Measuring and managing pain and performance

Pain and movement dysfunction are invariant sensory and motor expressions of health disorders. They are also complex, inter-related problems and may be accompanied by fatigue and depressed mood. Optimum management is predicated on the appropriate selection, application and interpretation of assessment measures. Research on pain and physical function using physical performance tests has shown that regardless of whether pain and impairment is a consequence of musculo-skeletal injury or systemic disease such as cancers, pain-free individuals outperform those with pain in terms of movement speed and endurance ability across a variety of performance tests (e.g. walk and reach tests, and repeated sit-to-stand and trunk flexion tests). Slow movements are characterized by fractionated and extraneous movement patterns. They are also associated with a relatively high level of muscle activity (amplitude and duration) throughout the task compared to fast movements. Slow movements are also relatively inefficient in terms of physiological energy and time burden. For a similar level of effort, individuals with pain are able to perform significantly less work. Our research has shown that individuals with pain move slower across a range of self-selected movement speeds i.e. slow, preferred and fast speeds. It is also apparent that patients systematically over estimate expected pain during task performance at faster speeds. Preliminary work using speed targeted treatment shows promise in terms of improving physical performance and reducing the burden of illness and physical dysfunction.     

Bulimia nervosa and obesity. Clinical and psycho-social features, and intervention

In this article, the authors deal with clinical and psycho-social aspects as well as treatment measures for nervous bulimia, overeating attacks and obesity. By studying these disorders, we have been able to notice the existence of common psycho-pathological characteristics. Impulsive behavior, more or less compulsive eating habits, and the presence of certain personality traits are different from nervous anorexia according to our study. However, our manner of viewing these disorders consists of considering nervous bulimia and overeating attacks as being clear psychiatric entities, while obesity can be a consequence, or not as seen in the majority of cases, of a psychiatric disorder, although there always exists a special weakness which causes one to suffer from these disorders and there exists a need for psychological support to complement a nutritional treatment program.     

Women planning and experiencing pregnancy and childbirth: information needs and sources

This paper reports the preliminary findings of a study of women planning a pregnancy and perinatal women with respect to their information needs and the sources of information they use. Fifty women, 7 planning a pregnancy, 30 pregnant and 13 postnatal, completed a questionnaire including questions about who they had approached for information about pregnancy issues, who had given them advice and why it was or was not useful, what they would currently like to know, and what they wished they had known during the previous three months. Results highlighted differences in the type of information provided by various sources: doctors and specialists were seen as primarily providing factual information; midwives also supplied information but more importantly gave reassurance and support; partners did not provide information but were valued for their support in a shared experience; and mothers and friends were primarily useful due to their own experiences. The findings also suggested the importance of information that is relevant to the women's current stage of pregnancy.     

Effective and Safe Anesthesia for Yorkshire and Yucatan Swine with and without Cardiovascular Injury and Intervention

The goal of this study was to identify an injectable anesthetic protocol that provides sedation sufficient for peripheral vascular catheterization, intubation, and transport while minimizing cardiovascular changes in Yorkshire and Yucatan pigs with and without cardiovascular injury and intervention (CI). Phase 1 examined the safety and efficacy of acepromazine–ketamine, diazepam–ketamine, midazolam–ketamine, and medetomidine–ketamine in 5 healthy Yorkshire pigs. For each drug combination, we obtained multiple measurements of heart rate, blood pressure, respiratory rate, temperature, sedation score, ability to catheterize and intubate, and recovery score. Phase 2 evaluated and refined the dose of the most effective Phase 1 anesthetic combination (midazolam–ketamine) in healthy and CI Yorkshire pigs (n = 53 trials). Phase 3 mirrored Phase 2 but tested midazolam–ketamine in healthy and CI Yucatan pigs (n = 34 trials). Midazolam (0.5 mg/kg)–ketamine (25 to 27 mg/kg) was the most effective anesthetic combination in healthy Yorkshire pigs, but this dose was less effective in healthy Yucatan pigs and CI Yorkshire and Yucatan pigs. Midazolam–ketamine resulted in tachycardia and apnea more frequently in CI pigs than healthy pigs. This combination also caused vomiting in one CI Yucatan pig. Overall, midazolam–ketamine provided safe and effective sedation for catheterization and intubation of both healthy and CI pigs. This study suggests Yucatan pigs may require a higher dose midazolam–ketamine to achieve the same level of sedation as that in Yorkshire pigs. Although anesthetic complication rates were higher in CI pigs, our results indicate that midazolam–ketamine can be safely used for sedation of both pig breeds with and without CI.Abbreviation: CI, cardiovascular injury and interventionPigs (Sus scrofa) are common models of cardiovascular injury and intervention (CI) that largely have replaced traditional canine cardiology models. Advantages of swine compared with dogs include anatomic and physiologic characteristics similar to humans, such as similar coronary artery distribution and effective collateralized blood flow to the myocardium after coronary artery blockage.²³ However, pigs are difficult to restrain and anesthetize due to their size and resistance to sedative drug combinations, including those with morphine.²⁴ Injectable sedative drugs may result in cardiovascular and respiratory effects such as increased cardiac work and oxygen consumption, tachycardia, bradycardia, apnea, hypertension, and hypotension.^{5,6,8-12,14,19,20,25-29} These side effects can pose considerable problems for CI pigs, and anesthesia protocols with minimal effects on cardiovascular function are needed. A literature review revealed no published studies of anesthetic protocols in swine with existing cardiovascular injury; published research is limited to investigating anesthesia protocols for experimental induction of CI or determining in vitro and in vivo drug effects on healthy cardiovascular systems.^{4-6,8-12,14,19-21,25-29} Other published studies have limited investigations to studying sedative and physiologic effects in healthy Yorkshire, Yucatan, mixed-breed, Landrace, and Gottingen miniature swine.^{2,3,10,13,17,18,20-22}We conducted the current study to address the need for a systematic investigation of anesthetic protocols in CI Yorkshire and Yucatan pigs. The goals of this study were to determine an injectable-only anesthetic protocol for both Yorkshire and Yucatan pigs that yielded sufficient sedation for peripheral vascular catheterization, sufficient duration for transport, and minimal cardiovascular effects while being safe and effective for CI pigs.     

Debrisoquine and dextromethorphan phenotyping and antidepressant treatment

The correlation between debrisoquine and dextromethorphan oxidation polymorphism was studied in 16 depressed in-patients. There was a close correlation between both phenotypes (r = 0.81 p less than 0.0017). During a treatment with amitriptyline during two weeks there was no significant modification of the dextromethorphan polymorphism. In the same way, the association of amitriptyline and toloxatone during two other weeks did not change this polymorphism in a significant way, even if there was a non significant shift towards higher values of the dextromethorphan metabolic ratio.     

Past and Future: Responsibility and Opportunity

Abstract

Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management. The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Splanchnic and peripheral glucose and lactate metabolism during and after prolonged arm exercise.

Splanchnic and peripheral exchange of glucose and gluconeogenic substrates was examined in 12 healthy subjects during 2 h of arm or leg exercise on a bicycle ergometer and during a 40-min postexercise recovery period. The work intensity corresponded to 30% of the maximal pulmonary oxygen uptake. The regional exchange of substrates was evaluated using catheter technique and indicator dilution methods for blood flow measurements. Our findings indicate that prolonged arm exercise as compared with exercise with the legs results in a greater increase in heart rate (25-40%) and a more marked reduction in splanchnic blood flow (10-30%) as well as higher arterial concentrations of lactate, free fatty acids, and catecholamines. The respiratory exchange ratio was consistently higher with arm exercise. In addition, arm exercise results in a greater fractional extraction and utilization of glucose by exercising muscle as well as a greater hepatic gluconeogenesis from lactate and glycerol. During recovery from prolonged arm exercise, leg muscle becomes an important site of lactate release to the splanchnic bed, despite a lack of net glucose uptake by the leg. Simultaneously, arm muscle shows an increase in glucose uptake in the absence of a net release of lactate. These coincident but discordant processes in the leg and arm during recovery suggest the occurrence of a redistribution of muscle glycogen from previously resting (leg) muscle to previously exercising (arm) muscle.     

'Good' and 'bad' stories: decisive moments, 'shock and awe' and being moral

Aim. Within this paper I explore some of the issues related to eliciting, interpreting, choosing and re‐telling stories gathered within narrative inquiry. Background. Most of the literature focusing on narrative inquiry and narratives makes little mention of what makes a story intrinsically ‘good’ or ‘bad’ although it is generally acknowledged that stories have moral lessons embedded within them and have a teaching/learning function. However, many of the moral issues associated with gathering, interpreting and re‐telling stories are not really addressed. Method. Adopting a reflexive stance, I draw on Cartier‐Bresson's notion of decisive moments and link this to narratives as a way of exploring what makes a story ‘good’/compelling as well as potentially ‘bad’/morally problematic. I develop the idea that narrative researchers may act as ‘horror magnets’ attracting ‘bad news’ stories and may be overlooking some of the more ‘neutral’ and ‘good’/‘good news’ stories. Conclusion. Narrative researchers may be adopting a ‘shock and awe’ approach to their stories without fully considering the potential impact. I propose that narrative researchers should engage in a morally proficient manner with participants/stories and conclude that a relational ethical approach can help us to ‘act well’ with people's stories. Relevance to clinical practice. Narrative inquiry and a storied approach to practice has much to offer researchers, practitioners and patients/families. Stories can get to the heart of patients’ experiences. Stories provide practitioners with one means of ‘acting well’ and in a relational way with their patients.     

Rapid and High-Throughput pan-Orthopoxvirus Detection and Identification using PCR and Mass Spectrometry

The genus Orthopoxvirus contains several species of related viruses, including the causative agent of smallpox (Variola virus). In addition to smallpox, several other members of the genus are capable of causing human infection, including monkeypox, cowpox, and other zoonotic rodent-borne poxviruses. Therefore, a single assay that can accurately identify all orthopoxviruses could provide a valuable tool for rapid broad orthopovirus identification. We have developed a pan-Orthopoxvirus assay for identification of all members of the genus based on four PCR reactions targeting Orthopoxvirus DNA and RNA helicase and polymerase genes. The amplicons are detected using electrospray ionization-mass spectrometry (PCR/ESI-MS) on the Ibis T5000 system. We demonstrate that the assay can detect and identify a diverse collection of orthopoxviruses, provide sub-species information and characterize viruses from the blood of rabbitpox infected rabbits. The assay is sensitive at the stochastic limit of PCR and detected virus in blood containing approximately six plaque-forming units per milliliter from a rabbitpox virus-infected rabbit.     

Migraine and ischaemic heart disease and stroke: potential mechanisms and treatment implications

The migraine-ischemia relationship is best understood in the context of the pathophysiology of migraine. Potential mechanisms of migrainous infarction (stroke occurring during migraine) include vasospasm, hypercoagulability, and vascular changes related to cortical spreading depression. Stroke occurring remote for the migraine attack may be related to arterial dissection, cardioembolism, and endothelial dysfunction. Endothelial dysfunction, a process mediated by oxidative stress, may be a cause or a consequence of migraine, and explain the relationship of migraine to vascular factors and ischemic heart disease. It remains uncertain whether stroke or myocardial infarction can be prevented by migraine prophylaxis, endothelial repair, platelet inhibition, or a combination of these strategies. Although triptans are generally considered safe for use in migraine, caution is warranted in those with multiple vascular risk factors. Known vascular disease is a contraindication to triptan use.     

Humanism and positivism in nursing: contradictions and conflicts

Nursing and nurse education have been influenced by a shift towards a broadly humanistic philosophy as a basis for practice At the same time, in attempts to develop a knowledge base and credibility as a profession, the vital importance of research has been acknowledged Both these aspects of nursing are increasingly forming the basis for all nursing courses However, in this paper, it is argued that the implicit adoption of notions of science based in a positivistic paradigm gives rise to conflicts with a humanistic philosophy It is contended that nursing has inherited a 'legacy of positivism', which promotes objectivity and reductionism and which excludes subjective meaning and the personal from the research process In part this has been due to the powerful influence of medical hegemony, which has defined the nature of legitimate knowledge and controlled nursing research through the gatekeeping function of doctors If nursing is to make progress in the development of a knowledge base, the contradictions between humanism and positivism must be acknowledged as a barrier to an integration of the art and science of nursing This paper suggests that what is required is a paradigm shift, a redefinition of nursing science, which not only rehumanizes the nature of research, but also refutes and challenges the notion of objectivity and the objective attitude     

Recognizing and treating anxiety and depression in adolescents. Normal and abnormal responses

Recognition of depressive and anxiety disorders in adolescents reduces morbidity, mortality, and lifetime risk for psychiatric illness and maladaptive behaviors. Effective treatments for these disorders are available and are associated with minimal severe side effects. Because adolescents tend to underreport their psychologic distress, screening for these disorders in the primary care setting is incumbent on the clinician. Depression or anxiety may be a primary or a secondary condition--with each other and with other medical illness. Substance abuse, including cigarettes, should not be overlooked as an accompanying risk factor for poor health care habits and as an indicator of degree of family (lack of) support. Adolescents at risk should be screened and their symptoms taken seriously. This brief overview does not focus on the need for primary care clinicians to seek assistance and support of psychiatrists in the diagnosis and development of treatment algorithms. All clinicians should be reminded that judgments about peoples' internal mental states and function are difficult to assess objectively and with compassion. Initial assessment in the primary care setting should include a telephone consultation with a reliable psychiatric colleague and referral for more in-depth evaluation in the event of more complicated course. These disorders need to be treated comprehensively because of the lifelong implications that having a chronic disease bear on the individual and his or her physiology. Primary care clinicians are pivotal instruments in engaging adolescents to embrace appropriate therapeutic measures for their current and future health.     

Bleeding risk and reversal strategies for old and new anticoagulants and antiplatelet agents

Summary. The most important adverse effect of antithrombotic treatment is the occurrence of bleeding. In the case of severe bleeding in a patient who uses anticoagulant agents or when a patient on anticoagulants needs to undergo an urgent invasive procedure, it may be useful to reverse anticoagulant treatment. Conventional anticoagulants such as vitamin K antagonists may be neutralized by administration of vitamin K or prothrombin complex concentrates, whereas heparin and heparin derivatives can be counteracted by protamine sulphate. The anti‐hemostatic effect of aspirin and other antiplatelet strategies can be corrected by the administration of platelet concentrate and/or desmopressin, if needed. Recently, a new generation of anticoagulants with a greater specificity towards activated coagulation factors as well as new antiplatelet agents have been introduced and these drugs show promising results in clinical studies. A limitation of these new agents may be the lack of an appropriate strategy to reverse the effect if a bleeding event occurs, although experimental studies show hopeful results for some of these agents.     

Point-of-care testing and recognizing and preventing errors

Jenny, the practice nurse of a busy GP surgery, was asked to carry out a commercially available test to exclude a diagnosis of infectious mononucleosis. The test was negative. The patient was prescribed amoxycillin and later developed a severe rash. However, the blood tests from the local pathology laboratory showed that the patient did have infectious mononucleosis. The GP discovered from colleagues that over the last few weeks other patients as the surgery had been recorded as having negative tests but positive laboratory results had later followed.     

European and American suspected and confirmed pulmonary embolism populations: comparison and analysis

Summary. Background: If the prevalence of pulmonary embolism (PE) differs significantly between the US and Europe, this observation could reduce the generalizability of diagnostic protocols for PE derived in either location.Objective: To determine possible causes and potential clinical consequences of these PE prevalence differences.Methods: Secondary analysis of three prospectively collected multicenter samples (two French and one from the US) including 3174 European and 7940 American PE‐suspected patients in Emergency departments (ED) (117 for Europe and 12 for US). Comparison of clinical features, resource use and outcomes of European‐ and US‐suspected PE populations in ED.Results: European patients evaluated for PE were significantly older and had a higher clinical pretest probability (CPP) for PE. The final PE prevalence was significantly higher in Europe, in the overall sample (26.5% vs. 7.6%) and in each level of CPP. Suspected European patients categorized as low CPP had a higher posttest probability than US low CPP patients. Suspected US patients categorized as high CPP had a much lower posttest probability of PE than in Europe. The mean number of tests performed for one PE diagnosis was lower in Europe (7.4 vs. 21.6). Among patients diagnosed with PE, European patients had a higher mean severity of illness score and a higher PE‐mortality rate (3.4% vs. 0.7%).Conclusions: Among patients suspected of a PE and those ultimately diagnosed with a PE, European patients had higher acuity, a higher pretest probability and worse outcome than US patients. The present study underscores the importance of disease prevalence for pretest probability scoring approaches and for significance interpretation of imaging tests.