Validation of the Danish version of the Critical Care Pain Observation Tool.

BACKGROUND: Assessing pain in critically ill patients is a challenge even in an intensive care unit (ICU) with a no sedation protocol. The aim of this study was to validate the Danish version of the pain assessment method; Critical Care Pain Observation Tool (CPOT) in an ICU with a no sedation protocol. METHODS: Seventy patients were included in this study. The patients were observed during a non-nociceptive procedure (wash of an arm) and a nociceptive procedure (turning). Patients were observed before, during, and 15 min after the two interventions (six assessments). Two observers participated in the data collection and CPOT scores were blinded to each other. Calculations of interrater reliability, criterion validity and discriminant validity were performed to validate the Danish version of CPOT. RESULTS: The results indicated a good correlation between the two raters (all scores > 0.9 and P < 0.05). About 48 (68.6%) of the included patients were able to self-report pain. We found a significantly higher mean CPOT score at the nociceptive procedure than at rest or the non-nociceptive procedure (P < 0.05). No correlation was found between CPOT scores and physiological indicators. Patients self-reported pain and CPOT showed a significant correlation (P < 0.05). A CPOT score of ≥ 3 correlated with patients' self-reported pain (ROC AUC 0.83). CONCLUSION: The Danish version of CPOT can be used to assess pain in critically ill patients, also when the ICU has a no sedation protocol. CPOT scores showed a good interrater reliability and correlates well with patient's self-reported pain.

Plasma brain-derived neurotrophic factor and prefrontal white matter integrity in late-onset depression and normal aging.

OBJECTIVE: To explore the relationship between brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF), cerebral deep white matter lesions (DWMLs), and measures of white matter integrity in patients with late-onset depression, with respect to vascular risk factors. METHOD: We examined 22 patients with late-onset depression and 22 matched controls. Quantification of plasma BDNF and VEGF levels were performed with enzyme-linked immunosorbent assay (ELISA) kits. Measures of white matter integrity comprised apparent diffusion coefficient (ADC) and fractional anisotropy (FA), obtained by diffusion tensor imaging (DTI). Effects of DWMLs, FA, ADC, and vascular risk factors on BDNF and VEGF were assessed using multiple linear regression. RESULTS: The BDNF and VEGF levels did not differ significantly between groups. With pooled data for patients and controls, the BDNF level was positively associated with both number (t = 2.14, P = 0.039) and volume (t = 2.04, P = 0.048) of prefrontal DWMLs and negatively associated with FA in prefrontal normal-appearing white matter (t = -2.40, P = 0.02), adjusted for age and gender. Smoking and hypercholesterolemia was positively associated with the BDNF (t = 2.36, P = 0.023) and VEGF levels (t = 2.28, P = 0.028), respectively. CONCLUSION: Our results suggest a role for BDNF in the complex pathophysiologic mechanisms underlying DWMLs in both normal aging and late-onset depression.

The influence of age, sex and cardiorespiratory fitness on maximal fat oxidation rate.

Fat oxidation decreases with age, yet no studies have previously investigated if aging affects the maximal fat oxidation rate (MFO) during exercise in men and women differently. We hypothesized that increased age would be associated with a decline in MFO and this would be more pronounced in women due to menopause, compared with men. In this cross-sectional study design, 435 (247/188, male/female) subjects of varying ages performed a DXA scan, a submaximal graded exercise test and a maximal oxygen uptake test, to measure MFO and cardiorespiratory fitness (CRF) by indirect calorimetry. Subjects were stratified into 12 groups according to sex (male/female), age (<45, 45-55 and >55 years), CRF (below average and above average). Women aged <45 years had a higher MFO relative to fat free mass (FFM) (mg/min/kg) compared with men, regardless of CRF. However, there were no differences in MFO (mg/min/kg FFM) between men and women, in the groups aged between 45-55 and >55 years. In summary, we found that women aged <45 years display a higher MFO (mg/min/kg FFM) compared with men and that this sexual divergence is abolished after the age of 45 years. Novelty: Maximal fat oxidation rate is higher in young women compared with men. This sex-related difference is attenuated after the age of 45 years. Cardiorespiratory fitness does not influence this sex-related difference.

Localization of white-matter lesions and effect of vascular risk factors in late-onset major depression.

BACKGROUND: Several studies suggest that patients with late-onset major depression (MD) have an increased load of cerebral white-matter lesions (WMLs) compared with age-matched controls. Vascular risk factors such as hypertension and smoking may confound such findings. Our aim was to investigate the association between the localization and load of WMLs in late-onset MD with respect to vascular risk factors. METHOD: We examined 22 consecutive patients with late-onset first-episode MD and 22 age- and gender-matched controls using whole-brain magnetic resonance imaging (MRI). The localization, number and volume of WMLs were compared between patients and controls, while testing the effect of vascular risk factors. RESULTS: Among subjects with one or more WMLs, patients displayed a significantly higher WML density in two white-matter tracts: the left superior longitudinal fasciculus and the right frontal projections of the corpus callosum. These tracts are part of circuitries essential for cognitive and emotional functions. Analyses revealed no significant difference in the total number and volume of WMLs between groups. Patients and controls showed no difference in vascular risk factors, except for smoking. Lesion load was highly correlated with smoking. CONCLUSIONS: Our results indicate that lesion localization rather than lesion load differs between patients with late-onset MD and controls. Increased lesion density in regions associated with cognitive and emotional functions may be crucial in late-onset MD, and vascular risk factors such as smoking may play an important role in the pathophysiology of late-onset MD, consistent with the vascular depression hypothesis.

Dynamic changes in corticospinal tracts after stroke detected by fibretracking.

BACKGROUND AND AIMS: The integrity of motor pathways and functional connectivity patterns are important in assessing plastic changes related to successful recovery, to obtain prognostic information and to monitor future therapeutic strategies of stroke patients. We tested the following hypotheses: (1) that changes in axonal integrity along the corticospinal tract after stroke can be detected as a reduction in fractional anisotropy; and (2) that sustained low fractional anisotropy is indicative of axonal loss and therefore is correlated with poor motor outcome, as measured by specific neurological motor scores. METHODS: We developed a segmentation tool based on magnetic resonance diffusion tensor imaging in conjunction with three dimensional fibretracking for longitudinal studies of the corticospinal tract, and used specific neurological motor scores to test the hypotheses in five stroke patients within the first week and 30 and 90 days after the stroke. RESULTS: Reduction in fractional anisotropy within the first weeks after stroke reflected a decline in axonal integrity, leading to Wallerian degeneration, and demonstrated a correlation between the temporal evolution of fractional anisotropy and motor function in patients with poor motor outcome. CONCLUSION: The study demonstrated the feasibility of fibretracking as a segmentation tool for mapping distal parts of the corticospinal motor pathways and showed that fractional anisotropy in the segmented corticospinal tract is a sensitive measure of structural changes after stroke.

Steroid reversibility test followed by inhaled budesonide or placebo in outpatients with stable chronic obstructive pulmonary disease. The Danish Society of Respiratory Medicine.

The aim of this study was evaluate the predictive value of a 2 week course of prednisolone on the effect of 6 months treatment with inhaled budesonide in patients with stable chronic obstructive pulmonary disease (COPD). Forty patients with stable COPD entered the study, and received prednisolone (37.5 mg o.d.) for 2 weeks. They were subsequently divided into steroid-irreversible and steroid-irreversible, using 15% of baseline as a dividing point. In each group patients were randomized to receive budesonide 400 micrograms b.i.d. or placebo for 6 months. During treatment with prednisolone, three patients dropped out because of side effects. Of the remaining 37, only two patients (5%) were reversible with prednisolone forced expiratory volume in 1s [(FEV1) > 15% of baseline], and among the steroid-irreversible, 26 patients were evaluated after 6 months treatment with either placebo or budesonide. No significant differences in spirometry values, symptoms, or number of exacerbations were found between these two groups. Reversibility with prednisolone is rarely seen in COPD. In outpatients with stable COPD and no signs of asthma or atopy, 2 weeks treatment with prednisolone seems to be of no value in choosing subsequent long-term therapy.

Parasites as stressors: plasma cortisol responses of goats infected with the stomach worm Haemonchus contortus to exogenous corticotropin (ACTH).

Ten male, juvenile pigmy goats of similar age and weight were allocated randomly to two groups. Goats in one group were each inoculated with 20,000 infective larvae of Haemonchus contortus. The other group served as uninfected controls. Goats were housed together, and precautions were taken to avoid the creation of differential, between group, stressogenic circumstances. Body weights, nematode egg production, hematocrits, and clinical signs were monitored over a 61-day period following inoculation of larvae. On Days 59 and 61, adrenal response tests (ART) were conducted by measuring the levels of plasma cortisol before and 2 h after administration of porcine ACTH at the rate of 0.35 I.U. kg-1 body weight on Day 59 and 2.2 I.U. kg-1 on Day 61. Although the infections did not reduce body weights, they were 'heavy' on the basis of egg production, and led to significant reductions in packed erythrocyte volumes. There was no significant difference between the groups of goats in the responses to ART, indicating that the infections did not produce sufficient stress to reduce the ability of the adrenal cortex to respond to exogenous ACTH.

Effects of low-level infections by coccidia and roundworms on the nutritional status of rats fed an adequate diet.

Experiments were conducted on male, Sprague-Dawley rats of the same age fed a standard laboratory diet to determine the comparative effects of single and concurrent subclinical infections by coccidia (Eimeria nieschulzi) and roundworms (Nippostrongylus brasiliensis) on nutritional status and metabolism. All infections produced anorexia, but it was more prolonged and intense with the concurrent ones. Feed:gain ratios were increased only by infections by nematodes alone, but average daily gains were reduced beyond the effect of anorexia (i.e., "specifically") only with the double infections. Infections by coccidia only, but not by nematodes only, specifically reduced the apparent digestibility of dry matter, organic matter and N; whereas only the apparent N digestibility was specifically reduced by the double infections. Balances of N were reduced in infected rats and pair-fed controls during anoretic periods, but significant differences between the daily means for infected and pair-fed rats occurred only erratically. Specific increases in urinary N loss did not occur with the single infections, but occurred on 2 d with the double ones. Increased losses of fecal N occurred with both coccidial and double infections, but they were much more pronounced in the latter. No effects of infection on the balances or carcass contents of Ca and P occurred. The only significant differences between mean empty carcass densities occurred with the double-infected and free-fed uninfected groups, with the mean for the uninfected group being the higher.

Effects of concurrent subclinical infections by coccidia (Eimeria christenseni) and intestinal nematodes (Trichostrongylus colubriformis) on apparent nutrient digestibilities and balances, serum copper and zinc, and bone mineralization in the pigmy goat.

Subclinical infections by the intestinal nematode Trichostrongylus colubriformis were established in 7 pigmy goats by inoculating each with 4,000 infective larvae 5 days/week for 18 weeks. At the start of the 14th week, 3 of the goats were orally inoculated daily with 10,000 sporulated oocytes of the coccidium Eimeria christenseni for 6 days, producing subclinical infections. During selected weeks, the goats were placed in metabolism cages to monitor feed consumption and collect orts, feces, and urine. Samples of rib, vertebra, and tibia were removed at time of death, on day 126. The superimposition of the coccidial infections on the nematode infections did not affect apparent ash, nitrogen, organic matter, or dry matter digestibilities; balances of nitrogen or phosphorus; serum copper or zinc concentrations; liveweights or feed conversion efficiencies. Mean calcium balances remained positive, although they were reduced during the first week of the superimposed coccidial infections. The mineralization of the matrix of the tibia and 4th lumbar vertebra was less in the goats with the superimposed coccidial infections than in those infected only with nematodes. Presence of the superimposed infections was associated with a decrease in the mean moisture and lipid contents of the tibia.

Effects of selenium on polymorphonuclear leukocyte function in goats.

Polymorphonuclear neutrophils (PMN) from goats fed selenium-deficient and selenium-adequate diets were tested for their ability to perform (i) random migration under agarose, (ii) leukotaxis toward serum chemotaxins under agarose, and (iii) phagocytosis of opsonized zymosan by chemiluminescence analysis. Function of PMN from goats fed the selenium-deficient diet was severely depressed, and incubation of these cells with selenium resulted in marked functional enhancement. Also, administration of selenium to goats fed the selenium-deficient diet resulted in increased PMN functions. Increase or decrease in PMN function was associated with corresponding alterations in blood, serum, and intracytoplasmic PMN glutathione peroxidase activities. It was concluded that a selenium-inadequate diet fed to goats results in depressed PMN function which is associated with physiologic changes in glutathione peroxidase levels.

Prevalence of Sarcocystis odocoileocanis from white-tailed deer in Alabama and its attempted transmission to goats.

Sarcocysts of Sarcocystis odocoileocanis were found in tissue sections of hearts and tongues examined by light microscopy from 30 (88%) of 34 white-tailed deer (Odocoileus virginianus). Hearts were infected less often (13 of 34, 38%) than were tongues (30 of 34, 88%). Sarcocysts of Sarcocystis odoi were not observed in the white-tailed deer examined. A gray fox (Urocyon cinereoargenteus) excreted sporocysts after consuming tongues of white-tailed deer infected with S. odocoileocanis. Two goats inoculated with either 50,000 or 500,000 sporocysts of S. odocoileocanis isolated from the gray fox did not have sarcocysts in tissue sections of the heart, tongue, diaphragm, or esophagus when examined 122 days postinoculation. Dogs fed these tissues from control or inoculated goats did not pass sporocysts in their feces. The present study demonstrates: (1) a high prevalence of S. odocoileocanis infection in white-tailed deer in Alabama, and (2) that goats are not suitable intermediate hosts for S. odocoileocanis.

The use of computers in cancer pain management.

OBJECTIVES: To provide an overview of the present use of computer technology in cancer pain management. DATA SOURCES: Review articles, research studies, and books pertaining to the use of computers in cancer pain management. CONCLUSIONS: The availability of computer resources for cancer pain and nursing are limited. However, the application of computer technology to cancer pain management has the potential to improve our delivery of care, educate both health care professionals and consumers, and improve outcome measures. IMPLICATIONS FOR NURSING PRACTICE: Computers can assist our efforts to improve quality of care, teaching, research, and communication with patients. It is essential for nurses to be knowledgeable about available computer resources and the application of new technology.

[Characteristics and treatment of acute pulmonary embolism. A study of 183 consecutive patients treated during the period 1995 to 1998]. / Karakteristik og behandling af akut lungeemboli. En undersøgelse af 183 konsekutive patienter behandlet i perioden 1995 til 1998.

The aim of the present study was to evaluate the clinical characteristics and mortality in patients with pulmonary embolism during 1995-1998. The diagnosis of pulmonary embolism in 183 patients was confirmed based on the clinical and lung scan findings. Compared to previous studies fewer cases with pulmonary embolism after surgery, immobilisation and history of trauma to lower extremity were noted. Deep vein thrombosis and electrocardiographic signs of acute right ventricular strains were found frequently, and should support the suspicion of pulmonary embolism. A normal plasma fibrin D-dimer was noted in several patients. When using the D-dimer for the diagnosis of pulmonary embolism the result given depends on the assay method used, the assay specific discriminatory level and duration of symptoms. The total one year mortality was 16% whereas the mortality due to pulmonary embolism was 6%.

Anesthesia alternatives for ophthalmic surgery.

1. Traditionally, local anesthesia has only been used in patients with coexisting diseases that jeopardize the safety of general anesthesia. Local anesthesia, however, provides a number of advantages that make it suitable for ophthalmic surgery of both the anterior and posterior segment. 2. Preoperative emotional and physical assessment and patient counseling is essential to the successful use of local anesthesia. 3. Anxiety that exists intraoperatively can be relieved by sedentary social diversions such as listening to music, handholding, and other holistic approaches. 4. Discomfort caused by draping can be eliminated by using a drapeholder that lifts the drapes away, providing the patient with a high flow of air.

Further studies on the properties of glucose 6-phosphate dehydrogenase from the coccidium Eimeria stiedai (Protozoa).

1. Glucose 6-phosphate dehydrogenase from Eimeria stiedai does not reduce NAD or any of its analogs tested. It does reduce NADP and its thionicotinamide and 3-acetylpyridine analogs. 2. It will accept D-glucose as substrate, but not 2-deoxy-D-glucose, glucose 1-phosphate, or 2-deoxy-D-glucose 6-phosphate. 3. Its response to a number of compounds that activate or inhibit the enzyme from other organisms has been determined. 4. The molecular weight is ca. 240,000 by gel chromatography, and only one isoenzyme could be detected by disc electrophoresis. 5. The enzyme resists conditions that commonly cause dissociation to lighter weight active forms.

Nursing approaches in local anesthesia for ophthalmic surgery.

1. Traditionally, local anesthesia has only been used in patients with coexisting diseases that jeopardize the safety of general anesthesia. Local anesthesia, however, provides a number of advantages which make it suitable for ophthalmic surgery of both the anterior and posterior segment. 2. Preoperative emotional and physical assessment and patient counseling is essential to the successful use of local anesthesia. 3. Anxiety that exists intraoperatively can be relieved by sedentary social diversions such as listening to music, handholding, and other holistic approaches. 4. Discomfort caused by draping can be eliminated by using a drapeholder which lifts the drapes away, providing the patient with a high flow of air.

Amiodarone during pregnancy.

A case study is presented in which amiodarone (A) was given during the whole of pregnancy and during the breast feeding period. An intensive observation of thyroid tests, serum concentrations of A and its metabolite, desethylamiodarone (DEA) was undertaken. The child was observed in the same way from birth until 2 months of age. The milk was analyzed for A and DEA. As reported in other published cases, transplacental passage was found and there was a relatively high concentration of amiodarone in the milk. Our child like the other children was healthy at birth, being euthyroid and with no goiter or corneal deposits. No effect was observed of the medication on growth, thyroid tests or cornea. It is concluded that amiodarone can be given during pregnancy but it is advisable to use as low doses as possible and control the serum concentrations at regular intervals. Breast feeding need not be forbidden.