Navigating the health care system: perceptions of patients with chronic pain.

A new framework is needed for patients with chronic pain and their primary care physicians that acknowledges the individual's experiences and provides evidence-informed education and better linkages to community-based resources. This study describes the experience of 19 chronic-pain sufferers who seek relief via the health care system. Their experiences were recorded through in-depth semistructured interviews and analyzed through qualitative methods. The participants reported early optimism, then disillusionment, and finally acceptance of living with chronic pain. Both individuals with chronic pain and their health care professionals need evidence-informed resources and information on best practices to assist them to manage pain. Empathetic communication between health care professionals and individuals with chronic pain is crucial because insensitive communication negatively affects the individual, reduces treatment compliance and increases health care utilization.

A new instrument for assessing quality of life in atopic dermatitis: international development of the Quality of Life Index for Atopic Dermatitis (QoLIAD).

BACKGROUND: Atopic dermatitis (AD) is a chronic or chronically relapsing inflammatory skin condition that can have a considerable impact on those affected. There are a number of instruments available to measure outcome in dermatological conditions but none have been developed specifically for AD. In addition, most measure symptoms and/or daily functioning, which are potential influences on quality of life (QoL) rather than assessments of the construct itself. OBJECTIVES: The aim of the current study was to develop a new instrument specifically designed to measure QoL in adults with AD-the Quality of Life Index for Atopic Dermatitis (QoLIAD). METHODS: The instrument was developed based on the needs-based model of QoL and was produced in several different countries simultaneously. Its content was derived from 65 in-depth interviews with relevant patients in the U.K., Italy and the Netherlands. The initial version of the measure was produced in U.K. English and translations were produced for the Netherlands, Italy, Germany, France and the U.S.A. using a dual translation panel methodology. A Spanish version was developed using the same adaptation process after the instrument was finalized. Field-test interviews were conducted with approximately 20 patients in each country to assess face and content validity. The instrument [in addition to the Dermatology Life Quality Index (DLQI) and the Psychological General Well-Being Schedule (PGWB)] was then administered to up to 300 AD patients in each country at two time points to finalize the instrument and test its psychometric properties. RESULTS: The initial version of the QoLIAD had 56 items that reflected the areas of need fulfillment identified in the qualitative interviews as having been affected by AD: mental and emotional stimulation, physical and emotional stability, security, sharing and belonging, self-esteem, personal development and fulfillment. Comments from patients in field-test interviews resulted in the removal of 14 items, to leave a 42-item instrument that was considered relevant and acceptable. The number of patients participating in the survey were 286 in the U.K., 46 in the Netherlands, 213 in France, 187 in Germany, 178 in the U.S.A. and 83 in Spain. Application of the Rasch model to these data identified the final 25-item QoLIAD. Unidimensionality was confirmed, with deviation of the total scale from the Rasch model evident at a single time point in one country only (the U.K.). All language versions, with the exception of the Dutch measure, had test-retest reliability coefficients in excess of 0.85. The test-retest in the Netherlands was 0.80. However, this country had the smallest sample size and the corresponding reliability for the DLQI was only 0.40. The QoLIAD had adequate internal consistency and the initial indications of construct validity were good. The levels of association with the DLQI indicated that the two instruments measure related but distinct constructs. CONCLUSIONS: The QoLIAD is a practical, reliable, valid and culturally applicable instrument for measuring the impact of AD and its treatment on QoL in clinical trials or in routine clinical practice.

Imatinib inhibits the in vitro development of the monocyte/macrophage lineage from normal human bone marrow progenitors.

The antileukaemic tyrosine kinase inhibitor, imatinib, has been reported to inhibit specifically the growth of bcr-abl expressing CML progenitors at levels of 0.1-5.0 microM, by blocking the ATP-binding site of the kinase domain of bcr-abl. Inhibition of the c-abl, platelet-derived growth factor receptor and stem cell factor receptor (c-kit) tyrosine kinases by imatinib has also been reported. Here, we demonstrate that imatinib significantly inhibits in vitro monocyte/macrophage development from normal bone marrow progenitors, while neutrophil and eosinophil development was less affected. Monocyte/macrophage inhibition was observed in semisolid agar and liquid cultures at concentrations of imatinib as low as 0.3 microM. The maturation of monocytes into macrophages was also found to be impaired following treatment of cultures with 1.0 microM imatinib. Imatinib blocked monocyte/macrophage development in cultures stimulated with and without M-CSF, suggesting that inhibition of the M-CSF receptor, c-fms, by imatinib was unlikely to be responsible. Imatinib may therefore have an inhibitory activity for other kinase(s) that play a role in monocyte/macrophage differentiation. This inhibition of normal monocyte/macrophage development was observed at concentrations of imatinib achievable pharmacologically, suggesting that imatinib or closely related derivatives may have potential for the treatment of diseases where monocytes/macrophages contribute to pathogenesis.

Acquisition of immune function during the development of the Langerhans cell network in neonatal mice.

The immunological function of the Langerhans cell (LC) network in neonatal skin was examined by defining the development of cutaneous immunity relative to the structure, phenotype and function of the epidermal LC network in neonatal, juvenile and adult mice. Analysis of epidermal sheets showed the presence of major histocompatibility complex (MHC) II+, multilectin receptor DEC-205- cells within the epidermis of 3-day-old mice; both cell density and DEC-205 expression increased until day 14. When visualized with antibodies directed at MHC II, the network was poorly formed in 3- and 7-day-old mice, as there was a lower cell density and poor MHC II expression on dendritic processes, compared to mice at day14. Application of a fluorescent antigen to 3-day-old mice revealed that the LC were inefficient in transporting antigen to the draining lymph node. There was an improvement at day 7 and by day 14 comparable numbers of antigen carrying cells were detected in the lymph nodes of 6-week-old mice. The reduced antigen carriage in 3- and 7-day-old mice correlated with a poor contact sensitivity response. This was not simply due to failure to present antigen, but development of immunosuppression, as transfer of T cells from adult mice that were previously treated with antigen when they were 3 days old, to adult recipients resulted in antigen specific immunosuppression. Analysis of CD80 and CD86 expression showed that LC from day 3 skin expressed CD80, but not CD86 and application of antigen through this skin was inefficient in upregulating CD86. These findings indicate that when the neonatal LC network is poorly developed it is functionally immature and antigen applied through this 'functionally immature network' results in antigen specific immunosuppression.

Prevention of autoimmunity by induction of cutaneous tolerance.

Autoimmune gastritis develops in 20-60% of BALB/c mice following thymectomy at 3 days after birth (3dnTx). Previously we identified the gastric H+/K+ ATPase as the causative autoantigen and mapped the immunoreactive T cell epitope to a carboxyl-terminal peptide on the gastric H+/K+ ATPase beta subunit. Here we show that autoimmune gastritis can be suppressed by immunizing 3dnTx mice through neonatal skin with the beta subunit peptide, in combination with the contact sensitizer TNCB. When spleen cells were transferred from suppressed mice to nude mice a proportion of recipient mice developed gastritis. These results indicate that pathogenic T cells were still present in the 3dnTx mice but the absence of gastritis indicates that their activity can be regulated following induction of cutaneous tolerance by immunizing through neonatal skin. We propose that cutaneous tolerance is induced through mediation of immature Langerhans cells in neonatal skin and that this tolerance prevented the autoreactivity of pathogenic T cells. This procedure will have implications for strategies to suppress autoimmunity.

Challenges to communication: supporting the patients with SCI with their diagnosis and prognosis.

This article discusses some of the common dilemmas that nurses experience when communicating with patients who have recently sustained a spinal cord injury. Drawing on the literature, this article highlights that the nurse's role in giving bad news is unique. Nurses are often in the position of clarifying information as patients become aware of their limitations. This awareness prompts the need for support for both patients and their families. Nurses must interact with patients during their adjustment to their losses, and this requires good communication skills. The experiences of other health professionals, particularly physicians, are helpful in providing guidance for nurses who reinforce information regarding the patient's diagnosis/prognosis. They must continue to interact with patients during their adjustment to their losses, and this requires good communication skills. This article offers insight into problems as well as strategies to assist nurses in developing their communication skills.

Bearing illness and injury.

This qualitative study examined how individuals with catastrophic illness and injury managed their personal and social world. The 28 males and females had endured their chronic conditions from 3 to 25 years prior to the study. Participants were individually interviewed. Responses were analyzed using grounded theory methods. Individuals with catastrophic illness and injury experienced three phases in bearing their situation: finding out, facing reality, and managing reality. Individuals did not progress through stages as has been argued by stage theorists. Rather, the phases flowed together and were reexperienced continuously. Individuals employed three strategies--protecting, modifying, and boosting--in all of the phases to help them endure their circumstances.

A randomised controlled trial to assess the relative benefits of large volume spacers and nebulisers to treat acute asthma in hospital.

OBJECTIVES: To compare the clinical effectiveness, acceptability, and cost benefit of administering beta2 agonists by means of a metered dose inhaler and large volume spacer with conventional nebulisers to children admitted to hospital with acute asthma. METHODS: A randomised controlled trial was conducted over five months. Sixty one children older than 3 years admitted to a large teaching hospital and a district general hospital with acute asthma completed the study. Children received either 5 mg of salbutamol up to one hourly by jet nebuliser, or up to 10 puffs of salbutamol 100 microg by means of a metered dose inhaler and spacer up to one hourly. RESULTS: Median hospital stay was 40 hours in the nebuliser group and 36.5 hours in the spacer group. Asthma disability scores at two weeks after discharge were significantly improved in the spacer group. Drug costs were pound 14.62 less for each patient in the spacer group. CONCLUSIONS: Large volume spacers are an acceptable, cost effective alternative to nebulisers in treating children admitted with acute asthma, provided that the children can use the mouthpiece, and symptoms are not severe. Their use facilitates effective home treatment by parents, with subsequent reduction in morbidity and re-admission rates.

Inflammatory pseudotumor of the trachea in a ten-month-old infant.

Inflammatory pseudotumors occur through a non-neoplastic process that involves abnormal proliferation of spindle cells (myoblasts and fibroblasts) with an inflammatory cell infiltrate. Clinically, radiographically, and grossly these lesions mimic malignant neoplasms but are readily distinguished histologically. We report an infant who presented with an inflammatory pseudotumor of his trachea that caused severe stridor.

Dietary fibre and the occurrence of gut symptoms in cystic fibrosis.

OBJECTIVE: To evaluate the effect of currently recommended energy rich cystic fibrosis diets on fibre intake and to investigate the relationship between fibre intake and the occurrence of gut symptoms. METHOD: Prospective completion of non-weighed five day food diaries by 28 children with cystic fibrosis and comparison of mean daily fibre intake with age matched controls who did not have cystic fibrosis. Prospective completion of similar diaries to a total of 68 children with cystic fibrosis and comparison of fibre and lipase intake with the occurrence of gut symptoms. RESULTS: Mean daily fibre intake in children with cystic fibrosis was 7.00 g compared with 14.65 g in controls (p < 0.001). Mean daily fibre intake in eight patients troubled with moderate or severe abdominal pain was 0.144 g/kg. This was significantly lower (p < 0.01) than mean values for 22 patients with occasional but mild symptoms (0.249 g/kg) and 38 with no gut symptoms (0.312 g/kg). There was a trend towards higher pancreatic enzyme doses (lipase/kg/day) in children with abdominal pain. CONCLUSIONS: Currently recommended cystic fibrosis diets have a low fibre content. A low residue diet might be an important factor in the pathogenesis of gastrointestinal symptoms.

Unbearable incidents: failure to endure the experience of illness.

Inherent in the illness experience are multiple assaults on one's self and one's body. These assaults may be interpersonal (such as an unwitting remark made from another), or intrapersonal (such as unrelenting symptoms that are a part of illness, injury or treatments). These assaults may accumulate until the situation becomes unbearable, the person can no longer 'take it', and the person loses control. In this paper, the authors examine the circumstances that resulted in the breakdown of endurance, and noted that while some of the factors remained unbearable, others are managed. The authors suggest that the patient's response, that is 'loosing it', may be beneficial. 'Losing it' is a means of ensuring changes in care for a patient, or aids in the relinquishment of unrealistic expectations of one's self and one's future. In all instances, however, the patient's plan of care should be carefully examined and, if necessary, modified.