Identifying Opportunities to Improve Pain Among Patients With Serious Illness

Context

Pain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams.

The effect of maternal caffeine ingestion on pancreatic function in the neonatal rat

Summary Pancreatic function was investigated in neonatal suckling offspring of caffeine-ingesting dams, with or without maternal sucrose supplementation, throughout pregnancy and lactation. In offspring of rats ingesting caffeine without sucrose supplementation, there was initial hyperinsulinaemia, followed by a progressive fall of plasma insulin to subnormal levels. This fall in plasma insulin coincided with depletion of pancreatic insulin stores. Both the fall in plasma insulin and depletion of pancreatic insulin stores were prevented by sucrose supplementation of caffeine-ingesting dams. Offspring of dams fed sucrose alone and control offspring also maintained pancreatic insulin stores and circulating insulin levels over the first 14 days of postnatal life. Pancreases from offspring of caffeine-exposed animals tested in vitro showed enhanced sensitivity of the insulin release process to glucose. This was reflected in the glucose concentration required to elicit half-maximal insulin release (2.4 ± 0.2 mmol/l for caffeine offspring, 2.3 ± 0.2 mmol/l for caffeine with sucrose, 3.8 ± 0.3 mmol/l for sucrose and 4.1 ± 0.3 mmol/l for control offspring, mean ± SEM). In contrast, offspring of sucrose-supplemented (with or without caffeine) dams showed increased sensitivity of the proinsulin biosynthetic process to glucose, whereas offspring of dams ingesting caffeine alone showed no significant enhancement of the biosynthetic process compared with control offspring. Thus enhanced sensitivity of the insulin secretory process to glucose without a change in the sensitivity of the biosynthetic process in the offspring of the caffeine ingesting (nonsucrose supplemented) dams could explain the progressive depletion of pancreatic insulin stores and eventual hypoinsulinaemia seen in this group.     

Gonorrhoea in the asymptomatic patient: Presentation and the role of contact tracing for heterosexual men and women and for homosexual men

Summary Clinically silent gonorrhoea is the major problem in the control of the disease. Only 12 per cent of infected women reported in 1974 because of symptoms, compared with 97 per cent of infected heterosexual men and only 35 per cent of homosexual men with gonococcal proctitis alone. Homosexual men, compared with heterosexual men, had twice as many subsequent sexual contacts after infection and had a higher incidence of early syphilis. Eighty-four per cent had experienced passive anorectal intercourse. Ninety-seven per cent of men with gonococcal urethritis reported because of symptoms, but occasionally (particularly after unsuccessful treatment) urethral gonorrhoea in men may be clinically silent and even require tests of the overnight urethral secretion for diagnosis. For women, and for homosexual men who have had passive anorectal (or oral) intercourse, the indication for attendance for tests for gonorrhoea should be having run the risk, and not the presence of symptoms. Routine tests of the anorectum for gonorrhoea are essential in cases of women at risk, and for most homosexual men since over 80 per cent of these men will have had passive anorectal intercourse. Because gonococcal infections following treatment-failure are often clinically silent in both women and men, symptoms cannot be relied upon to indicate such failure. Follow-up smears and cultures are always essential.

---

Kasuistik von Patienten mit asymptomatischer Gonorrhöe und die Bedeutung der durch Personen durchgeführten Kontaktermittlung bei heterosexuellen Männern und Frauen sowie bei homosexuellen Männern

Zusammenfassung Die asymptomatische Gonorrhöe ist das Hauptproblem bei der Kontrolle dieser Krankheit. Nur 12 Prozent der erfaßten infizierten Frauen im Jahre 1974 kamen wegen Beschwerden zur Untersuchung im Gegensatz zu 97 Prozent der infizierten heterosexuellen Männer und nur 35 Prozent der homosexuellen Männer mit isolierter gonorrhoischer Proktitis. Im Vergleich mit heterosexuellen Männern hatten homosexuelle Männer zweimal so viel sexuelle Kontakte nach der Infektion und eine höhere Inzidenz einer Syphilis im Frühstadium. 84 Prozent hatten passiven anorektalen Verkehr gehabt. 97 Prozent der Männer mit gonorrhoischer Urethritis meldeten sich wegen Beschwerden, aber gelegentlich (insbesondere nach unzureichender Behandlung) kann die gonorrhoische Urethritis bei Männern klinisch stumm sein und sie kann sogar Untersuchungen der nächtlichen urethralen Sekretion zur Diagnose erfordern. Für Frauen und für homosexuelle Männer, die passiven anorektalen (oder oralen) Verkehr gehabt haben, sollte der Grund ihres Kommens nicht das Vorhandensein von Symptomen sein, sondern ein mögliches eingegangenes Infektionsrisiko. Routine-Untersuchungen der Analgegend auf Gonorrhöe sind bei Frauen nach entsprechendem Geschlechtsverkehr unbedingt erforderlich, gleichfalls bei den meisten homosexuellen Männern, weil über 80 Prozent dieser Männer wohl einen passiven anorektalen Verkehr gehabt haben werden. Da Gonokokken-Infektionen nach Behandlungsversagen bei Männern und Frauen oft asymptomatisch sind, ist das Verschwinden der Symptome keine verläßliche Indikation für eine erfolgreiche Behandlung. Ständige Überwachung in Form von Abstrichen und kulturellen Untersuchungen ist auf alle Fälle erforderlich.

---

---

This paper was presented in part on 27 September 1974 at a meeting of the British Society for Antimicrobial Chemotherapy.     

Abnormalities of serotonin metabolism and their relation to symptoms in untreated celiac disease.

BACKGROUND AND AIMS: Serotonin (5-hydroxytryptamine [5-HT]) is a key modulator of gut function that in excess causes nausea, vomiting, and diarrhea. We recently showed that patients with post-infective irritable bowel syndrome have increased postprandial release of 5-HT associated with low-grade T-cell mediated inflammation. Celiac disease is another common disease in which a T-cell enteropathy is associated with increased mucosal 5-HT levels. Our aim was to determine how this inflammatory lesion influenced 5-HT bioavailability and how changes in 5-HT related to the symptoms of nausea, vomiting, and diarrhea seen in untreated celiac patients. METHODS: Fasting plasma and platelet 5-HT and postprandial plasma 5-HT levels were measured after a high-carbohydrate meal in celiac patients (n = 18) and healthy controls (n = 18) using high-pressure liquid chromatography. Dyspepsia was assessed during the postprandial period using a questionnaire. Finally, we compared the histology and mucosal 5-HT levels in duodenal biopsy specimens from celiac patients and controls. RESULTS: Celiac patients had increased 5-HT-containing enterochromaffin cell numbers and significantly higher peak plasma 5-HT levels (P = .0002), postprandial area under the curve (P = .0006), and platelet 5-HT stores (P = .031) than controls. Peak 5-HT levels correlated significantly with postprandial dyspepsia scores (P = .005). Celiac patients had higher duodenal 5-HT levels (P = .007) than controls. CONCLUSIONS: Celiac disease is associated with increased mucosal 5-HT content and enhanced 5-HT release from the upper small bowel, which correlates with postprandial dyspepsia. Serotonin excess may mediate dyspeptic symptoms in untreated celiac disease.     

Depression or resilience? A participatory study to identify an appropriate assessment tool with Kanien’kéha (Mohawk) and Inuit in Quebec

Purpose

We present a study on selection of a psychometric scale to be clinically used among Indigenous people with depression. Our aim was to select a psychometric tool for cultural adaptation with Mohawk and Inuit in Quebec.

Methods

We selected three depression scales and three protective factor scales based on: strong validity for psychometric properties, evidence for good psychometric qualities across translations, avoidance of cognitively complex sentences, brevity, and clarity. We submitted the scales for consultation, and followed qualitative participatory methods with Mohawks of Kahnawake and Inuit from Nunavik living in an urban environment. We collected data through ten focus groups with advisory committees, and carried out a thematic analysis of the information.

Results

The advisory groups considered the measurement scales to be unsafe. The major components that hindered their acceptance were: numeric rating, self-evaluation (versus supportive interaction), and a focus on symptoms rather than supportive factors. The participants preferred the Growth and Empowerment Measure due to its empowering approach. They voiced that it is necessary to develop a culturally sensitive and safe tool which facilitates interactions between the person and the practitioner.

Conclusion

This project provides valuable information about the perspectives of local Indigenous peoples regarding mental health and factors of empowerment and resilience. The ideal tool should be flexible in terms of the content and its use as compared to the conventional psychometric strategies. A tool developed with the Indigenous perspective on wellbeing could be used in psychological and psychiatric intervention as well as in social and community services.

     

Plasma zinc and its relationship to clinical symptoms and drug treatment in rheumatoid arthritis.

Total plasma zinc levels in patients with rheumatoid arthritis on different therapeutic treatments were determined in conjunction with total serum proteins, serum albumin and globulin, and articular index of joint tenderness, erythrocyte sedimentation rate, rheumatoid factor, serum copper, and serum iron. There were significantly lower zinc levels in patients with rheumatoid arthritis on nonsteroidal anti-inflammatory drugs than in patients on levamisole and penicillamine. Zinc levels correlated positively with serum albumin, and there was an inverse correlation between zinc levels and both ESR and globulin concentration in all rheumatoid patients. However, the correlation coefficient varied in the different treatment groups. The results of this study support the hypothesis that low plasma zinc level in rheumatoid arthritis is one of the nonspecific features of inflammation.