conclusion

Both versions of the TSK-FIN demonstrated substantial intertest reliability, good test–retest reliability, good internal consistency and acceptable limits of agreement, suggesting their suitability for clinical use. However, subjects tended to score higher when using the computer version. As such, in an ideal situation, data should be collected in a similar manner throughout the course of rehabilitation or clinical research.     

What are the criteria for evaluation and prevention of venous thromboembolism?

Venous thromboembolism occurs frequently in both medical and surgical units. Although we possess the therapeutic means to prevent this condition, the question is how to assess the benefit induced by a treatment in relation to the haemorrhagic risk? The primary evaluation criteria and the evaluation method must be correctly chosen. While phlebography is the reference method for diagnosing deep venous thrombosis, the limitations associated with this method have led to the promotion of other diagnostic techniques, and clinical criteria or composite criteria are increasingly used. These different approaches--with their respective advantages and limitations--will be developed.     

Immunotherapy for head and neck cancer: the future of treatment?

Introduction: Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide with >500,000 cases diagnosed each year. HNSCC patients often present to the clinic with advanced disease and are managed with a multi-disciplinary approach consisting of surgery, chemotherapy, and/or radiation. Morbidity and quality of life issues are major challenges in this patient population due to the debilitating effects of standard of care treatment paradigms. There is a critical need for new therapeutic approaches to manage HNSCC with better anti-tumor activities and toxicity profiles. Immunotherapy has gained traction as a precision medicine initiative to manage solid malignancies.

Areas covered: The authors review current knowledge of immune escape mechanisms and discuss key immunotherapies in HNSCC with an emphasis on clinical trials data.

Expert opinion: The excitement over the potential of immunotherapy to manage solid malignancies, including HNSCC is high and warranted based on the impressive clinical data accrued to date. Research in immunity and immune modulation in cancer has been invigorated and offers the potential to reveal novel vulnerabilities that may be exploitable pharmacologically. The evolution of immunotherapy will continue and move toward rational combinations with other immunotherapies or molecularly-targeted agents in the first-line, adjuvant, and recurrent/metastatic settings in HNSCC.     

microRNA and the pathogenesis of ovarian cancer--a new horizon for molecular diagnostics and treatment?

Ovarian cancer is the leading cause of death among gynecologic malignancies and despite advances in treatment, more than 50% of all patients will experience recurrence, resulting in worse overall prognosis. Therefore, identification of novel biomarkers for ovarian cancer is of significant interest. microRNA (miRNA) constitute a class of small gene regulatory RNA molecules (18-24 nt) and by sequence complementarity, they negatively regulate messenger RNA (mRNA) translation of target genes. Rising data are available that miRNA are functionally involved in the pathogenesis of ovarian cancer. In this regard, recent advances in profiling studies revealed a variety of miRNA candidates, differently expressed in ovarian carcinomas and in disease-specific conditions like hypoxia or chemo-resistance. This review abstracts recent efforts on establishing miRNA as novel molecular biomarkers for ovarian cancer and depicts the existing preliminary framework for defining peripheral-blood derived miRNA as novel circulating biomarkers. Beside these clinical implications, we highlight the current functional understanding of miRNA alteration and discuss major challenges in miRNA profiling approaches. Finally, we briefly outline methodologies to therapeutically modulate miRNA expression in cancer and try to assess how miRNA can improve our conceptual understanding and the clinical management of ovarian cancer.     

Statins for everybody? New evidence on the efficacy and safety of the inhibitors of HMG Co-A reductase

Classically, the statins are the first choice drugs when treating dyslipidemias, especially in patients with hypercholesterolemia alone or accompanied by hypertriglyceridemia. The recent evidence of the effectiveness, safety and impact comes from hard endpoints, as demonstrated in 6 trials which included more than 40,000 subjects. The statins are being recommended for the treatment of a large number of patients with overt coronary heart disease, regardless of serum cholesterol levels, in patients with acute phases of coronary syndromes, and in patients without apparent coronary heart disease with moderate risk and average serum cholesterol and LDL cholesterol levels. These drugs are also being prescribed to patients with high-risk medical conditions that are "equivalent to coronary heart disease," like diabetes, lower limb atherosclerosis, or vascular cerebral disease, independent of the basal serum cholesterol levels or LDL cholesterol ranging from normal to high. Despite all the evidence collected as to the efficacy and safety of these drugs, the statins are not sufficiently used in daily practice, probably due to the ignorance of new concepts and the doubts related to the safety that may be cleared by careful analysis of 6 major studies with these drugs.     

Can the type of catheter and the use of irradiated red blood cells for transfusion in neonates influence the occurrence of hemolysis?

AimTo compare hemolysis marker levels of irradiated and non-irradiated packed red blood cells (PRBCs) after infusion by different neonates intravenous catheter.MethodExperimental study. Irradiated and non-irradiated PRBCs administered in vitro in peripheral intravenous catheter (PIVC),Umbilical (UC), and peripheral intravenous central catheter (PICC). Collected aliquots directly from PRBC bag, after filling the infusion system and catheter infusion. The hemolytic markers analyzed were: degree of hemolysis; hematocrit–Hct; total hemoglobin–THb; free hemoglobin–FHb; potassium– K; and lactate dehydrogenase–LDH.ResultsPVIC did not significantly influence hemolysis marker levels. The UC infusion influenced levels of FHb (p = 0.005), K (p = 0.001) and THb (p = 0.001); while PICC demonstrated significant effect on FHb (p = 0.010), degree of hemolysis (p = 0.026) and LDH (p = 0.050) levels in non-irradiated and irradiated PRBCs.ConclusionIn vitro infusion of irradiated and non-irradiated PRBCs resulted in significant changes in the levels of UC and PICC hemolysis markers, however, such levels do not contraindicate their use in neonatal transfusion.     

Campylobacter genes responsible for the development and determinant of clinical features of Guillain-Barré syndrome

Progress has been made in Guillain-Barré syndrome, a post-infectious autoimmune neuropathy, especially on identifying Campylobacter jejuni genes responsible for the development and determinant of clinical features. C. jejuni strains carrying a sialyltransferase gene (cst-II), which is essential for the biosynthesis of ganglioside-like lipooligosaccharides, are associated with the development of Guillain-Barré syndrome. The C. jejuni sialyltransferase (Cst-II) consists of 291 amino acids, and the 51st determines its enzymatic activity. Strains with cst-II (Thr51) expressed GM1-like and GD1a-like lipooligosaccharides, whereas strains with cst-II (Asn51) expressed GT1a-like and GD1c-like lipo-oligosaccharides. Patients infected with the cst-II (Thr51) strains had anti-GM1 or anti-GD1a IgG antibodies, and showed limb weakness. Patients infected with the cst-II (Asn51) strains had anti-GQ1b IgG antibodies, and showed ophthalmoplegia and ataxia. The cst-II gene is responsible for the development of Guillain-Barré and Fisher syndromes, and the polymorphism (Thr51/Asn51) determines which syndrome develops after C. jejuni enteritis.     

ASME proposals for reform of SHO training: threat or opportunity for the specialty of accident and emergency?

A report is made on proposals for change in postgraduate medical training that may have profound implications for the specialty of accident and emergency (A&E). The proposals are detailed with their background and rationale, together with some of their possible effects on A&E.     

Evaluation of the blood analyzer ABL 735 radiometer for determination of the percentage of fetal hemoglobin in fetal and neonatal blood

Objective: To evaluate the quality of measurements of percentage fetal hemoglobin (HbF) using the blood analyzer ABL?735 and to compare the results with the HbF measurements using the Biorad‐Variant (the gold standard). Methods: The percentage of HbF in fetal blood, obtained during intrauterine transfusions or from the umbilical cord blood of preterm and term babies, and from the red blood cells of adults who had given blood for transfusion, was determined spectrophotometrically (ABL‐735) and by high pressure liquid chromatography (Biorad‐Variant). Blood pH values were also measured with the ABL?735. Reproducibility (mean difference between duplo measurements) and the relationships between the HbF percentages measured by both methods were calculated. Results: Reproducibility was independent of the HbF percentage and was more reliable with the Biorad‐Variant method (0.3%) than with the ABL‐735 method (2.1%). Regression analysis showed that the ABL‐HbF percentages were often underestimated. Serious aberrations were observed at low pH values (<7.00) on the recalculated ABL‐HbF percentages. For samples with pHs >7.00 a relatively good relationship was found between the pH‐corrected ABL‐HbF percentages and those of the Biorad‐Variant values. Conclusion: The HbF percentage measured with the ABL blood analyzer is only moderately accurate if the HbF percentage is corrected for the pH.