[Multicenter study of pain assessment in hospitals]. / Estudio multicéntrico de la evaluación del dolor en el medio hospitalario.

OBJECTIVE: To evaluate the recording of pain intensity in hospital charts. METHODS: A cross-sectional study was carried out in 15 hospitals in a sample of admitted patients with pain. Clinical data, including pain intensity, were gathered from the hospital records. Multiple analysis of variance was used to identify factors related to the intensity of pain recorded in the patients' charts. RESULTS: A total of 1038 patients with a mean (SD) age of 56.1 (18.9) years were included. Pain intensity was noted in the charts of 47.9% (95% confidence interval [CI], 44.9%-50.9%) of the patients. Pain intensity had been noted for 68.9% (95% CI, 61.4%-76.4%) of the patients with cancer, 43% (95% CI, 38.2%-47.8%) of postoperative patients, 38.2% (95% CI, 35%-41.4%) of trauma patients, and 26.6% (95% CI, 16.9%-36.3%) of postpartum women. There was great interhospital variability. Factors associated with the recording of pain intensity in medical charts were hospital characteristics (large hospitals, teaching hospitals, hospitals and internal medicine and surgical specialities) and type of patient (cancer and trauma cases and patients reporting pain to the staff). CONCLUSION: There is inadequate written recording of intensity of pain in hospitals, even though there is considerable interhospital variation. Pain intensity assessment and recording is an indicator of quality of health care and should become a routine practice in hospital health care.

Impact of 3-Monthly Vitamin D Supplementation Plus Exercise on Survival after Surgery for Osteoporotic Hip Fracture in Adult Patients over 50 Years: A Pragmatic Randomized, Partially Blinded, Controlled Trial.

OBJECTIVE: To determine whether 3-monthly supplementation of an oral vitamin D widely used in Spain (calcifediol) plus daily exercise could influence survival at one and four years after surgery for osteoporotic hip fracture. DESIGN: A pragmatic, randomized, partially single-blind placebo-controlled study. SETTING: Patients admitted to a tertiary university hospital for acute hip fracture. PARTICIPANTS: 675 healthy adult patients undergoing surgery for osteoporotic hip fracture were recruited from January 2004 to December 2007. INTERVENTION: Patients were randomized to receive either 3-monthly oral doses of 3 mg calcifediol (Hidroferol Choque®) or placebo in the 12 months postsurgery. Patients who received calcifediol were also given an exercise programme. The placebo group received standard health recommendations only. MEASUREMENTS: The primary endpoint was survival at 1 year and at 4 year follow-up. We also recorded new fractures, medical complications and anti-osteoporotic treatment compliance. RESULTS: We included a total of 88 patients, aged 62 to 99 years. Mean age was 82 years and 88.6% were women. At 12 months, 10 (11.3%) patients had died, 9 of them, from the non-intervention group. At 4 years after surgery, 20 (22.7%) had died, 3 (3.4%) from the intervention group and 17 (19.3%) from the non-intervention group. At this time, survival curve analysis showed 93% survival in the intervention group and 62% in the non-intervention group (p=0.001). At 12-month follow up, there were 18 new fractures, 9 in each group. The non-intervention group had more medical complications, with significant differences at visit 2 (p = 0.04) and 3 (p = 0.02) but not at visit 4 (p = 0.18). No significant differences between groups were found regarding treatment compliance. CONCLUSION: 3-monthly, oral supplements of 3 mg calcifediol plus daily exercise improved survival at one-year and four-year follow up after surgery for an osteoporotic hip fracture.

Prevalence of pain in adults admitted to Catalonian hospitals: a cross-sectional study.

OBJECTIVE: To survey the prevalence of pain in patients admitted to different hospitals of Catalonia and to describe which factors are related to pain. METHODS: A cross-sectional study was performed in 1675 patients from fifteen hospitals in Catalonia (Spain). Clinical and demographic data, as well as the existence of pain intensity evaluations and analgesic therapy, were obtained from medical charts. Characteristics of pain were given by patients after being interviewed by trained interviewers. The main-outcome measure was the existence of pain (at the interview, in the previous 24h, at the admission and at any time after admission) that was assessed by a visual analogue scale (VAS). The relationship of prevalence of pain to patients' characteristics was carried out by means of a multiple-logistic-regression model with pain presence as the dependent variable of interest. RESULTS: A great variability in the prevalence and intensity of pain among different hospitals was observed. At the time of the interview, 48.5% (95% CI: 46.1-50.9%) of the patients had pain and the median VAS was 40mm (range: 10-100mm), and the prevalence of pain during the previous 24h was similar (47.6%; 95% CI: 45.2-50%). At admission, 26.7% (95% CI: 24.6-28.8%) of patients were in pain, whereas 62% (95% CI: 59.7-64.3%) reported having pain at some time during their stay. Pain intensity annotations were absent in 51.3% (95% CI: 47.9-54.7%) of the medical records of the patients with pain. The factors associated with pain were younger age, female gender, presence of surgery, orthopaedic surgery wards, large hospital and prescribed analgesics. CONCLUSION: A high prevalence of clinically relevant pain in in-patients was found as well as a great variability according to type of patients, clinical wards and hospitals. This study gives clear evidence of the lack of adequate management of pain in the majority of the hospitals and calls for the implementation of organisational and educational measurements that may settle this epidemic problem.

Denosumab or Zoledronic Acid in Postmenopausal Women With Osteoporosis Previously Treated With Oral Bisphosphonates.

CONTEXT: Denosumab and zoledronic acid (ZOL) are parenteral treatments for patients with osteoporosis. OBJECTIVE: The objective of the study was to compare the effect of transitioning from oral bisphosphonates to denosumab or ZOL on bone mineral density (BMD) and bone turnover. DESIGN AND SETTING: This was an international, multicenter, randomized, double-blind trial. PARTICIPANTS: A total of 643 postmenopausal women with osteoporosis previously treated with oral bisphosphonates participated in the study. INTERVENTIONS: Subjects were randomized 1:1 to sc denosumab 60 mg every 6 months plus iv placebo once or ZOL 5 mg iv once plus sc placebo every 6 months for 12 months. MAIN OUTCOME MEASURES: Changes in BMD and bone turnover markers were measured. RESULTS: BMD change from baseline at month 12 was significantly greater with denosumab compared with ZOL at the lumbar spine (primary end point; 3.2% vs 1.1%; P < .0001), total hip (1.9% vs 0.6%; P < .0001), femoral neck (1.2% vs -0.1%; P < .0001), and one-third radius (0.6% vs 0.0%; P < .05). The median decrease from baseline was greater with denosumab than ZOL for serum C-telopeptide of type 1 collagen at all time points after day 10 and for serum procollagen type 1 N-terminal propeptide at month 1 and at all time points after month 3 (all P < .05). Median percentage changes from baseline in serum intact PTH were significantly greater at months 3 and 9 with denosumab compared with ZOL (all P < .05). Adverse events were similar between groups. Three events consistent with the definition of atypical femoral fracture were observed (two denosumab and one ZOL). CONCLUSIONS: In postmenopausal women with osteoporosis previously treated with oral bisphosphonates, denosumab was associated with greater BMD increases at all measured skeletal sites and greater inhibition of bone remodeling compared with ZOL.

Reoperation for prosthetic aortic valve obstruction in the era of echocardiography: trends in diagnostic testing and comparison with surgical findings.

OBJECTIVES: We sought to: 1) identify trends in the diagnostic testing of patients with prosthetic aortic valve (AVR) obstruction who undergo reoperation and 2) compare diagnostic test results with pathologic findings at surgery. BACKGROUND: It is unclear whether Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have reduced hemodynamic catheterization rates. METHODS: We reviewed 92 consecutive cases ofAVR reoperation at a single center from 1989 to 1998, comparing 49 cases of mechanical AVR obstruction (group A) to 43 cases of bioprosthetic obstruction (group B). Preoperative Doppler TTE was performed in all cases. RESULTS: In group A cases, there was a marginally significant trend towards lower catheterization rates for the Gorlin AVR area, from 36% in 1989 to 1990 to 10% in 1997 to 1998 (p = 0.07), but diagnostic TEE utilization (47% of cases) did not vary. The cause of mechanical AVR obstruction was pannus in 26 cases (53%), mismatch (P-PM) in 19 (39%) and thrombosis in 4 (8%). The mechanism (pannus/thrombus vs. mismatch) was identified in 10% by TTE and 49% by TEE (p < 0.001). In group B cases, hemodynamic catheterization rates (21%) and diagnostic TEE utilization (21%) did not vary with time. Obstruction was caused by structural degeneration in 37 cases (86%), thrombosis in 3 (7%), mismatch in 2 (5%) and pannus in 1 (2%). The mechanism was correctly identified in 63% by TTE and in 81% by TEE (p = 0.18). CONCLUSIONS: Doppler TTE is the primary means to diagnose AVR obstruction; hemodynamic catheterization is not routinely needed. In unselected patients with mechanical AVR obstruction, TEE differentiation of pannus or thrombus from mismatch is challenging.

Long-term maintenance of psoriatic human skin on congenitally athymic (nude) mice.

Transplantation of involved psoriatic and nonpsoriatic human skin onto congenitally athymic (nude) mice has been performed successfully. Although biopsies at selected intervals demonstrate that the excess glycogen deposition normally seen in psoriasis is no longer consistently present, the psoriatic grafts did retain the usual characteristic histologic differences throughout the life of the animal, up to 11 weeks. This grafting procedure potentially represents a useful method whereby the study of psoriasis can be made in a nonhuman, living system.

Clinical characteristics and outcome in postinfarction pseudoaneurysm.

The clinical characteristics and outcome in 22 patients with postinfarction pseudoaneurysm were studied. The medium-term outcome was poor (median follow-up 3.6 years), but cardiac rupture was uncommon in patients treated conservatively.

Outcome of reoperation for aortic valve prosthesis-patient mismatch.

We report a single center's 10-year experience with 21 consecutive cases of repeat aortic valve replacement for prosthesis-patient mismatch (P-PM) in which there was no hospital mortality among 12 patients treated for isolated P-PM. With an overall survival of 92% at a median follow-up of 4.5 years and functional class I symptoms in most survivors (73%), we conclude that repeat surgery for isolated P-PM has a relatively low mortality and a good intermediate-term clinical outcome.

Diagnosis of right atrial metastatic melanoma by transesophageal echocardiographic-guided transvenous biopsy.

Traditionally, tissue diagnosis of malignant melanoma metastatic to the heart necessitated thoracotomy or was done at autopsy. More recently, right or left ventricular endomyocardial biopsy under fluoroscopic guidance has been used to confirm metastatic involvement of the heart by various neoplasms including malignant melanoma; results have been excellent, and morbidity has been low. High-quality images of intracardiac masses with excellent anatomic details can be obtained by transesophageal echocardiography. Herein we describe a 73-year-old man with a history of malignant melanoma in whom cardiac metastatic involvement was documented by percutaneous transesophageal echocardiographic-guided transvenous biopsy of a right atrial mass; thus, the need for a more invasive approach to tissue documentation was avoided.

Apical hypertrophic cardiomyopathy in a father and daughter.

Apical hypertrophic cardiomyopathy is described in a father and his daughter. In both, identical segments of the left ventricle were involved by the hypertrophic process with differing degrees of severity. We suggest that the morphologic findings described are due to a single gene with an autosomal dominant mode of inheritance.

Hypergonadotropic hypogonadism with congestive cardiomyopathy: an autosomal-recessive disorder?

We report on two sisters with ovarian dysgenesis and secondary hypergonadotropic hypogonadism and congestive cardiomyopathy. Their parents are first cousins. It is suggested that these are the main manifestations of a previously unreported autosomal-recessive syndrome.

Tetralogy of Fallot with pulmonary atresia in siblings.

We present two sisters with tetralogy of Fallot and pulmonary valve atresia. Both had identical anatomical findings as seen at cardiac catheterization and angiography and verified operatively, with, in particular, identical bronchial circulation and pulmonary valve structure. The parents are first cousins and there is no history of other affected relatives. We suggest that this is a specific, recessively inherited type of tetralogy of Fallot.

Fractured occluder disc: a previously unrecognized complication of the Starr-Edwards disc prosthesis.

Fracture of the occluder disc of a low-profile Starr-Edwards prosthesis is a hitherto unrecognized complication. We describe a patient who presented with right heart failure and severe pulmonary hypertension 27 years after mitral valve replacement with a model 6520 caged-disc prosthesis. At surgery, there was a longitudinal split in the occluder disc, and organized thrombus was lodged between the split segments. This case offers a unique opportunity to study the long-term effects of wear on the polyethylene poppet and Stellite cage.

Two dimensional echocardiographic demonstration of an unusual complication of aortic infective endocarditis.

The two dimensional echocardiographic findings of aortic root abscess have been described. The echocardiographic findings in a patient with aortic valve endocarditis complicated by abscess formation, tear in the intima of the ascending aorta, and rupture of abscess cavity into the right ventricle are reported.

Emergency valve replacement during acute carditis--case reports.

Two patients are described with acute rheumatic carditis and severe heart failure who failed to respond to aggressive medical treatment with steroids, salicylates, inotropic agents and afterload reduction. In both cases, cardiac catheterization revealed severe aortic and mitral regurgitation with preserved myocardial contractility. Emergency double valve replacement was successfully performed with marked improvement in both patients. The diagnosis and evaluation of the condition, as well as the unique problems confronted in the post-operative course are discussed.