Opioid Use in End-of-Life Care in Patients With Interstitial Pneumonia Associated With Respiratory Worsening

ABSTRACT

The authors investigated the treatment outcome of patients with severe interstitial pneumonia (IP) who received opioids during end-of-life care. Twenty-two consecutive patients were retrospectively evaluated before and after continuous administration of opioids for 24 hours. All subjects died within 21 days; the mean survival period after opioid administration was 5.6 days. Six of the 22 patients (27%) died within 24 hours after opioids were initiated. In the other 16 patients, respiratory rate was significantly decreased after opioid use and there was a small, nonsignificant improvement in dyspnea measured by the Borg scale without adequate evaluation and records (n = 6). However, hypercapnia with over 10 mm Hg of Paco₂ developed in two patients. Paco₂ tended to be elevated after opioid use in all patients, although the change was not significant. An extremely poor outcome was attributable to the disease progression of IP in six of the patients with Pao₂/F_Io₂ levels below 100. The other 16 patients showed both positive and negative effects as expected. Clinicians should assess dyspnea prior to opioid administration, since the purpose of the opioid administration is to relieve dyspnea. Dyspnea should be monitored and recorded in routine clinical practice, at least after hospitalization.     

The Psychological Status of Children With Cancer

The psychological and social functioning of a sample of 16 children with cancer was assessed 3–5 years after diagnosis using Achenbach's Child Behavior Checklist. Analysis indicated that 81% of the children were involved in age-appropriate social interactions and the same percentage showed normal behavioral patterns.
No significant differences were found due to gender, type of tumor, or behavior over time. The children in this sample appeared to be functioning normally, both psychologically and socially, three to five years after a diagnosis of cancer.     

Factors Associated With Home Discharge Among Veterans With Stroke

Objective

To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs.

Design

Retrospective observational study.

Setting

Veterans Affairs facilities nationwide.

Participants

Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565).

Intervention

Not applicable.

Main Outcome Measure

Discharge location after hospitalization.

Results

There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11–1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03–.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50–.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63–.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07–1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76–.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77–.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78–.97), and serious nutritional compromise (OR=.49; 95% CI=.40–.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge.

Conclusions

We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.     

Efficacy of Virtual Reality Combined With Real Instrument Training for Patients With Stroke: A Randomized Controlled Trial

ObjectiveTo investigate the efficacy of real instrument training in virtual reality (VR) environment for improving upper-extremity and cognitive function after stroke.DesignSingle-blind, randomized trial.SettingMedical center.ParticipantsEnrolled subjects (N=31) were first-episode stroke, assessed for a period of 6 months after stroke onset; age between 20 and 85 years; patients with unilateral paralysis and a Fugl-Meyer assessment upper-extremity scale score >18.InterventionsBoth groups were trained 30 minutes per day, 3 days a week, for 6 weeks, with the experimental group performing the VR combined real instrument training and the control group performing conventional occupational therapy.Main Outcome MeasuresManual Muscle Test, modified Ashworth scale, Fugl-Meyer upper motor scale, hand grip, Box and Block, 9-Hole Peg Test (9-HPT), Korean Mini-Mental State Examination, and Korean-Montreal Cognitive Assessment.ResultsThe experimental group showed greater therapeutic effects in a time-dependent manner than the control group, especially on the motor power of wrist extension, spasticity of elbow flexion and wrist extension, and Box and Block Tests. Patients in the experimental group, but not the control group, also showed significant improvements on the lateral, palmar, and tip pinch power, Box and Block, and 9-HPTs from before to immediately after training. Significantly greater improvements in the tip pinch power immediately after training and spasticity of elbow flexion 4 weeks after training completion were noted in the experimental group.ConclusionsVR combined real instrument training was effective at promoting recovery of patients’ upper-extremity and cognitive function, and thus may be an innovative translational neurorehabilitation strategy after stroke.     

Vasospasm-lnduced Myocardial Infarction With Sumatriptan

Sumatriptan, a 5-hydroxytryptamine¹ (5-HT₁) receptor agonist is an effective abortive agent for migraine headaches. A common side effect in 3% to 7.9% of patients is chest pain. Although most cases of chest pain are not thought to be of cardiac origin, its mechanism is not entirely understood. Rare examples of electrocardiogram changes consistent with transient ischemia have been reported. Isolated instances of angina, arrhythmia, myocardial infarction, and death have been temporally associated with sumatriptan administration. In most cases, it is unclear whether underlying cardiovascular disease existed or contributed to this adverse event. We report the history of a 56-year-old female patient with migraine who experienced myocardial infarction shortly after using sumatriptan, despite having had a normal cardiovascular evaluation. As she had a normal cardiac catheterization after the event, we find it probable that sumatriptan induced coronary vasospasm and myocardial infarction.     

Cation Metabolism During Propofol Sedation With and Without EDTA in Patients With Impaired Renal Function

Objective: To compare the effects of propofol with and without disodium edetate (EDTA) on cation metabolism in intensive care unit (ICU) patients with renal insufficiency who received propofol or propofol plus EDTA (propofol EDTA) for sedation and mechanical ventilation. Design: Double-blind, randomised, multicentre study. Setting: Medical and surgical ICUs from 5 hospitals. Patients: Thirty-nine ICU patients with acute and chronic renal impairment expected to require at least 24 hours of continuous sedation and respiratory failure necessitating mechanical ventilation. Interventions: Propofol or propofol EDTA administered for sedation by continuous intravenous infusion. Measurements and Results: The depth of sedation, as measured by the Modified Ramsay Sedation Scale, was similar in the 2 groups, when adjusted for dosing differences. The amount of propofol required to maintain adequate sedation was decreased in both groups compared to propofol requirements in ICU patients with normal renal function. EDTA levels were elevated at baseline in both groups. In the propofol EDTA group, the EDTA levels increased further by 20 % but decreased to below baseline EDTA levels at 48 hours after sedation. In the propofol group, EDTA levels decreased during sedation and remained below baseline levels at 48 hours after sedation. Patients in both groups were hypocalcaemic and hyperphosphataemic at baseline with low levels of 1,25-dihydroxyvitamin D and elevated parathyroid hormone (PTH) levels. Other than a slight difference in ionised serum calcium levels at 4 h after the start of sedation, there were no significant differences observed in serum calcium levels between the two groups. There were no significant differences in 1,25-dihydroxyvitamin D or PTH levels over time between the two groups. There was no significant effect on renal function in either group. Conclusions: The results of this study suggest that adding EDTA to propofol does not adversely affect cation homeostasis or renal function when used for sedation of ICU patients with renal insufficiency. Although EDTA levels increased over time from baseline levels in patients with renal insufficiency who receive propofol EDTA, this increase does not appear to be clinically significant, and EDTA levels return to below baseline levels within 48 hours of discontinuing the propofol EDTA infusion. The efficacy of propofol with and without EDTA also appears comparable in these patients.     

Cation Metabolism During Propofol Sedation With and Without EDTA in Patients With Impaired Renal Function

Objective: To compare the effects of propofol with and without disodium edetate (EDTA) on cation metabolism in intensive care unit (ICU) patients with renal insufficiency who received propofol or propofol plus EDTA (propofol EDTA) for sedation and mechanical ventilation. Design: Double-blind, randomised, multicentre study. Setting: Medical and surgical ICUs from 5 hospitals. Patients: Thirty-nine ICU patients with acute and chronic renal impairment expected to require at least 24 hours of continuous sedation and respiratory failure necessitating mechanical ventilation. Interventions: Propofol or propofol EDTA administered for sedation by continuous intravenous infusion. Measurements and Results: The depth of sedation, as measured by the Modified Ramsay Sedation Scale, was similar in the 2 groups, when adjusted for dosing differences. The amount of propofol required to maintain adequate sedation was decreased in both groups compared to propofol requirements in ICU patients with normal renal function. EDTA levels were elevated at baseline in both groups. In the propofol EDTA group, the EDTA levels increased further by 20 % but decreased to below baseline EDTA levels at 48 hours after sedation. In the propofol group, EDTA levels decreased during sedation and remained below baseline levels at 48 hours after sedation. Patients in both groups were hypocalcaemic and hyperphosphataemic at baseline with low levels of 1,25-dihydroxyvitamin D and elevated parathyroid hormone (PTH) levels. Other than a slight difference in ionised serum calcium levels at 4 h after the start of sedation, there were no significant differences observed in serum calcium levels between the two groups. There were no significant differences in 1,25-dihydroxyvitamin D or PTH levels over time between the two groups. There was no significant effect on renal function in either group. Conclusions: The results of this study suggest that adding EDTA to propofol does not adversely affect cation homeostasis or renal function when used for sedation of ICU patients with renal insufficiency. Although EDTA levels increased over time from baseline levels in patients with renal insufficiency who receive propofol EDTA, this increase does not appear to be clinically significant, and EDTA levels return to below baseline levels within 48 hours of discontinuing the propofol EDTA infusion. The efficacy of propofol with and without EDTA also appears comparable in these patients.     

Management of Children With Suspected Esophageal Burns

In order to determine the presence and extent of esophageal burns, esophagoscopy should be performed within 48 hours after accidental ingestion of a caustic.

Prevention of a stricture is the main objective in treating esophageal burns. Administration of antidotes and emetics is not recommended, since most multiple esophageal strictures result from regurgitation of the alkali after neutralizing agents have been given.

Effective treatment includes esophageal dilatations and administration of corticosteroids and antibiotics.     

持续心理干预对脑卒中患者疼痛的影响

目的探讨持续心理干预对脑卒中后疼痛患者的影响。方法将98例脑卒中患者随机分为心理干预组（n=53）和对照组（n=45）。对照组予常规护理,心理干预组在此基础上予心理干预,延续至脑卒中发生后3个月。在入院时、脑卒中后3个月采用数字评分法（NRS）进行评分。结果脑卒中发生后3个月内,卒中后疼痛的比例逐渐升高,年轻患者、女性和出血性卒中患者卒中后疼痛发生率较高,持续心理干预可以明显改善患者的NRS评分。结论脑卒中后疼痛是卒中常见的远期并发症,持续心理干预能够明显降低脑卒中后疼痛的发生率和NRS评分。     

Functional Outcomes Associated With Adaptive Seating Interventions in Children and Youth With Wheeled Mobility Needs

Objective

To determine the parent-reported functional outcomes associated with adaptive seating devices for wheeled mobility devices used by young people aged 1 to 17 years.

Design

Longitudinal case series.

Setting

Homes of participating parents.

Participants

Parents (N=70, 63 mothers, 6 fathers, 1 grandmother) who had children with adaptive seating needs.

Intervention

Adaptive seating system for wheeled mobility devices.

Main Outcome Measure

Family Impact of Assistive Technology Scale for Adaptive Seating (FIATS-AS).

Results

All parents completed the FIATS-AS 4 times—2 times before and 2 times after their child received a new adaptive seating system. Mixed-design analysis of variance did not detect significant mean differences among the FIATS-AS scores measured at baseline and 2 and 8 months after receiving the seating system (F_2,134=.22, P=.81). However, the FIATS-AS detected a significant interaction between age cohort and interview time (F_4,134=4.5, P<.001, partial η²=.16). Post hoc testing confirmed that 8 months after receiving the seating system was associated with a large improvement in child and family functioning for children <4 years, maintenance of functioning for children between 4 and 12 years, and a moderate decline in functioning for youth between 13 and 17 years.

Conclusions

Adaptive seating interventions for wheeled mobility devices are associated with functional changes in the lives of children and their families that interact inversely with age. Future controlled longitudinal studies could provide further empirical evidence of functional changes in the lives of children and their families after the introduction and long-term use of specific adaptive seating interventions.     

Health Care Resource Utilization and Costs for Adults With Mild Traumatic Brain Injury With Chronic Vestibular Impairment

ObjectiveTo quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI).DesignRetrospective matched cohort study.SettingIQVIA Integrated Data Warehouse.ParticipantsPeople with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882).InterventionsNot applicable.Main Outcome MeasuresAll-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis.ResultsPeople with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only.ConclusionsPeople who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.     

Replacing the Echolalia of Children With Autism With Functional Use of Verbal Labeling

We evaluated the direct and generalized effects of cues-pause-point language training procedures on immediate echolalia and correct responding in two children with autism. The overall goal was to teach the children to remain quiet before, during, and briefly after the presentation of questions and then to verbalize on the basis of the cues (pictures) whose labels represented the correct responses. A multiple baseline design across question/response pairs demonstrated that echolalia was rapidly replaced by correct responding on the trained stimuli and there were clear improvements in one childs responding to untrained stimuli. These results replicate and extend previous research with adults with mental retardation and autism which demonstrated that cues-pause-point procedures can be effective in teaching individuals displaying echolalia to use their verbal labeling repertoires functionally.     

Abortive Headache Therapy With Intramuscular Dihydroergotamine

During a six month period, intramuscular dihydroergotamine mesylate (1 mg.) was given to 43 patients (75 headache episodes) who presented to the office after oral medications failed to abort their headaches. Headaches were successfully aborted in 71%, with most responses occurring between 30-minutes and 4-hours after injection. Side effects were common (61%) but not serious; sedation developed in 25%, nausea in 24%, transient worsening of headaches in 15%, body aches in 11%, diarrhea in 5%, and in 13%, headaches that were successfully aborted relapsed within 24 hours. Intramuscular dihydroergotamine, although under-used, is cost effective, practical, and well suited for busy medical offices. Its appropriate use can reduce the need for narcotic analgesics and emergency room visits.     

Posterior Ischemic Optic Neuropathy Associated With Migraine

Anterior ischemic optic neuropathy is a well-recognized clinical syndrome that has been described in patients after an episode of migraine with visual aura (classic migraine) and, less commonly, after an episode of visual aura without headache (acephalgic migraine). Little emphasis, however, has been placed on migraine associated retrobulbar or posterior ischemic optic neuropathy. We report two cases of visual loss presumed to be due to posterior ischemic optic neuropathy that occurred In the setting of otherwise typical migraine episodes. We review the English language literature on Ischemic optic neuropathy associated with migraine. Although most cases of ischemic optic neuropathy associated with migraine are of the anterior variety, posterior ischemic optic neuropathy should be considered in the differential diagnosis of any patient with acute loss of vision and evidence for a retrobulbar optic neuropathy, during or after an attack of migraine headache or following an otherwise typical episode of visual aure without headache (acephalgic migraine).     

Adrenergic Dysregulation and Pain With and Without Acute Beta-Blockade in Women With Fibromyalgia and Temporomandibular Disorder

In patients with fibromyalgia syndrome (FMS) and temporomandibular disorder (TMD), stress and pain may chronically enhance sympathetic activity, altering cardiovascular responses and worsening pain. This study examined cardiovascular, epinephrine (EPI), norepinephrine (NE), cortisol and clinical pain responses in 54 female patients with these disorders and 34 controls. In a subsample of 10 FMS, 10 TMD patients and 16 controls, using a counterbalanced, double-blind, crossover design, the same responses were assessed after intravenous administration of low dose propranolol vs placebo. Testing included baseline, postural, speech and ischemic pain stressors. FMS patients showed lesser heart rate (HR) increases to posture challenge but greater blood pressure (BP) increases to postural and speech tasks than controls, as well as higher overall BP and greater total vascular resistance (TVR) than TMDs or controls. TMDs showed higher overall cardiac output and lower TVR than controls. Both FMS and TMD groups showed lower baseline NE than controls, and TMDs showed lower overall EPI and NE levels. Group differences in HR, EPI and NE were abolished after propranolol although BP, CO and TVR differences persisted. In both FMS and TMD, the number of painful body sites and ratings of total clinical pain obtained 4 times during each session were significantly lower after beta-blockade vs placebo.PerspectiveThese findings support the hypothesis that both FMS and TMD may frequently involve dysregulation of beta-adrenergic activity that contributes to altered cardiovascular and catecholamine responses and to severity of clinical pain. Acute treatment with low-dose propranolol led to short-term improvement in all these domains.     

Epiduroscopy for Patients With Lumbosacral Radicular Pain

Lumbosacral radicular pain is a pain in the distribution area of one of the nerves of the lumbosacral plexus, with or without sensory and/or motor impairment. A major source of lumbosacral radicular pain is failed back surgery, which is defined as persistent or recurrent pain, mainly in the region of the lower back and legs even after technically, anatomically successful spine surgeries. If lumbosacral radicular neuropathic pain fails to respond to conservative or interventional treatments, epiduroscopy can be performed as part of a multidisciplinary approach. Epiduroscopy aids in identifying painful structures in the epidural space, establishing a diagnosis and administering therapy. The novelty consists in the use of an epiduroscope to deliver therapies such as adhesiolysis and targeted administration of epidural medications. Clinical trials report favorable treatment outcomes in 30% to 50% of patients. Complications are rare and related to the rate or volume of epidural fluid infusion or inadvertent dural puncture. In patients with lumbosacral radicular pain, especially after back surgery, epiduroscopy with adhesiolysis may be considered (evidence rating 2 B+).     

Rehabilitation of the Elbow Extension With Motor Imagery in a Patient With Quadriplegia After Tendon Transfer

Grangeon M, Guillot A, Sancho P-O, Picot M, Revol P, Rode G, Collet C. Rehabilitation of the elbow extension with motor imagery in a patient with quadriplegia after tendon transfer.

Objective

To test the effect of a postsurgical motor imagery program in the rehabilitation of a patient with quadriplegia.

Design

Crossover design with kinematic analysis.

Setting

Rehabilitation Hospital of Lyon. Study approved by the local Human Research Ethics Committee.

Participants

C6-level injured patient (American Spinal Injury Association Impairment Scale grade A) with no voluntary elbow extension (triceps brachialis score 1).

Intervention

The surgical procedure was to transfer the distal insertion of the biceps brachii onto the triceps tendon of both arms. The postsurgical intervention on the left arm included 10 sessions of physical rehabilitation followed by 10 motor imagery sessions of 30 minutes each. The patient underwent 5 sessions a week during 2 consecutive weeks. The motor imagery content included mental representations based on elbow extension involved in goal-directed movements. The rehabilitation period of the right arm was reversed, with motor imagery performed first, followed by physical therapy.

Main Outcome Measures

The kinematics of upper-limb movements was recorded (movement time and variability) before and after each type of rehabilitation period. A long-term retention test was performed 1 month later.

Results

Motor imagery training enhanced motor recovery by reducing hand trajectory variability—that is, improving smoothness. Motor performance then remained stable over 1 month.

Conclusions

Motor imagery improved motor recovery when associated with physical therapy, with motor performance remaining stable over the 1-month period. We concluded that motor imagery should be successfully associated with classic rehabilitation procedure after tendon transfer. Physical sessions may thus be shortened if too stressful or painful.     

Nonspecific Tenosynovitis With Effusion at the Ankle

Symptoms of biliary tract disease are not always relieved after a primary operation. The incidence of overlooked common duct stones indicates the need for operative cholangiography at the time of primary biliary tract surgery. Nonsurgical disease also may cause a patient's symptoms. A complete survey of the entire gastrointestinal tract is mandatory to reduce the number of secondary operations.     

Persistent Post-DuraI-Puncture Headache Treated With Epidural Infusion of Dextran

SYNOPSIS
A retrospective review was done on medical records of 13 patients with persistent post-dural-puncture headaches after one or more epidural blood patches. Headache occurred in nine patients with post-laminectomy syndrome after "wet taps" while performing epidural blocks. In two patients post-dural-puncture headache appeared after long term implanted intrathecal catheters were removed. In two other cases headache developed after spinal anesthesia. Treatment included bed rest, intravenous hydration and at least one epidural blood patch; three patients were given 60 milliliters of epidural saline, without success. Eight epidural catheters were inserted through the lumbar access and five through the caudal approach. Initially, a bolus of 20 milliliters of dextran-40 was given followed by an infusion of 3 mL/hr, until 12 hours after the head pain and any other related symptoms subsided. In all patients the headache disappeared within 20 hours after initiating therapy (9.55 mean hours, SD ± 0.79). In five patients headache ceased in less than five hours. Nausea and photo-phobia subsided earlier. Patients with post-dural-puncture headache resistant to other treatments, including at least one epidural blood patch, were successfully treated by a bolus followed by continuous epidural infusion of dextran-40.