Chronic pain-associated behaviors in the nursing home: resident versus caregiver perceptions

Pain assessment in nursing home residents poses challenges since many of these individuals are too cognitively impaired to respond to traditional self-report instruments. Assessment of pain behavior in this population offers a logical alternative. The purpose of this study was to compare perceptions of behaviors identified as being pain-related in 42 nursing home residents with chronic pain, as reported by residents themselves, their nursing home caregivers and their family caregivers. Our specific research agenda was to identify the most salient behaviors that signal pain in nursing home residents; to determine the test-retest agreement of residents' self-perceived pain behaviors; to learn of the confidence that caregivers feel regarding assessment of residents' pain behavior; and to examine the agreement between caregivers and residents about pain behaviors in particular residents. We also wanted to compare residents' and caregivers' ratings of the residents' pain intensity. Finally, we explored the beliefs of nursing home staff about the influence of dementia on pain and pain assessment. Twenty-two of 26 pain-related behaviors identified by residents showed fair to perfect test-retest agreement (kappas 0.40–1). For the vast majority of pain-related behavior items, kappas for resident–caregiver agreement were <0.30. Agreement with regard to pain intensity was similarly poor (r=−0.19–0.34). Confidence in pain rating was high for both nurse (on average, 7.2 on a scale of 0–10) and family (on average, 6.7) caregivers. Seventy-one percent of nurses felt that pain assessment is more difficult in demented individuals, but that cognitive function does not influence pain prevalence. While nursing home residents with chronic pain and their caregivers have different perceptions regarding which behaviors are pain-related, additional studies are required to determine the underpinnings of these differing perceptions and to determine the extent to which formal pain behavior observation protocols will be useful for evaluating nursing home residents with chronic pain.     

Application of a telomerase-based circulating tumor cell (CTC) assay in bladder cancer patients receiving postoperative radiation therapy: A case study

BackgroundMuscle invasive bladder carcinoma is an often lethal disease that requires aggressive treatment. Improved assays would contribute to better risk prediction and clinical management of this disease. A telomerase-based assay to detect circulating tumor cells (CTCs) may usefully fulfill this role.MethodsTwo patients (C1 and C2) were enrolled onto an IRB-approved bladder biomarker study before initiating post-operative radiation therapy (RT) for muscle invasive bladder carcinoma. Blood samples were taken at predefined intervals: before, during, and after RT and then retrospectively correlated with imaging studies and disease course.ResultsC1 began RT for positive resection margins on surgical pathology, at which time CTCs were undetectable and pelvic imaging demonstrated no evidence of disease. However, following the completion of treatment, the patient’s CTC count was found to have increased to 202 CTCs/mL, and MRI demonstrated new abdominal and pelvic masses consistent with progressive disease. C1 ultimately died of disease with distant and local failure. Conversely, C2 was found to have 632 CTCs/mL before the initiation of RT for positive surgical margins, although imaging demonstrated no visible masses. At the conclusion of RT, repeat imaging showed changes that were indeterminate for either tumor recurrence or post-radiation effects. However, the patient’s CTC count had dropped to 184 CTCs/mL. Furthermore, a second follow-up assay performed 6 months later revealed no detectable CTCs and repeat imaging showed complete resolution of worrisome imaging changes, thus excluding tumor progression.ConclusionsTo our knowledge this is the first report of a telomerase-based assay to identify CTCs in bladder cancer patients. Further studies are required to fully determine the ultimate clinical utility of this assay. However, the two patient vignettes described here illustrate how serial CTC assays may track the disease course and inform the management of bladder cancer patients undergoing adjuvant RT and potentially chemotherapy.     

Entrapped coronary angioplasty stent balloon due to nondeflation: Percutaneous retrieval by a simple technique

Complication due to hardware failure may happen even in the most straightforward interventional procedures. We report an unusual complication of nondeflation of coronary stent balloon entrapped within the coronary tree. The nondeflated balloon was retrieved percutaneously by a simple technique. © 2010 Wiley‐Liss, Inc.     

Assessing the usability of methods of public reporting of adverse drug reactions to the UK Yellow Card Scheme

Objectives The aim of this study, which was part of the first independent evaluation of patient reporting of adverse drug reactions (ADRs) to the Yellow Card Scheme, was to observe the three reporting systems (paper, internet and telephone) ‘in use’ in a simulated setting to identify aspects which facilitated or hindered reporting. Methods Forty adult participants were recruited from the general public using posters in pharmacies and a press article, and from a pool of volunteer simulated patients maintained by University of Nottingham medical and pharmacy schools. The participants, in seven groups that met at different times, were asked to ‘think aloud,’ as they were individually observed completing the reporting process for the paper and internet system, highlighting their thoughts and any issues encountered. They were asked to talk about their experience of reporting immediately after they had reported by telephone. Data from the field notes were analysed thematically and supplemented with relevant information from digital audio recordings. Conclusions Usability testing using the ‘think aloud’ approach worked well and identified areas of the Yellow Card reporting system which could be improved. Whilst the three methods of reporting available to the public are all reasonably ‘fit for purpose’, there were many suggestions identified for improving ease of completion and data quality, especially for the internet system. When systems for reporting of ADRs are designed, they should be tested by potential users before they are launched, so that potential problems are identified in advance.     

P-(3-酰氨基-4-取代苯基-2-吖丁啶酮基-1)-苯乙酸和P-(3-酰氨基-4-取代苯基-2-吖丁啶酮基-1)-苯乙酮的合成及抑制β-内酰胺酶作用

为研究吸电子基团远离环氮的单环β-内酰胺类化合物对β-内酰胺酶的抑制作用,设计与合成了21个新的p-(3-酰氨基-4-取代苯基-2-吖丁啶酮基-1)苯乙酸和p-(3-酰氨基-4-取代苯基-2-吖丁啶酮基-1)苯乙酮类化合物,经元素分析、红外光谱、核磁共振氢谱和质谱证实。生物活性测定表明,其中15个具有游离羧基的水溶性化合物对试验的腊样芽胞杆菌和绿脓杆菌产生的β-内酰胺酶有抑制作用。     

Mucosal injury from targeted anti-cancer therapy

Background With the increased use of so-called targeted anti-cancer therapies, there has been a change in toxicities that patients are experiencing. As most targeted therapies are given in conjunction with more traditional chemotherapeutic agents, toxicities of these combination therapies are also evolving. Whilst we increasingly understand the mechanisms underlying the toxicities of chemotherapy and radiotherapy, the addition of targeted treatments requires a new understanding of both toxicity and interacting mechanisms. Aims The aims of this review (which formed the basis of an invited plenary lecture at the 2006 Annual conference of the Multinational Association of Supportive Care in Cancer) were to define targeted anti-cancer therapy, to describe its known impact on the mucosa, either alone, or in combination with chemotherapy with or without radiotherapy, and finally to provide an outline for future directions in research into mucosal injury from targeted anti-cancer therapies. Methodology Two separate literature reviews were conducted. The combined reviews produced 700 papers of which approximately 70 were included in the review. Results As with mucosal injury (or mucositis) in general, the studies are hampered by a lack of mucosal injury as primary endpoint, and the variable definitions and levels of reporting. The depth to which mucosal injury was studied was also inadequate. However, it is clear that the key to understanding toxicity is to understand the mechanism of action of the drug, from which it should be possible to predict the toxicities that will occur. Conclusions With the increasing use of targeted anti-cancer therapies, mucosal injury, particularly in its manifestations of diarrhoea, and mouth ulcers, is becoming even more prominent. More publications of basic and clinical research in this area is required. Presented as an invited lecture at the MASCC/ISOO 18th International Symposium of Supportive Care in Cancer in Toronto, Canada, June 2006.     

Cardiac screening for pregnant intravenous drug abusers

We performed screening two-dimensional and M-mode echocardiograms on 23 pregnant intravenous drug abusers who had systolic murmurs that clinically appeared physiologic. Although no patient had symptoms or a history of cardiac disease, all but two of the women were evaluated as having unexpected cardiac valvular changes. The majority of morphologic valvular findings on echocardiography consisted of either a mitral valve prolapse or valvular leaflet thickening. However, two of these 21 women were identified as having a previously undiagnosed aortic or tricuspid vegetation for which they subsequently received prophylactic antibiotic therapy during labor and delivery. Notably, two additional women among the group with morphologic valvular changes ultimately developed subacute bacterial endocarditis. Atypically, the clinical illness occurred antenatally for one of the two women with a mitral valve prolapse and 18 months postpartum for another women with unexplained valvular thickening. On the basis of these observations, a more liberal use of echocardiography in the care of the pregnant intravenous drug abuser population is suggested for evaluation of otherwise seemingly innocuous systolic murmurs.