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.

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.

Histopathological findings in oesophageal carcinoma with and without preoperative chemotherapy.

AIMS: To investigate the pathological effects of preoperative chemotherapy on oesophageal carcinoma. METHODS: Qualitative and quantitative changes in oesophageal carcinoma after preoperative chemotherapy were assessed by examination of biopsy specimens before treatment and resected specimens. RESULTS: Of 13 patients with adenocarcinoma treated with 5-fluorouracil, adriamycin, and mitomycin (FAM), nine showed minor histological changes compared with 14 control cases. All 12 patients with squamous carcinoma treated with preoperative mitomycin, ifosfamide, and cisplatin (MIC) showed noticeable histological changes when compared with the 13 control cases. Changes included complete ablation (n = 1) and partial regression (n = 5) of the tumour. A quantitative estimate of the proportion of tumour to stroma showed no difference between control adenocarcinomas and those treated with chemotherapy. There was, however, a significant reduction (p < 0.01) in the proportion of tumour to stroma in the treated squamous group compared with the controls. There was no relation between the degree of response in squamous carcinomas and the degree of differentiation of the tumour. Patients in which squamous carcinomas responded well, as assessed quantitatively, showed a tendency to better survival at one year. CONCLUSIONS: Histopathological changes attributable to chemotherapy can be observed in oesophageal carcinoma. The response of squamous carcinoma to MIC is histologically more evident than that of adenocarcinoma to FAM. A quantitative technique may be useful in assessing the effect of chemotherapy in oesophageal squamous carcinoma.

Importance of low serum vitamin B12 and red cell folate concentrations in elderly hospital inpatients.

To determine the functional importance of the low B12 and red cell folate concentrations repeatedly observed in the elderly 200 consecutive patients admitted to a geriatric unit were studied. Forty six of the patients had low serum concentrations of B12 (15), red cell folate (26), or both (five). Serum B12 and red cell folate concentrations correlated with mean cell volume, and serum B12 correlated with the neutrophil lobe count. Bone marrow deoxyuridine suppression was abnormal in 35% of the patients with low vitamin concentrations, but 55% of those with abnormal deoxyuridine suppression had morphologically normal bone marrow, and 73% had a normal mean cell volume. In patients with low vitamin values the deoxyuridine suppressed value correlated with the haemoglobin concentration and neutrophil lobe count. Thus synthesis of thymidylate was impaired by vitamin B12 or folate deficiency in at least 8% of newly admitted elderly patients, many of whom had normal blood counts despite the biochemical disturbance affecting haemopoiesis. A nutritionally depleted diet may have been responsible for many of the low vitamin values.

Retrograde cerebral perfusion: clinical experience in emergency and elective aortic operations.

We recently have used retrograde cerebral perfusion via the superior vena cava in association with hypothermic circulatory arrest as an adjunct to cerebral protection during aortic arch operations. Between April 1993 and March 1994, 23 patients (14 male; 9 female; median age, 64 years; age range, 25 to 76 years; 14 emergency, 9 elective) underwent operation on the ascending aorta, aortic arch, or both for acute dissection (11) or aneurysm (12). Aortic root replacement was performed in 13 patients (7 with arch replacement), ascending aortic replacement in 7 (4 with arch replacement), isolated aortic arch replacement in 2, and repair of sinus of Valsalva aneurysm in 1. Coronary artery bypass grafting was performed in 4 patients. Hypothermic circulatory arrest (15 degrees C) and retrograde cerebral perfusion were implemented in all cases (median circulatory arrest time, 21 minutes; range, 13 to 51 minutes; median retrograde cerebral perfusion time, 20 minutes; range, 12 to 50 minutes). Three hospital deaths occurred (atheromatous embolic stroke, sepsis, rupture of infrarenal aortic aneurysm). The remaining patients had no neurologic damage (median intensive therapy unit stay, 1 day; range, 1 to 5 days). Retrograde cerebral perfusion is easy to establish and safe, and may improve brain protection during hypothermic circulatory arrest.

Phase II study of mitomycin, ifosfamide and cisplatin in adenocarcinoma of the oesophagus.

We evaluated the effect of brief neoadjuvant chemotherapy in patients with apparently operable adenocarcinoma of the oesophagus. Two courses of mitomycin (6 mg/m2), ifosfamide (3 g/m2) and cisplatin (50 mg/m2;MIC) were given followed by evaluation of response by barium swallow and computed tomography scan. Of 20 patients, 17 completed both courses and 4 (20%) showed a partial response. Toxicity was generally mild and consisted principally of nausea and vomiting. Altogether, 15 patients were surgically explored; resection was completed in 12 patients, 3 of whom died in hospital (25%). Neoadjuvant therapy with MIC offers no advantage over surgery alone.

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.

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.

Determinants of need and unmet need among cancer patients residing at home.

De-hospitalization of cancer treatment, particularly for those with advanced disease, can complicate adjustment and strain the capacity of caregiver networks to meet patients' daily needs. Outpatient staff should be able to recognize patients who need help to meet their daily needs as well as those who are not getting enough help. This study describes the physiological and social determinants of need and unmet need for assistance among 629 cancer patients with advanced disease initiating a course of outpatient chemotherapy and/or radiation therapy. Areas of needs examined through telephone interviews with participating patients were: personal care, instrumental tasks (housework, shopping, and cooking), and transportation. Physiological factors (metastases, disease stage, and functional status) were associated with need for assistance in all three areas. Also, older age (over 65) and low income predicted need for help with personal care, and women were more likely than men to report illness-related need for assistance with instrumental tasks and transportation. Unmet need was primarily associated with patients' social support system (e.g., children living nearby and perceived resiliency of network helpers). These findings highlight the need for outpatient staff to evaluate patients' informal care resources as well as patients' symptoms and impairments in deciding who should be referred for home care services.

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.

Circular myotomy and Belsey repair for acquired shortening of the oesophagus.

Fourteen patients with shortening of the oesophagus due to chronic reflux oesophagitis have been treated by a combination of an oesophageal lengthening procedure with a standard anti-reflux repair. Their ages ranged from 18 to 78 years and eight were male. Thirteen patients had a reflux stricture (with additional penetrating ulcer in six) and one had a columnar-lined oesophagus. A complete circular myotomy was performed just below the level of the aortic arch, in combination with a Belsey Mark IV anti-reflux repair. There were no deaths post-operatively but one patient required re-operation for haemorrhage and one underwent oesophageal dilatation before discharge. All patients have now been followed up for over 5 years. Nine patients have required no further treatment for their oesophageal problems, two required two early dilatations each, two required multiple dilatations and one required oesophageal resection for stricture. We suggest that this combination merits further evaluation in the management of patients with short oesophagus due to reflux.

Surgical treatment of massive hydrothorax complicating continuous ambulatory peritoneal dialysis.

Acute hydrothorax is a well-recognized complication of continuous ambulatory peritoneal dialysis and is often regarded as a contraindication to its use. We report three cases treated by surgical closure of a communication between the peritoneal and pleural cavities enabling CAPD to continue successfully. This is a simple, safe and effective procedure which merits wider use as an alternative to transferring the patient to permanent hemodialysis.

Homograft aortic valve and root replacement for severe destructive native or prosthetic endocarditis.

Ten male patients with a mean age of 57.5 years (range 27-75 years) underwent homograft aortic valve or root replacement for destructive aortic valve endocarditis. Six patients had native valve endocarditis (one with associated native mitral valve endocarditis) and four had prosthetic valve endocarditis (one with associated prosthetic mitral endocarditis). Causative organisms were Streptococci in six patients, Staphylococci in one, Q fever in one and no organisms were isolated in the remaining two patients. All the patients were operated while on antibiotics (mean lengths of treatment 13 days; range 2-42). The main indication for surgery was cardiogenic shock in five patients, progressive cardiac failure in four patients and uncontrolled sepsis in one patient. Operative procedures involved homograft aortic root replacement with coronary reimplantation (seven patients; associated prosthetic mitral valve replacement in one patient), infracoronary homograft aortic valve replacement (three patients) and a number of other procedures were performed to reconstruct the disrupted cardiac anatomy. Patients were followed up for a mean of 13.2 months (range 2-21). One patient died 4 months postoperatively of an unrelated cause; all the others are asymptomatic with no evidence of recurrent endocarditis. We conclude that homograft aortic valve or root replacement is an effective method of managing destructive aortic valve endocarditis.

Primary immotile oesophagus in young patients.

Since 1984 we have identified 14 patients under the age of 45 years with severe, unexplained loss of oesophageal motility. The ages at presentation ranged from 20 to 42 years and nine were female. Barium swallow was normal in eight patients and showed minor abnormalities in six. Twenty-four hour pH studies were normal in all patients and the only endoscopic abnormality was minimal oesophagitis in three. Upper oesophageal sphincter resting pressures and cervical motility were normal except in one patient. Motility in the body of the oesophagus was severely reduced in all patients with a mean peristaltic amplitude of 10 mmHg. Lower oesophageal sphincter resting pressures were reduced in 11 patients and normal in three, with incomplete sphincter relaxation in three. All patients have been followed up for a minimum of 3 years without progression of their symptoms or the development of a secondary cause. Six patients have undergone repeat manometry and pH studies with no changes. We conclude that there is a group of young patients who appear to undergo severe primary loss of oesophageal motility for reasons that have not yet been identified. It is important to identify these patients so that inappropriate surgery can be avoided.

Assessment of the response to chemotherapy in oesophageal cancer.

Thirty-eight patients with localised oesophageal carcinoma have been studied by computed tomography (CT) and barium swallow before and after preoperative chemotherapy and the results correlated with the pathological findings in the resected specimen. Overall 48% of patients showed a complete or partial response to chemotherapy on CT, compared with 50% on barium and 94% on pathological examination. This study highlights deficiencies in CT scanning and barium swallow as methods of assessing the regression of tumor bulk following chemotherapy for oesophageal carcinoma. We suggest that strict and specific criteria will have to be laid down before the results of chemotherapy in this disease can be reliably and accurately evaluated.

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.

Results of surgical revascularization in ischaemic heart failure without angina.

Seventeen patients with severe ischaemic heart failure without angina were studied prospectively to determine the effects of surgical revascularization on exercise tolerance, peak oxygen consumption and left ventricular function at rest and during inotropic stimulation at 3 months after surgery. Suitability for surgery was assessed by the presence of ischaemia identified by thallium scintigraphy and stress electrocardiographic (ECG) testing and the left ventricular response to dobutamine measured by radionuclide ventriculography. One patient died awaiting surgery and one required cardiac transplantation. Fifteen patients underwent coronary artery surgery with two perioperative deaths. Thirteen patients were restudied 3 months after surgery. Mean treadmill exercise time (362 +/- 204 s to 562 +/- 303 s, P < 0.05) and peak oxygen consumption (14.9 +/- 3.5 ml/kg per min to 20.8 ml/kg per min, P < 0.01) increased significantly. Resting ejection fraction was not changed after surgery (20 +/- 5% to 21 +/- 6%) but ejection fraction during derived from thermodilution Swan-Ganz catheter data both at rest during dobutamine stimulation were unchanged after surgery. At 13 +/- 3 months after surgery there had been three sudden deaths and one patient had undergone successful cardiac transplantation. Of the remaining nine patients, three had improved to NYHA symptomatic class I, three were in NYHA class II and three in NYHA class III. Repeat treadmill exercise testing in seven patients showed that the improvement in exercise capacity evident in the first follow-up visit was maintained during long-term follow-up.

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.

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.

A phase II study of 5-fluorouracil, adriamycin and mitomycin-C in adenocarcinoma of the oesophagus.

We have evaluated the effect of 5-fluorouracil 600 mg/m2, doxorubicin ('Adriamycin') 40 mg/m2, and Mitomycin-C 4 mg/m2 (FAM) in two groups of patients with adenocarcinoma of the oesophagus, as either a preoperative or primary treatment. Response was assessed by barium swallow, CT scan, and measurement of metastases where present. Toxicity was as reported for FAM in gastric cancer. In the operated group 8 of 22 patients (36%) showed a partial response following two courses of FAM. Resection was completed in 20 patients, with six hospital deaths (30%). Of the 14 patients who were discharged from hospital, 8 have died (median 8 months) and 6 are alive at 12 to 27 months, with known recurrence in 1. In the non-operated group 6 of 17 patients (35%) showed a response, one complete, following one to six (mean 4.2) courses of FAM. Fifteen patients have died (median 5 months), and 2 are alive and free from disease at 12 and 17 months. Neoadjuvant therapy with FAM in adenocarcinoma of the oesophagus offers no advantage over surgery alone, although with inoperable disease FAM may be of use in palliation.