Outcomes in acute pain trials: systematic review of what was reported?

Single-dose clinical trial methods for evaluating analgesics have been used successfully for over 50 years. The aims of this review were to examine which pain measurement scales have been used in high quality acute pain trials, to investigate other common measurements or characteristics, to confirm that different scales used by standard methods give the same estimate of analgesic effect, to investigate remedication methodologies and the potential of 'time to remedication' as a standard outcome. Published reports of randomised, double blind, placebo-controlled trials, investigating at least 20 adult patients (10 patients per treatment arm) experiencing moderate or severe pain using at least one standard pain intensity or pain relief scale were sought. Key design features, outputs and outcomes were catalogued for each report. The main outcomes reported were misleading, detailing only the mean values of data with a demonstrably skewed distribution. After 50 years, the reporting of results from acute pain trials warrants a fresh look. Possible improvements include reporting the number of patients with certain levels of pain relief, or the actual number (percentage) of patients with a certain level of pain relief at a certain time, or more useful information on remedication from trials of at least 12 h duration. Most useful would be all three. Further exploration would only be possible from analysis at the individual patient level.     

Performance points. The reform club

The improvement Partnership for Hospitals programme is the vanguard of Modernization Agency work. It is based on statistical process control to eliminate variations in performance, especially in elective service. All starred trusts will join IPH by next April.     

Clinical management. Where medicine meets management. Sink or swim

A Nottingham GP is working with local government colleagues to secure funding for well-being initiatives. Trust in one's GP has been identified as a key factor in social cohesion, and primary care can play a significant role in healing fragmented communities. Several PCTs are using the GMS contract to bring practices together and provide a wider and more integrated service.     

Modernisation. The road to perfection

The Pursuing Perfection programme, piloted in four areas, lays down joint improvement strategies for directors of social services and NHS trusts. The programme dares to think what a perfect service would be like, and how it could be achieved. It uses the 'no needless...' formulation to eliminate risk.     

Disability, identity and the "expressivist objection"

The practice of prenatal screening for disability is sometimes objected to because of the hurt and offence such practices may cause to people currently living with disabilities. This objection is commonly termed "the expressivist objection". In response to the objection it is standardly claimed that disabilities are analogous to illnesses. And just as it would be implausible to suppose reduction of the incidence of illnesses such as flu sends a negative message to ill people, so it is not plausible to suppose prevention of disability sends a negative message to disabled people. The expressivist objection hinges, however, upon a view of the relationship between disability and self identity which sees disability as part of the identity of the disabled person, in a way in which illnesses such as flu cannot be. This possibility is generally not considered in critiques of the expressivist objection. In this paper, an "identity claim" to the effect that disabilities can be identity constituting is accepted and the force of the expressivist argument is reconsidered in the light of its acceptance. It is concluded that even when such an identity claim is accepted, the expressivist objection is still not morally compelling.     

Estimation of errors in determining intrathoracic blood volume using thermal dilution in pigs with acute lung injury and haemorrhage

Background. Global end diastolic volume (GEDV) has a constantand predictable relationship to intrathoracic blood volume (ITBV).The present study assesses the difference between ITBV derivedfrom GEDV and ITBV measured directly in pigs with acute lunginjury (ALI) and mild haemorrhage. Methods. We caused ALI in 12 anaesthetized pigs by i.v. injectionof oleic acid and removed 10% of estimated blood volume. EVLW,GEDV, ITBV (COLD; Pulsion Medical Systems),