Assessment of pain.

UNLABELLED: Valid and reliable assessment of pain is essential for both clinical trials and effective pain management. The nature of pain makes objective measurement impossible. Acute pain can be reliably assessed, both at rest (important for comfort) and during movement (important for function and risk of postoperative complications), with one-dimensional tools such as numeric rating scales or visual analogue scales. Both these are more powerful in detecting changes in pain intensity than a verbal categorical rating scale. In acute pain trials, assessment of baseline pain must ensure sufficient pain intensity for the trial to detect meaningful treatment effects. Chronic pain assessment and its impact on physical, emotional, and social functions require multidimensional qualitative tools and health-related quality of life instruments. Several disease- and patient-specific functional scales are useful, such as the Western Ontario and MacMaster Universities for osteoarthritis, and several neuropathic pain screening tools. The Initiative on METHODS: Measurement, and Pain Assessment in Clinical Trials recommendations for outcome measurements of chronic pain trials are also useful for routine assessment. Cancer pain assessment is complicated by a number of other bodily and mental symptoms such as fatigue and depression, all affecting quality of life. It is noteworthy that quality of life reported by chronic pain patients can be as much affected as that of terminal cancer patients. Any assessment of pain must take into account other factors, such as cognitive impairment or dementia, and assessment tools validated in the specific patient groups being studied.

An investigation into the transverse and impact strength of "high strength" denture base acrylic resins.

A range of materials, often marketed as high strength resins is available. These materials are often expensive options to conventional heat-cured acrylic resin. The aim of this study was to investigate transverse and impact strength of five "high strength" acrylic resin denture base materials. A conventional heat-cured acrylic resin was used as a control. Specimens were prepared as specified in the International Standard Organization (ISO 1567: 1988) and British standards for the Testing of Denture Base Resins (BS 2487: 1989) and the British Standard Specification for Orthodontic resins (BS 6747: 1987) for transverse bend and impact testing. The impact strength was measured using a Zwick pendulum impact tester and the transverse bend strength measured using a Lloyds Instruments testing machine. The results showed that Metrocryl Hi, Luctitone 199 and N.D.S. Hi all had an impact strength which was significantly higher than the control. For the modulus of rupture, there was a significant difference between Sledgehammer and the other groups. There was no significant difference between the other groups and the control. For the modulus of elasticity, Sledgehammer produced the highest value followed by the control. The remaining four materials had a modulus of elasticity less than the control.

Receiving help at home: the interplay of human and technological assistance.

OBJECTIVES: This research investigated use of mobility equipment as a substitute for human assistance and also examined whether use of mobility equipment results in out-of-pocket cost savings associated with formal home care services. METHODS: The authors analyzed data collected from 9,230 respondents to the Adult Followback Survey of the Disability Supplement to the 1994 and 1995 National Health Interview Survey (NHIS-D) who reported both mobility and limitations in daily living activities to test study hypotheses, using regression analyses to control for selection effects in mobility equipment use. RESULTS: Use of canes and crutches (but not walkers and wheelchairs) reduced both formal and informal hours of care received per week by sample members; there was also evidence of substitution on the individual activities of daily living task level. Use of canes and crutches was also associated with lower out-of-pocket costs for formal helping services. DISCUSSION: Findings suggest that canes and crutches are effective and efficient home care resources that have the potential to increase the autonomy of adults with disabilities and to facilitate chronic condition self-management.

Targeting risk for unmet need: not enough help versus no help at all.

OBJECTIVES: This study examined factors associated with unmet need for care among persons aged 18 and older who need help with daily living tasks. The analysis focused on two types of unmet need: not enough (or inadequate) help and no help at all. METHODS: The authors used multinomial logistic regression to examine differences between persons with long-term care needs who (a) had all their needs met; (b) received inadequate help; and (c) received no help at all. Data were from the Adult Followback to the National Health Interview Survey on Disability (NHIS-D) for 1994 and 1995. RESULTS: The determinants of inadequate care versus no care differed with respect to age, gender, level of impairment, and insurance status. Whereas age and gender were important in determining inadequate care, insurance coverage and availability of social support were key factors related to a situation of no care. DISCUSSION: The present study demonstrates that the characteristics of groups reporting inadequate care versus no care, and the factors associated with these situations, are quite different. Nevertheless, the most important demographic risk factors for both types of unmet need mirror demographic groups currently on the increase in the U.S. population.

A new Ti-5Ag alloy for customized prostheses by three-dimensional printing (3DP).

Three important considerations in the fabrication of customized cranio-maxillofacial prostheses are geometric precision, material strength, and biocompatibility. Three-dimensional printing (3DP) is a rapid part-fabrication process that can produce complex parts with high precision. The aim of this study was to design, synthesize by 3DP, and characterize a new Ti-5Ag (wt%) alloy. Silver nitrate was found to be an appropriate inorganic binder for the Ti powder-based skeleton, and the optimum sintering parameters for full densification were determined. The hardness of the Ti-5Ag alloy was shown to be much higher than that of a pure titanium sample. Potentiodynamic measurements, carried out in saline solution at body temperature, showed that the Ti-5Ag alloy had good passivation behavior, similar to that of pure titanium. It is concluded that the Ti-Ag system may be suitable for fabrication of customized prostheses by 3DP.

Canes, crutches and home care services: the interplay of human and technological assistance.

This brief reports the results of a study investigating the efficacy of canes, crutches, walkers, and wheelchairs for people who need assistance with everyday activities and asks the question, does low assistive technology replace human help for people with disabilities? Study results show that canes and crutches are low cost, versatile aids that can partially substitute for human assistance by reducing the overall number of hours of care required. They can also reduce out-of-pocket expenses for supportive services. Walkers and wheelchairs, on the other hand, appear to supplement, rather than substitute for, human assistance. The brief concludes by recommending that greater use of canes and crutches be actively encouraged to increase the independence of people who need help with daily activities.

Stage of life course and social support as a mediator of mood state among persons with disability.

OBJECTIVE: This research seeks to determine which aspects of social support are most effective in mediating mood state among working-age and elderly adults with disability (N = 442). METHODS: Participants were identified through random-digit dialing of telephone exchanges and administration of a disability screen. Multiple regression was used to model multiple aspects of social support while holding sociodemographic and disability indicators constant. RESULTS: Analyses revealed that network size and confidence in the reliability of helping networks are significantly and negatively related to depressed mood. Confidant support was related to lower levels of depressed mood for younger respondents only. Neither marital status, advisor support, nor social integration were related to mood. DISCUSSION: Both instrumental and emotional support are key in mediating depressed mood among this population. We conclude that all types of social support are not equally effective in mediating mood among people with disability.

Prognostic value of exercise echocardiography in women in the community setting.

Treadmill stress echocardiography was performed in 1,136 women with known or suspected coronary artery disease whose clinical course was then evaluated a mean of 33 months later (range 12 to 60). The strongest predictor of an adverse outcome was the presence of a resting or an exercise-induced wall motion abnormality.

Gender roles, marital intimacy, and nomination of spouse as primary caregiver.

Using data from a sample of married men and women undergoing treatment for cancer, we tested two potential hypotheses for the unequal representation of husbands and wives as spousal caregivers, including societal gender role norms and emotional closeness in the marital relationship. Multivariate analyses support both hypotheses; wives are only one third as likely as husbands to select their spouses as caregivers, and spouses who name their mates as confidants are three times more likely than those who do not to also name them as caregivers. We conclude that although gender role norms are key to caregiver selection, the intimacy inherent in the caregiving role renders an emotionally close marriage an important criterion to the selection of spouse as caregiver.

Fine needle cytology of palpable head and neck lesions: a comparison of sampling methods with and without suction.

Patients attending the ear, nose and throat (ENT) department at St James's University Hospital, Leeds, UK, for evaluation of palpable head and neck lesions have a fine needle cytology (FNC) specimen taken and receive the result at the same out-patient visit. This study was designed to discover if there is a significant difference in the efficiency of the methods with and without suction. The method was chosen randomly on each occasion and the adequacy or otherwise of the specimen was determined taking into account the site and nature of the lesion and the total cellularity of the sample. The level of blood contamination was also compared by each method. When benign and malignant lesions from all sites were analysed together the method with suction produced a significantly higher number of adequate samples than the method without suction. The exception was in the case of samples from lymph node lesions measuring < 1 cm, where adequate specimens were only obtained without suction. The non-suction technique was particularly poor at sampling salivary gland lesions in the 1-1.5 cm category. There was no significant difference in the level of blood contamination between the two methods at any site. These results are at variance with most other similar studies and possible reasons for this are discussed.

Relationship of dopamine to serotonin in the neonatal 6-OHDA rat model of Lesch-Nyhan syndrome.

Rats were treated as neonates with either 6-hydroxydopamine (6-OHDA) 100 micrograms or vehicle intracisternally. Upon maturation, animals receiving 6-OHDA were assigned to four groups, with two of the four groups receiving intraventricular 5,7-dihydroxytryptamine (5,7-DHT) 75 micrograms bilaterally. At 94 days of age, animals were injected with either SKF-38393 (3.0 mg/kg, intraperitoneally (i.p.)), a dopamine D1 agonist, or m-chlorophenylpiperazine (m-CPP) (3.0 mg/kg, i.p.), a 5-HT2C agonist, in an attempt to evoke behaviors such as stereotypical chewing, head-nodding, self-biting and self-mutilation. Both SKF-38393 and m-CPP induced the target behaviors in animals receiving 6-OHDA alone. Animals receiving additional 5,7-DHT treatment did not show any of the target behaviors in response to SKF-38393, but exhibited a much higher sensitivity to m-CPP. Pre-treatment with SCH-23390 in animals receiving 6-OHDA alone was effective in preventing SKF-38393-induced target behaviors, but not those induced by m-CPP. Pre-treatment with mianserin partially antagonized the effects of both SKF-38393 and m-CPP in these same animals. In groups receiving both neonatal 6-OHDA and adult 5,7-DHT, mianserin was effective in reducing m-CPP-induced behaviors, while SCH-23390 was largely ineffective. These data provide evidence of a serial relationship between the D1 and 5-HT2C receptor systems in the neostriatum of animals receiving neonatal 6-OHDA lesions.

Should coronary artery bypass grafting be performed at the same time as repair of a post-infarct ventricular septal defect?

OBJECTIVE: The value of coronary artery bypass grafting (CABG) at the time of repair of a post-infarct ventricular septal defect (VSD) remains controversial. The aim of this study was to analyse the effect of CABG on early mortality and survival following repair of an acquired VSD. METHODS: Over 23 years, 179 patients, 118 male, 61 female, mean age 66 years (range 43-80), have undergone repair of a post-related VSD in our unit. A total of 29 patients, who predominantly form the earlier part of the series, were operated on greater than 1 month after the infarct and are, therefore, excluded. Coronary angiography was performed in 98 (65.3%) of the remaining 150 patients. Of these, 41 had coronary artery disease (CAD) limited to the infarct-related vessel and 57 had additional significant CAD. Those with CAD limited to the infarct-related vessel were not grafted (Group A). Of those, 40 with significant CAD underwent CABG at the time of VSD repair (Group B) and 17 did not (Group C). In 52 patients the coronary anatomy was not documented (Group D). Risk factors for early mortality were evaluated using logistic regression. Actuarial survival was compared using log rank and Wilcoxon tests. Cox's proportional hazards method was used to determine factors affecting survival. RESULTS: Overall, 30 day mortality was 32%. CABG did not significantly decrease operative mortality (logistic regression). There was no statistically significant difference in early mortality or actuarial survival between the four groups. CABG was not associated with an increased survival (Cox's method). CONCLUSIONS: Concomitant CABG at the time of VSD repair does not affect early mortality nor confer survival benefits. There seems to be no demonstrable benefit in revascularisation at the time of repair and, therefore, it may be unnecessary to perform CABG or coronary angiography in these patients.

Evaluation of risperidone in the neonatal 6-hydroxydopamine model of Lesch-Nyhan syndrome.

Rats were treated as neonates with 6-hydroxydopamine (6-OHDA) 100 mg free base in 10 microl intracisternally. Upon maturation, animals were injected with L-dopa and placed in photocell cages for monitoring of locomotion, stereotypies, and self-mutilation. Pretreatment with either risperidone or SCH-23390 significantly reduced locomotion and stereotypies. SCH-23390 eliminated L-dopa induced self-mutilation in all subjects, while risperidone eliminated self-mutilation in all but one subject.

The prevalence and consequences of unmet need. Contrasts between older and younger adults with disability.

OBJECTIVES: This article investigates the prevalence, determinants, and consequences of unmet need for assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and transportation in a randomly selected sample of adults with disability residing in Springfield, Massachusetts. METHODS: Respondents were contacted through random digit dialing, and eligibility was determined through a disability screen. Eligible individuals were stratified by age; 632 people were interviewed (78% of contacted eligibles). The prevalence of need and unmet need for ADLs, IADLs, and transportation assistance was calculated separately by age strata, as was the prevalence of selected negative consequences attributed to inadequate help with specific activities. The determinants of unmet need were modeled using logistic regression. RESULTS: The prevalence of unmet need for assistance with individual ADLs ranged from 4.1% (eating) to 22.6% (transferring) of the full sample. Unmet need for IADLs assistance was higher, ranging from 15.9% (cooking) to 34.6% (heavy housekeeping). Respondents younger than age 65 reported higher levels of unmet need for IADLs and transportation help than respondents age 65 or older; members of the younger group also were more likely to report five of the seven negative consequences attributed to inadequate help with IADLs and transportation (eg, missing medical appointments). Regression results revealed inability to meet expenses, having few or no reliable helpers, and impairment severity to be key determinants of unmet need. CONCLUSIONS: Financial problems, and not age per se, placed working age adults at elevated risk of unmet need in this study. The consequences of inadequate help can impede management of chronic health conditions, and may compromise individuals' ability to maintain a safe and reasonable quality of community living.

The treatment decision-making process: age differences in a sample of women recently diagnosed with nonrecurrent, early-stage breast cancer.

This research utilizes retrospective, self-report data collected from a nonprobability sample of women recently diagnosed with nonrecurrent, early-stage breast cancer to better understand how the treatment decision-making process varies with patient age. Three important areas--context, decision-making style, and influencing factors--are examined using bivariate and multivariate analyses. Findings indicate that although patients recalled similar contextual attributes, they reported attitudes, behavior, and considerations that differed by age. Older women were less likely than their younger counterparts to have desired participation in therapy selection, sought out medical information, or considered the possibility of recurrence when making treatment decisions.

Risperidone antagonism of self-mutilation in a Lesch-Nyhan patient.

1. The case is described of a 28-year old male with a diagnosis of Lesch-Nyhan syndrome. 2. Chronic treatment with the atypical neuroleptic risperidone at 4 mg daily has maintained a significant reduction in occurrence of self-mutilation.

Cervical intraepithelial neoplasia: false negative smears.

In the early days of cervical cytology there was a general assumption that mistakes would be a rare occurrence. These expectations were unrealistic given the fatiguing nature of the work and its dependence on human judgement. Media attention and the introduction of quality control have highlighted inadequacies in the service. The reasons for both sampling and screening errors which give rise to the issuing of false negative smear results need to be understood before measures can be taken to minimise them. An acceptable error rate should be recognised and, if possible, improved upon. Further investigations into the role of human papilloma virus (HPV) in the development of cervical cancer, and evaluation of automated screening, should lead to improvements in the cervical screening programme.