Pain levels experienced with activities after cardiac surgery.

BACKGROUND: Acute pain is common after cardiac surgery and can keep patients from participating in activities that prevent postoperative complications. Accurate assessment and understanding of pain are vital for providing satisfactory pain control and optimizing recovery. OBJECTIVES: To describe pain levels for 5 activities expected of patients after cardiac surgery on postoperative days 1 to 6 and changes in pain levels after chest tube removal and extubation. METHODS: Adults who underwent cardiac surgery were asked to rate the pain associated with various types of activities on postoperative days 1 to 6. Pain levels were compared by postoperative day, activity, and type of cardiac surgery. Pain scores before and after chest tube removal and extubation also were analyzed. RESULTS: Pain scores were higher on earlier postoperative days. The order of overall pain scores among activities (P < .01) from highest to lowest was coughing, moving or turning in bed, getting up, deep breathing or using the incentive spirometer, and resting. Changes in pain reported with coughing (P = .03) and deep breathing or using the incentive spirometer (P = .005) differed significantly over time between surgery groups. After chest tubes were discontinued, patients had lower pain levels at rest (P = .01), with coughing (P = .05), and when getting up (P = .03). CONCLUSIONS: Pain relief is an important outcome of care. A comprehensive, individualized assessment of pain that incorporates activity levels is necessary to promote satisfactory management of pain.     

Experimental stress fractures of the tibia. Biological and mechanical aetiology in rabbits

We have shown that stress fractures can be induced in the tibial diaphysis of an animal model by the repeated application of non-traumatic impulsive loads. The right hind limbs of 31 rabbits were loaded for three to nine weeks and changes in the bone were monitored by radiography and bone scintigraphy. The presence of stress fractures was confirmed histologically in some cases. Most animals sustained a stress fracture within six weeks and there was a positive correspondence between scintigraphic change and radiological evidence. Microscopic damage was evident at the sites of positive bone scans. The progression, location, and time of onset of stress fractures in this animal model were similar to those in clinical reports, making the model a useful one for the study of the aetiology of stress fractures.     

The relationship between price of services, quality of care, and patient time costs for general dental practice.

OBJECTIVE: To examine the relationships between price of services, quality of care, and patient time costs in private practices of general dentists. DATA SOURCE/STUDY SETTING: In October 1992, a 3.7 percent sample of eligible general dentists in part-time or full-time private practice in 1991 was randomly drawn from a sampling frame tailored from data gathered by the 1991-1992 American Dental Association Distribution of Dentists census of all United States dentists. DATA COLLECTION: A mail survey was used to collect data on dentist demographic characteristics, dental practice characteristics practice finances, and insurance. The survey was completed and returned by 3,048 general dentists (77 percent response rate). Local area population characteristics were obtained from secondary sources. STUDY DESIGN: Two-stage least squares regression was used to evaluate the structural relationships between price of services, quality of care, and time costs to patients. Structural equations were estimated for four different quality of care measures and two time costs. PRINCIPAL FINDINGS: Price of services and quality of care were significantly related to each other. Higher quality of care was associated with higher price of services and, reciprocally, higher price of services was associated with higher quality of care. Shorter waits for a new patient appointment were associated with higher prices. Higher price of services, lower quality of care, and longer waits for a new patient appointment were related to shorter in-office waiting time. CONCLUSIONS: The implication of these findings is that if price of services is constrained, then the quality of care provided by the dentist may also be reduced.     

Severe cerebral edema in a patient with anasarca and hypernatremia.

We describe a woman whose fatal post-liver transplantation cerebral edema was unexpected and of unusual pathogenesis. Her severe cerebral edema is of considerable pathophysiologic interest: 1) it developed in the setting of marked anasarca and persistent hypernatremia, and 2) although hepatic function was poor, it was not considered sufficiently deranged to induce cerebral edema. Furthermore, there was no histologic evidence of hepatic rejection or antemortem hepatic necrosis. We postulate that an impairment of the blood brain barrier in association with a degree of hepatic dysfunction insufficient by itself to cause cerebral edema permitted the brain interstitial fluid volume to increase pari passu with ECF expansion. Cytotoxic cerebral edema and vascular engorgement may also have contributed to a life-threatening increase in intracranial pressure.     

Comparison of the effects of fluticasone propionate aqueous nasal spray and loratadine on daytime alertness and performance in children with seasonal allergic rhinitis.

BACKGROUND: Concern has been directed at the relative sedating properties of lipophilic and lipophobic antihistamines, but few studies have sought to determine the comparative benefit of seasonal allergic rhinitis (SAR) treatments in controlling symptoms and consequently improving alertness. OBJECTIVE: To compare the relative contributions of fluticasone propionate aqueous nasal spray and loratadine in enhancing daytime performance in 8- to 17-year-old children. METHODS: All participants had a documented history of SAR, positive response to a skin prick (wheal 3-mm greater than negative control or equal to the positive control) for seasonal aeroallergens, and clinically identifiable symptoms at the time of randomization. Following confirmation during baseline of current SAR symptoms, participants were randomized to 1 of the 2 treatments and returned 2 weeks later for evaluation of symptom control, quality of life, attention, reaction time, and memory. RESULTS: Children in the fluticasone propionate aqueous nasal spray group but not the loratadine group demonstrated improvement in nasal symptoms, nasal quality of life score, and composite verbal memory. No differences were identified on any scores from the Conners Continuous Performance Test. CONCLUSIONS: Treatments that most effectively control SAR symptoms are also likely to provide the greatest benefit to children whose daytime functioning, including their capacity to learn at school, is compromised by their illness.     

Antibodies in guinea-pigs immunized with kidney and lung basement membranes

The cross-reaction of antibodies to tubular basement membrane (TBM) with alveolar basement membrane (ABM) has been studied in guinea-pigs with tubulointerstitial (TI) nephritis. Forty-three of fifty-two Hartley guinea-pigs immunized with rabbit TBM in complete Freund's adjuvant developed TI nephritis. In addition to linear deposits of guinea-pig IgG and C3 in the TBM, thirty-two of the nephritic animals showed linear immune deposits in ABM; twelve of these animals had thickened alveolar septa and increased numbers of polymorphonuclear (PMN) leucocytes in lung tissue. Sera and eluates of kidney and lung from nephritic guinea-pigs reacted strongly with TBM and more weakly with ABM of normal animals. Absorption experiments suggested that antibodies to TBM and ABM were closely related or identical. Only a minority of guinea pigs immunized with TBM showed in vivo binding of IgG to glomerular basement membrane (GBM). Immunization of guinea-pigs with lung-homogenate-induced antibodies binding to TBM and ABM (in approximately 45% of animals) and to GBM (in approximately 30% of animals). Immunization with crude GBM-induced antibodies which reacted preferentially with TBM and ABM. In contrast, collagenase-treated GBM-induced antibodies preferentially reactive with GBM. TI nephritis was induced in both Strain 13 and Strain 2 guinea-pigs, but the nephropathy developed much faster in Strain 13 animals. Immunization with rabbit TBM-induced antibodies reactive with ABM in 25% of Strain 13 guinea-pigs and in 50% of Strain 2 guinea-pigs, respectively.     

Induction of a stable hapten-specific immunosuppression by a hapten conjugated to poly(N-vinylpyrrolidone) (PVP).

The ability of a hapten coupled to a clinically permissive synthetic polymer (NIP-PVP) to induce suppression was investigated. NIP coupled to the low molecular weight non-immunogenic form of poly(N-vinylpyrrolidone) (PVP) was found to be capable of inducing a hapten-specific longlasting suppression of both primary and secondary responses. The previous use of PVP as a plasma expander in humans makes this polymer a potentially suitable tool for the induction of specific immunosuppression to a variety of clinically important drug and tissue specific epitopes. The possible use of low molecular weight PVP for that purpose will be investigated further, specifically with larger antigenic components.     

Glomerulonephritis in NZW kidneys grafted into NZB/W mice.

After left nephrectomy, 3 10-week old NZB/W mice received orthotopic grafts of kidneys from parental NZW mice of the same age. At autopsy conducted at the age of 33-38 weeks, glomerulonephritis of similar extent was noted in the recipients' own and in the grafted kidneys. Also, very similar granular deposits of immunoglobulins and complement were demonstrated in these kidneys. It was concluded that the absence of glomerulonephritis in NZW mice cannot be attributed to the refractoriness of their kidney to this disease.