Which factors can aid clinicians to identify a risk of pain during the following month in patients with bone metastases? A longitudinal analyses.

PURPOSE: Explore clinical factors associated with higher pain intensity and future pain in patients with bone metastases to identify patients who can benefit from closer follow-up or pain-modifying interventions. METHODS: This is a secondary analysis of 606 patients with bone metastases included in a multicenter longitudinal study. The dependent variables were "average pain" and "worst pain" in the last 24 h (0-10 NRS). Twenty independent variables with potential association to pain intensity were selected based on previous literature. Cross-sectional analyses were performed with multiple linear regression to explore factors associated with pain intensity at baseline. Longitudinal data were analyzed with a generalized equation models to explore current factors associated with pain intensity at the next visit in 1 month. RESULTS: Current pain intensity (p < 0.001), sleep disturbances (p 0.01 and 0.006), drowsiness (p 0.003 and 0.033) and male gender (p 0.045 and 0.001) were associated with higher average and worst pain intensity in 1 month. In addition, breakthrough pain was related to higher worst pain intensity (p 0.003) in 1 month. The same variables were also associated with higher average pain intensity at baseline. CONCLUSION: Higher current pain intensity, sleep disturbances, drowsiness, male gender, and breakthrough pain are factors associated with higher pain intensity in patients with bone metastases at the next follow-up in 1 month. These factors should be assessed in clinical practice and may aid clinicians in identifying patients that can benefit from closer follow-up or interventions to prevent lack of future pain control. TRIAL REGISTRATION IN CLINICALTRIALS.GOV : NCT01362816.

The barriers and facilitators for recognising distress in people with severe dementia on general hospital wards.

Introduction: psychological symptoms and delirium are common, but underreported in people with dementia on hospital wards. Unrecognised and untreated symptoms can manifest as distress. Identifying distress accurately therefore could act as a trigger for better investigation and treatment of the underlying causes. The challenges faced by healthcare professionals to recognise and report distress are poorly understood. Methods: semi-structured interviews with a purposive sample of 25 healthcare professionals working with older people in general hospitals were conducted. Interviews were analysed generating themes that describe the facilitators and barriers of recognising and caring for distress in dementia. Results: regardless of training or experience all participants had a similar understanding of distress, and identified it as a term that is easily understood and communicated. All participants believed they recognised distress innately. However, the majority also believed it was facilitated by experience, being familiar with their patients and listening to the concerns of the person's usual carers. Barriers to distress recognition included busy ward environments, and that some people may lack the skill to identify distress in hypoactive patients. Conclusion: distress may be a simple and easily identified marker of unmet need in people with dementia in hospital. However, modifiable and unmodifiable barriers are suggested that reduce the chance of distress being identified or acted on. Improving our understanding of how distress is identified in this environment, and in turn developing systems that overcome these barriers, may improve the accuracy with which distress is identified on hospital wards.

Neuropathic pain in cancer: systematic review, performance of screening tools and analysis of symptom profiles.

BACKGROUND: The objectives of this study were to evaluate the methodological quality of rigorous neuropathic pain assessment tools in applicable clinical studies, and determine the performance of screening tools for identifying neuropathic pain in patients with cancer. METHODS: Systematic literature search identified studies reporting use of Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Douleur Neuropathique en 4 (DN4) or painDETECT (PDQ) in cancer patients with a clinical diagnosis of neuropathic or not neuropathic pain. Individual patient data were requested to examine descriptor item profiles. RESULTS: Six studies recruited a total of 2301 cancer patients of which 1564 (68%) reported pain. Overall accuracy of screening tools ranged from 73 to 94%. There was variation in description and rigour of clinical assessment, particularly related to the rigour of clinical judgement of pain as the reference standard. Individual data from 1351 patients showed large variation in the selection of neuropathic pain descriptor items by cancer patients with neuropathic pain. LANSS and DN4 items characterized a significantly different neuropathic pain symptom profile from non-neuropathic pain in both tumour- and treatment-related cancer pain aetiologies. CONCLUSIONS: We identified concordance between the clinician diagnosis and screening tool outcomes for LANSS, DN4 and PDQ in patients with cancer pain. Shortcomings in relation to standardized clinician assessment are likely to account for variation in screening tool sensitivity, which should include the use of the neuropathic pain grading system. Further research is needed to standardize and improve clinical assessment in patients with cancer pain. Until the standardization of clinical diagnosis for neuropathic cancer pain has been validated, screening tools offer a practical approach to identify potential cases of neuropathic cancer pain.

Diagnosing postoperative neuropathic pain: a Delphi survey.

BACKGROUND: Although postoperative pain is traditionally considered to be nociceptive in origin, a proportion of patients experience a significant neuropathic component to their pain experience. Diagnosing neuropathic pain in this setting is challenging, and there are no published guidelines or screening tools designed for use in the immediate postoperative setting. We hypothesized that acute pain specialists were diagnosing a neuropathic component to acute pain, and this study aimed to obtain an expert agreed list of pain characteristics that could be used to aid diagnosis. METHODS: A three-round Internet-based Delphi survey of acute pain specialists was used to generate a list of acute neuropathic pain characteristics, and achieve consensus on the importance of each item. Items were ranked on a 1-10 scale of importance, with a median score of ≥ 7 considered important and an inter-quartile range of ≤ 3 indicative of consensus. Cronbach's α was used to investigate internal consistency. RESULTS: Twenty-four items were generated by round 1 of the Delphi survey. Fourteen panellists participated in round 2, and 10 in round 3. After round 3, consensus of opinion was achieved for 13 items, with nine rated as important in the diagnosis of acute neuropathic pain. CONCLUSIONS: The Delphi survey suggests that neuropathic pain in the immediate postoperative period is diagnosed in a different way to chronic neuropathic pain, with items such as response to medications considered more useful than signs such as those representing autonomic changes.

Vanadate induction of pancreatic amylase mRNA in diabetic rats.

Amylase activity and mRNA abundance are reduced to less than 1% of normal levels in diabetic rat pancreas. Administration of vanadate in drinking water restored normal amylase activity and amylase mRNA levels. These results demonstrate an effect of vanadate on pancreatic acinar cells and suggest that vanadate can mimic the effect of insulin on transcription of the pancreatic amylase gene.

The uses of hopelessness.

If most emotional problems, like most medical problems, are caused by bad luck as well as by factors over which man has control, then those who suffer from such problems must accept a burden of helplessness. When patients and their families overuse theories of causality to avoid accepting their helplessness and to create an illusory sense of human control, unjust assignment of responsibility and excessive expectations for change may erode self-esteem and make change more difficult. The authors present examples of interventions that challenge the overuse of theories of causality. Although these interventions aroused hopelessness, they also fostered realistic hope and change.

The value of hospital-based treatment for the homeless mentally ill.

The access of the homeless mentally ill to the benefits of psychiatric hospitalization has been excessively limited by deinstitutionalization, the devaluation of the benefits of inpatient evaluation and treatment, a shortage of public-sector psychiatric beds, and a tendency to regard the homeless mentally ill as untreatable. A pilot program was devised to increase the access of the homeless mentally ill to short-term hospital-based treatment within a public mental health system in which beds are in short supply. The program's usefulness demonstrates the value of hospital-based treatment for this population and suggests that hospital-based treatment is currently underutilized.

Paranoid psychosis due to flecainide toxicity in malignant neuropathic pain.

Flecainide was used to treat malignant neuropathic pain but despite using therapeutic doses, toxicity occurred resulting in paranoid psychosis. Monitoring of flecainide levels in vulnerable populations is suggested to guide prescribing.

Staphylococcal meningitis following Synchromed intrathecal pump implant: a case report.

Staphylococcal meningitis associated with implantation of an intrathecal drug pump for spasticity was successfully treated by intrathecal vancomycin delivered by the same pump. This produced high CSF antibiotic levels, and the pump and catheter system did not have to be removed. We are unable to identify a similar case reported in the literature to date.

Death rattle: an audit of hyoscine (scopolamine) use and review of management.

This study investigated the pattern and determinants of hyoscine (scopolamine) use for death rattle by a retrospective analysis of 100 consecutive deaths in a 22-bed hospice. Patient diagnoses, duration of stay, and doses and route of administration of hyoscine used in the final 48 hr before death were recorded. One-half of the patients received hyoscine in some form during the final 24 hr before death. Patients who were in the hospice for longer than 9 days and those with cerebral malignancy were given the highest doses of hyoscine in the final 24 hr (z = -2.558, P = 0.011, and z = -1.968, P = 0.048, respectively). Response to hyoscine appears to be variable, and a distinction is proposed between death while due to salivary secretions (type 1) and that due to bronchial secretions (type 2) to explain the observed patterns of use. It is likely that hyoscine is more efficacious in treating type 1 death rattle than it is in treating type 2 death rattle.

Personal computer teleradiology interhospital image transmission of neonatal radiographs to facilitate tertiary neonatology telephone consultation and patient transfer.

OBJECTIVE: Our purpose was to study the ability of personal computer teleradiology (PCT) to improve the quality of communication between physicians during newborn infant transfers and consultations. STUDY DESIGN: In the first part of the study 36 radiographs of neonatal intensive care unit patients were transmitted by PCT. The pediatrician reviewed the original films and three neonatologists reviewed the PCT images. Their interpretations were scored by use of criteria established by a neutral reader. In the second part chest x-ray films (CXR) of 31 newborns weighing > 2000 gm with respiratory distress were transmitted by PCT. A pediatrician and three neonatologists participated in an exercise to simulate a telephone neonatology consultation. Patient severity assessments as measured by assignments to receive intermediate or intensive care were compared before and after neonatologists viewed the PCT image of the CXR. RESULTS: In part 1 of the study neonatologists correctly identified 98%, 91%, and 98% of the x-ray interpretation scoring items, whereas at best the pediatrician identified 82% of the scoring items (p = 0.002). In part 2 neonatologists correctly assigned patient care levels an average of 73% after reviewing a standard clinical profile and a written description of the infant's CXR. After reviewing a PCT image of the infant's CXR, patient care level assignments were correctly assigned an average of 67%. The interpretation of the PCT CXR image was consistent with the radiologic report of record in 90 of 93 interpretations (31 cases read by three neonatologists). CONCLUSIONS: PCT represents an inexpensive means to accurately send a radiographic image over the phone as part of a telephone consultation. Neonatologists were able to interpret teleradiology images more accurately than a pediatrician reviewing the original film. Although this did not result in an improvement in the neonatologists' ability to determine patient severity on the basis of the model used in part 2, their identification of serious radiographic findings missed by the pediatrician can only suggest that teleradiology may be beneficial in certain instances. Although verbal communication can often suffice in a telephone consultation or transfer, there may be specific instances when visualizing a radiographic image such as an x-ray film or computed tomographic scan can provide important information that cannot be optimally described verbally. Rural hospitals can form interhospital image transmission links with tertiary center resources.

Intravenous lignocaine in the management of primary fibromyalgia syndrome.

Ten patients with primary fibromyalgia syndrome were treated with intravenous infusions of lignocaine on a daily basis for six days. This treatment produced a clinically useful improvement in pain relief and mood scores at the time of discharge on day seven and at follow-up on day thirty.

Cervical dorsal column stimulation relieves pain of brachial plexus avulsion.

Five patients with deafferentation pain due to brachial plexus avulsion injuries were treated with cervical dorsal column stimulation (DCS). This has produced a clinically useful improvement in pain relief and mood scores during a mean follow-up period of 13.5 months. No complications have been encountered and the advantages of DCS are discussed.

Questions of training--choice or force?

Three contrasting views are presented in three short papers: that a short period of oncology training should be mandatory for trainees in palliative medicine; that many disciplines are important in palliative medicine and training programmes should be tailored to the needs of individuals while recognizing that there will always need to be close cooperation between oncology and palliative medicine; and that a short period of training in palliative medicine should be mandatory for those wishing to pursue a career in oncology.

Effect of vanadate on renal hypertrophy and sorbitol accumulation in streptozotocin induced diabetes in rats.

Vanadate has been previously shown to normalize blood glucose in streptozotocin-induced diabetic (STZ-DM) rats. The effect of a previously studied dose of vanadate (0.8 mg/ml) in drinking water on blood glucose, renal hypertrophy, and whole kidney polyol accumulation was studied in STZ-DM rats. Rats with diabetes of 5 weeks duration had higher blood glucose, greater urinary output, higher kidney weight, lower body weight, and higher kidney to body weight ratios than controls. Whole kidney sorbitol concentrations were significantly increased in diabetes but myo-inositol levels were unchanged vs control animals. After four weeks of oral vanadate treatment, blood glucose, urine volume, and kidney weights were similar to control values. Kidney to body weight ratios fell below that of the STZ-DM animals, but because body weights remained decreased, the kidney to body weight ratios were not normalized. Renal sorbitol levels returned to control values and renal myo-inositol levels remained unchanged in STZ-DM and normal animals treated with vanadate. These results provide evidence that vanadate therapy may result in regression of the hypertrophy and polyol accumulation characteristic of diabetic nephropathy in STZ-DM rats. This effect is most likely due to normalization of blood glucose by the insulin-mimetic activity of vanadate treatment.