Comparison of different pain scoring systems in critically ill patients in a general ICU

Background

Pain in critically ill patients in the intensive care unit (ICU) is common. However, pain assessment in critically ill patients often is complicated because these patients are unable to communicate effectively. Therefore, we designed a study (a) to determine the inter-rater reliability of the Numerical Rating Scale (NRS) and the Behavioral Pain Scale (BPS), (b) to compare pain scores of different observers and the patient, and (c) to compare NRS, BPS, and the Visual Analog Scale (VAS) for measuring pain in patients in the ICU.

Methods

We performed a prospective observational study in 113 non-paralyzed critically ill patients. The attending nurses, two researchers, and the patient (when possible) obtained 371 independent observation series of NRS, BPS, and VAS. Data analyses were performed on the sample size of patients (n = 113).

Results

Inter-rater reliability of the NRS and BPS proved to be adequate (kappa = 0.71 and 0.67, respectively). The level of agreement within one scale point between NRS rated by the patient and NRS scored by attending nurses was 73%. However, high patient scores (NRS ≥4) were underestimated by nurses (patients 33% versus nurses 18%). In responsive patients, a high correlation between NRS and VAS was found (r_s = 0.84, P < 0.001). In ventilated patients, a moderate positive correlation was found between the NRS and the BPS (r_s = 0.55, P < 0.001). However, whereas 6% of the observations were NRS of greater than or equal to 4, BPS scores were all very low (median 3.0, range 3.0 to 5.0).

Conclusion

The different scales show a high reliability, but observer-based evaluation often underestimates the pain, particularly in the case of high NRS values (≥4) rated by the patient. Therefore, whenever this is possible, ICU patients should rate their pain. In unresponsive patients, primarily the attending nurse involved in daily care should score the patient's pain. In ventilated patients, the BPS should be used only in conjunction with the NRS nurse to measure pain levels in the absence of painful stimuli.     

Lichen planus and cicatricial conjunctivitis: disease course and response to therapy of 11 patients

Background Lichen planus is an autoimmune, inflammatory dermatosis of unknown cause that affects the skin and mucous membranes. Objective The aim of this study was to report the clinical features and response to therapy in a series of patients with ocular lichen planus. Methods A retrospective chart review was performed to identify patients with ocular lichen planus. Information about clinical presentation, treatment, and therapeutic response was extracted from the medical records. Results Eleven patients with ocular lichen planus were identified. The diagnosis was confirmed histologically for 10 patients. Nine patients were women. The average time from onset of ocular symptoms to diagnosis was 4.1 years. Eight patients had mucous membrane involvement at other sites. Disease was well controlled in eight patients. Conclusion Lichen planus should be considered in the differential diagnosis of cicatricial conjunctivitis, especially when severe lichen planus is noted at other sites.     

胶质母细胞瘤患者低钠血症与患者生存率预测并无相关性（英文）

Glioblastoma is a devastating malignancy with a dismal survival rate.Currently,there are limited prognostic markers of glioblastoma including IDH1,ATRX,MGMT,PTEN,EGFRv Ⅲ,and others.Although these biomarkers for tumor prognosis are available,a surgical biopsy must be performed for these analyses,which has morbidity involved.A non-invasive and readily available biomarker is sought after which provides clinicians prognostic information.Sodium is an electrolyte that is easily and quickly obtained through analysis of a patient's serum.Hyponatremia has been shown to have a predictive and negative prognostic indication in multiple cancer types,but the role of glioblastoma patients' serum sodium at the time of diagnosis in predicting glioblastoma patient survival has not been determined.We assessed whether hyponatremia at the time of glioblastoma diagnosis correlates to patient survival and show that in our cohort of 200 glioblastoma patients,sodium,at any level,did not significantly correlate to glioblastoma survival,unlike what is seen in multiple other cancer types.We further demonstrate that inducing hyponatremia in an orthotopic murine model of glioblastoma has no effects on tumor progression and survival.