Pain experienced by patients hospitalized at the National Cancer Institute of Milan: research project "towards a pain-free hospital"

According to the data of the literature, the prevalence of pain in cancer patients at various stages of the disease and the settings of care range from 38 to 51%, with an increase of up to 74% in the advanced and terminal stages. Despite published World Health Organization (WHO) guidelines for pain management, 42 to 51% of cancer patients receive inadequate analgesia and 30% receive no analgesics at all. A 3-year Research Project "Towards a Pain-free Hospital", which began one year ago, is ongoing at the National Cancer Institute of Milan. The research is organized in three subsequent steps. In the 1st one, a series of patient- and staff-oriented evaluation tools are used to assess the level of appropriateness of pain communication, assessment, management and control of the in-patients. The 2nd step will implement a number of continuing educational interventions aimed at improving patient awareness and staff knowledge of the appropriate pain assessment and management in order to respond to the patient's pain problem. In the 3rd step, all the assessment tools used in step one will be applied again to establish the prevalence of pain, the causes and intensity and patient satisfaction with pain management and to evaluate the impact of the interventions performed during the 2nd step regarding the overall ability of our hospital to tackle pain emergency in the hospitalized cancer population. The results relative to the 1st step are herein reported, in particular as regards the study on prevalence, causes, severity of pain, the interference of pain with sleep, mood and concentration, the use of pain medications and the relief obtained, the structural validity and internal consistency of the assessment tool used. A total of 258 patients hospitalized for at least 24 h were interviewed by 9 physicians using a brief structured questionnaire prepared ad hoc: 51.5% of the patients presented pain during the previous 24 h caused by surgery (49.6%) or by the tumor mass itself (29.3%). Out of the 133 patients with pain, a high degree (much or very much) of pain at rest was present in 27.1% and pain on movement in 30.8%; 31.6% did not take any analgesic treatment, and 14.3% of the latter reported a high degree of pain at rest and 21.4% on movement. Pain interfered with sleep from much to very much in 28.8% and with irritability and nervousness in 15.9% of the patients. In the 91 patients taking analgesics, 57.2% reported a high degree of pain relief. A high degree of pain and interference, however, was associated with low relief levels. The assessment tool used was shown to have a good structural validity and internal consistency (Chrombach alpha index of interference scale = 0.73). Although the Milan Cancer Institute has the longest tradition in Italy of pain assessment by means of validated tools and pain management according to the WHO guidelines and educational efforts in this field, the results of the study clearly show that it is necessary to persevere with continuing educational and informative programs in order to reduce the frequency and severity of pain and thus improve the quality of life of in-patients.     

The acutely dislocated knee: evaluation and management

Acute knee dislocations are uncommon orthopaedic injuries. Because they often spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee, resulting in multidirectional instability. Associated meniscal, osteochondral, and neurovascular injuries are often present and can complicate management. The substantial risk of associated vascular injury mandates that vascular integrity be confirmed by angiography in all suspected knee dislocations. Evaluation and initial management must be performed expeditiously to prevent limb-threatening complications. Definitive management of acute knee dislocation remains a matter of debate; however, surgical reconstruction or repair of all ligamentous injuries likely can help in achieving the return of adequate knee function. Important considerations in surgical management include surgical timing, graft selection, surgical technique, and postoperative rehabilitation.     

Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial

Studies employing noninvasive pressure support ventilation in cardiogenic pulmonary edema have been performed in the intensive care unit when overt respiratory failure is already present and in small groups of patients. In this multicenter study, performed in emergency departments, 130 patients with acute respiratory failure were randomized to receive medical therapy plus O2 (65 patients) or noninvasive pressure support ventilation (65 patients). The primary end point was the need for intubation; secondary end points were in-hospital mortality and changes in some physiological variables. Noninvasive pressure support ventilation improved PaO2/FIO2, respiratory rate, and dyspnea significantly faster. Intubation rate, hospital mortality, and duration of hospital stay were similar in the two groups. In the subgroup of hypercapnic patients noninvasive pressure support ventilation improved PaCO2 significantly faster and reduced the intubation rate compared with medical therapy (2 of 33 versus 9 of 31; p=0.015). Adverse events, including myocardial infarction, were evenly distributed in the two groups. We conclude that during acute respiratory failure due to cardiogenic pulmonary edema the early use of noninvasive pressure support ventilation accelerates the improvement in PaO2/FIO2, PaCO2, dyspnea, and respiratory rate, but does not affect the overall clinical outcome. Noninvasive pressure support ventilation does, however, reduce the intubation rate in the subgroup of hypercapnic patients.     

Behavioral interactions produced by co-administration of 7-OH-DPAT with cocaine or apomorphine in the rat

 Previous research from our laboratory suggests that low doses (<0.1 mg/kg) of the dopamine (DA) D₃-preferring agonist 7-hydroxy-N,N-di-n-propyl-2-aminotetralin (7-OH-DPAT) attenuate conditioned place preference (CPP) produced by the indirect DA agonist d-amphetamine, but enhance d-amphetamine-induced stereotypic behaviors. This study further examined the effects of 7-OH-DPAT on behaviors produced by the indirect DA agonist, cocaine, and the non-selective direct DA agonist, apomorphine. To examine whether 7-OH-DPAT would alter cocaine and apomorphine dose-response curves for motor behaviors and CPP, 0.1 mg/kg 7-OH-DPAT was co-administered with 0–30 mg/kg cocaine and 0–3 mg/kg apomorphine. To establish place conditioning, drug injections were paired with one of two distinctly different compartments, whereas saline injections were paired with the other compartment. Locomotion, sniffing, oral stereotypy, and headbobbing were measured following acute and repeated drug administration during conditioning, and place conditioning was assessed 24 h following the last conditioning day.7-OH-DPAT enhanced cocaine- and apomorphine-induced stereotypies following repeated administration. 7-OH-DPAT also attenuated cocaine-CPP, but potentiated apomorphine-CPP. Furthermore, 7-OH-DPAT attenuated locomotion produced by high doses of apomorphine. The attenuation of cocaine-CPP by 7-OH-DPAT likely involves stimulation of D₂/D₃ autoreceptors in the mesolimbic pathway, whereas the potentiation of apomorphine-CPP likely involves stimulation of D₂/D₃ postsynaptic receptors. Furthermore, it is suggested that attenuation of apomorphine-induced locomotion by 7-OH-DPAT likely involves stimulation of postsynaptic D₃ receptors in the mesolimbic pathway. Thus, if postsynaptic D₃ receptors are involved in mediating CPP and locomotion, then stimulation of D₃ receptors may facilitate CPP but inhibit locomotion. Received: 20 May 1998 / Final version: 17 September 1998     

Cardiovascular fitness and health in patients with end-stage osteoarthritis

Objective. To evaluate the cardiovascular fitness of a group of patients with severe osteoarthritis (OA). Methods. Thirty-seven patients with end-stage OA were evaluated just before hip or knee replacement surgery. Severity of arthritis was evaluated using standardized techniques. Patients and age- and sex-matched controls underwent a single, maximal, symptomlimited, cardiopulmonary exercise test using arm or leg ergometry and a metabolic cart to measure expired respiratory gases. Results. Severe musculoskeletal disability and deformity was confirmed in the OA patient group. During exercise testing, OA patients were able to perform physiologically maximal cardiopulmonary exercise. Arthritis patients were noted to be severely deconditioned, with reduced peak oxygen consumption (OA hips mean ± SD 14.9 ± 4.2 versus control hips 19.0 ± 4.6, P < 0.0001; OA knees 12.8 ± 3.7 versus control knees 17.6 ± 5.2 ml/kg/minute, P < 0.0005). A trend for more frequent manifestations of coronary heart disease in OA patients than in controls (27% versus 13%; P > 0.05) was also noted. Conclusion. Patients with end-stage lower extremity OA are severely deconditioned. This may place them at incremental risk for the development of coronary heart disease.     

Real-world scenarios help improve selection of radiology employees.

Choosing the right candidate through the interview process is critical, particularly in light of rapidly changing skills in various technologies. The authors have changed the interviewing process at Jeanes Hospital in Philadelphia in order to examine and evaluate multiple objectives simultaneously. To do this, they created an instrument that elicits impromptu responses to real-world radiology situations. Such responses help assess a potential candidate's training, emotional strength, technical experience and growth potential. They also determine how much additional training the potential candidate will need to be effective in the department. Using the instrument helps sharpen the assessment of candidate traits such as face-to-face communication skills and response time. The impact on hiring is positive. Quality staff, improved patient care and improved patient safety are only some of the results. Many of the questions included on the instrument come from past problem situations and help the interviewers to determine whether a candidate understands underlying issues and the seriousness of situations. The goal is to ensure that patient care and productivity are not hampered by unusual situations. When a concrete difference is detected between a candidate's response and the department's needs, it is possible to assess the cost-effectiveness of training for the discrepancy. For entry-level candidates, the question is whether the person is trainable. Consistently using this interview document forces hiring managers to identify specific abilities, traits and experience desirable in the workplace.