Adult-Onset Subacute Sclerosing Panencephalitis With a 30-Year Latent Period.

Subacute sclerosing panencephalitis (SSPE) is a rare progressive neuroinfectious disease due to a late complication of the measles virus. The hallmark clinical features of this disease include behavioral changes, myoclonus, dementia, visual disturbances, and pyramidal and extrapyramidal signs. The presence of characteristic high-amplitude periodic complexes on electroencephalography and raised antibody titers against measles in the cerebrospinal fluid help solidify the diagnosis. We present a case of a 40-year-old patient with SSPE who initially developed ophthalmologic manifestations 30 years after the primary measles infection. This case highlights both typical and atypical features of SSPE and provides a diagnostic framework for evaluating cases that fall outside of the standard scope of this disease.

Predictors of urinary incontinence in community-dwelling frail older adults with diabetes mellitus in a cross-sectional study.

BACKGROUND: Diabetes mellitus is a potent risk factor for urinary incontinence. Previous studies of incontinence in patients with diabetes have focused on younger, healthier patients. Our objective was to characterize risk factors for urinary incontinence among frail older adults with diabetes mellitus in a real-world clinical setting. METHODS: We performed a cross-sectional analysis on enrollees at On Lok (the original Program for All-Inclusive Care of the Elderly) between October 2004 and December 2010. Enrollees were community-dwelling, nursing home-eligible older adults with diabetes mellitus (N = 447). Our outcome was urinary incontinence measures (n = 2602) assessed every 6 months as "never incontinent", "seldom incontinent" (occurring less than once per week), or "often incontinent" (occurring more than once per week). Urinary incontinence was dichotomized ("never" versus "seldom" and "often" incontinent). We performed multivariate mixed effects logistic regression analysis with demographic (age, gender and ethnicity), geriatric (dependence on others for ambulation or transferring; cognitive impairment), diabetes-related factors (hemoglobin A1c level; use of insulin and other glucose-lowering medications; presence of renal, ophthalmologic, neurological and peripheral vascular complications), depressive symptoms and diuretic use. RESULTS: The majority of participants were 75 years or older (72%), Asian (65%) and female (66%). Demographic factors independently associated with incontinence included older age (OR for age >85, 3.13, 95% CI: 2.15-4.56; Reference: Age <75) and African American or other race (OR 2.12, 95% CI: 1.14-3.93; Reference: Asian). Geriatric factors included: dependence on others for ambulation (OR 1.48, 95% CI: 1.19-1.84) and transferring (OR 2.02, 95% CI: 1.58-2.58) and being cognitively impaired (OR 1.41, 95% CI: 1.15-1.73). Diabetes-related factors associated included use of insulin (OR 2.62, 95% CI: 1.67-4.13) and oral glucose-lowering agents (OR 1.81, 95% CI: 1.33-2.45). Urinary incontinence was not associated with gender, hemoglobin A1c level or depressive symptoms. CONCLUSIONS: Geriatric factors such as the inability to ambulate or transfer independently are important predictors of urinary incontinence among frail older adults with diabetes mellitus. Clinicians should address mobility and cognitive impairment as much as diabetes-related factors in their assessment of urinary incontinence in this population.

Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark.

OBJECTIVES: To determine a pooled, quantitative estimate of the length of time needed after breast or colorectal cancer screening before a survival benefit is observed. DESIGN: Meta-analysis of survival data from population based, randomized controlled trials comparing populations screened and not screened for breast or colorectal cancer. Trials were identified as high quality by reviews from the Cochrane Collaboration and United States Preventive Services Task Force. SETTING: Trials undertaken in the United States, Denmark, United Kingdom, and Sweden. POPULATION: Screened patients older than 40 years. PRIMARY OUTCOME MEASURES: Time to death from breast or colorectal cancer in screened and control populations. INTERVENTIONS: Fecal occult blood testing for colorectal cancer screening, mammography for breast cancer screening. RESULTS: Our study included five and four eligible trials of breast and colorectal cancer screening, respectively. For breast cancer screening, 3.0 years (95% confidence interval 1.1 to 6.3) passed before one death from breast cancer was prevented for every 5000 women screened. On average across included studies, it took 10.7 years (4.4 to 21.6) before one death from breast cancer was prevented for 1000 women screened. For colorectal cancer screening, 4.8 years (2.0 to 9.7) passed before one death from colorectal cancer was prevented for 5000 patients screened. On average across included studies, it took 10.3 years (6.0 to 16.4) before one death from colorectal cancer was prevented for 1000 patients screened. CONCLUSIONS: Our results suggest that screening for breast and colorectal cancer is most appropriate for patients with a life expectancy greater than 10 years. Incorporating time lag estimates into screening guidelines would encourage a more explicit consideration of the risks and benefits of screening for breast and colorectal cancer.

ß2-adrenergic receptor genotype and other variables that contribute to labor pain and progress.

BACKGROUND: ß2-Adrenergic receptor (ß2AR) activity influences labor. Its genotype affects the incidence of preterm delivery. We determined the effect of ß2AR genotype on term labor progress and maternal pain. METHODS: We prospectively enrolled 150 nulliparous parturients in the third trimester and obtained sensory thresholds, demographic information, and DNA. Cervical dilation, pain scores, and labor management data were extracted with associated times. The association of genetic and demographic factors with labor was tested using mixed effects models. RESULTS: Parturients who express Gln at the 27 position of the ß2AR had slower labor (P < 0.03). They progressed from 1-10 cm dilation in approximately 21 h compared with 14 h among other patients. Asian ethnicity, previously associated with slower labor, is highly associated with this polymorphism (P < 0.0001). Heavier and black patients had slower latent labor (P < 0.01, 0.01). Neuraxial analgesia was associated with slower labor progress (P < 0.0001). It could take up to 36 h for parturients who were black and/or more than median weight (165 lb) to transition from 1 cm cervical dilation to active labor. However, after this active phase began, labor rates among these patients were similar to that of other parturients. CONCLUSIONS: We detected a strong association between ß2AR genotype and slower labor. Asian ethnicity may be a proxy for ß2AR genotype. Black women and those of higher than average weight have slower latent labor. These results confirm many of the associations found when this mathematical model was applied to a large retrospective cohort, further validating this approach to description and analysis of labor progress.

Nicotine nasal spray as an adjuvant analgesic for third molar surgery.

PURPOSE: To determine the efficacy of preoperatively administered nicotine nasal spray (3 mg) for analgesia after third molar (TM) surgery. MATERIALS AND METHODS: A single-center, prospective, randomized, double-blind, crossover trial was conducted. The study population consisted of 20 nonsmoking patients referred to the Department of Oral and Maxillofacial Surgery of Columbia University College of Dental Medicine for extraction of all 4 TMs. Each patient received nicotine nasal spray or placebo spray before TM surgery. At a subsequent visit the contralateral TMs were removed with prior administration of the alternate treatment. For an hour postoperatively, subjects reported information on pain and nausea, and hemodynamic variables were recorded at 15-minute intervals. Telephone follow-up was recorded for 5 days postoperatively, where patients reported information on pain, nausea, and use of hydrocodone/acetaminophen as rescue analgesia. RESULTS: Nicotine treatment was associated with a highly significant decrease in pain reported during the 5 days after TM surgery. There was no difference in the amount of hydrocodone/acetaminophen used or amount of nausea reported. There was a small but significant increase in heart rate after nicotine treatment compared with placebo during the first hour after surgery. There was no difference in blood pressure between groups. CONCLUSION: Pain is well controlled by hydrocodone/acetaminophen in most patients after TM surgery. However, there is significant variability in pain reported. Nicotinic agonists represent a new class of analgesic that can be considered for patients who are expected to have significant opioid-resistant pain after TM surgery. Caution should be used with patients in whom a small increase in heart rate would be deleterious.

Length of stay for older adults residing in nursing homes at the end of life.

OBJECTIVES: To describe lengths of stay of nursing home decedents. DESIGN: Retrospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older. PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006. MEASUREMENTS: The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission. RESULTS: The mean age of decedents was 83.3 ± 9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1-20) and 13.7 ± 18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P <.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke). CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.

A transdermal nicotine patch is not effective for postoperative pain management in smokers: a pilot dose-ranging study.

BACKGROUND: Nicotine has an antinociceptive effect in animal models. The analgesic effect in humans has been examined, but studies have had mixed results. A proposed etiology is variability in chronic nicotine exposure because of differences in tobacco smoking rates and second-hand smoke exposure. In this study, we examined the postoperative analgesic effect of a transdermal nicotine patch in smokers in a parallel design to a previous study in nonsmokers. METHODS: We conducted a randomized, double-blind, prospective, placebo-controlled trial of 28 patients undergoing abdominal or pelvic surgery who required patient-controlled analgesia and an overnight hospital stay. Before anesthetic induction, a transdermal nicotine patch was applied (0, 5, 10, or 15 mg). The primary outcome variable was postoperative pain reported over the first hour and over the next 5 days using a standard numerical rating scale. Secondary outcome variables were pain medication use, hemodynamic values, nausea, and sedation. RESULTS: Patients treated with nicotine reported higher pain scores than those treated with placebo over the first hour after surgery (P < 0.01, average numerical rating scale increase = 0.67) and there was no difference between groups in the subsequent 5 days (P > 0.05). There was no significant dose effect. Diastolic blood pressure in the first hour was higher in the placebo group compared with the nicotine-treated group (P < 0.01, average increase = 11 mm Hg). There was no difference in nausea or sedation. CONCLUSIONS: Transdermal nicotine, 5-15 mg, failed to relieve postoperative pain or reduce opioid use in smokers.

Mathematical modeling of the pain and progress of the first stage of nulliparous labor.

BACKGROUND: Patient characteristics may contribute to the progress and pain of labor. Quantitative evaluation of the effects of patient characteristics requires robust mathematical models of labor progress and labor pain. METHODS: The authors retrospectively studied 100 sequential deliveries from each of five self-reported ethnic groups (Asian, Black, Hispanic, Other, and White). Demographic variables, cervical dilation, and numerical rating scores for pain before analgesia and cervical dilation were abstracted from the automated medical record. Labor progress was modeled with a biexponential function describing the latent and active phases of labor. Labor pain was modeled as a sigmoid function of cervical dilation by using a previously validated mathematical model. The covariates, including self-described ethnicity, were analyzed with NONMEM. RESULTS: The biexponential function described the time course of labor progress better than several alternative functions, including the sigmoidal function introduced by Friedman. The sigmoidal function of labor pain described its dynamic nature well, with substantial intersubject variability. Asian women had slower active labor than other ethnicities (P < 0.01). Asian women also reported less pain during their labor compared to all other patients (P < 0.001). Slower labor progress was associated with less rapid progression of pain, but this did not obviate the effect of Asian ethnicity on pain. Neuraxial analgesia is strongly associated with slower labor (P < 0.0001). Greater maternal weight was associated with slower active labor (P < 0.0001). CONCLUSIONS: Mathematical models can be used to detect subtle effects of patient covariates on the progress and pain of the first stage of labor. Asian women and heavier women had slower labor and slower onset of labor pain than others. These effects were modest compared with the substantial remaining unexplained subject-to-subject variability in labor progress and labor pain.

Transdermal nicotine patch for postoperative pain management: a pilot dose-ranging study.

BACKGROUND: Nicotine has been shown to be antinociceptive in the postoperative period in animal studies. Human studies with nasal nicotine sprays have had mixed results, possibly due to variability in pharmacokinetics and potential patient variables such as exposure to nicotine in tobacco smokers. In this pilot study, we examined the analgesic effect of a transdermal nicotine patch applied before surgery in nonsmokers. METHODS: We conducted a randomized, double-blind, prospective placebo-controlled trial of 40 subjects, undergoing general surgery that required postoperative patient-controlled analgesia and an overnight hospital admission. Immediately before surgery, a transdermal nicotine patch containing 0, 5, 10, or 15 mg was applied. The primary outcome variable was pain report using a numerical rating scale (NRS) in the first hour after surgery and over the next 5 days. Secondary outcomes were pain medication use, hemodynamic values, nausea, and sedation. RESULTS: Patients treated with nicotine reported lower pain scores when compared with those treated with placebo during the first hour after surgery (P = 0.003, average NRS decrease = 1.4, 95% CI = 0.3-2.6) and for 5 days after surgery (P = 0.03, average NRS decrease = 1.0, 95% CI = 0.1-1.9). There was no increased benefit of nicotine with doses larger than 5 mg. There was a trend suggesting decreased pain medicine use, increased nausea, decreased tachycardia, and slightly decreased systolic blood pressure in the nicotine groups, but these values did not reach significance. CONCLUSIONS: Transdermal nicotine, 5-15 mg, reduced postoperative pain scores but failed to decrease the need for opioid analgesics or opioid-related side effects after general surgical procedures.

The development and validation of a dynamic model to account for the progress of labor in the assessment of pain.

BACKGROUND: Labor pain is often described as the worst pain in a woman's life, but the experience is highly variable. Although many factors have been linked to labor pain, it has been difficult to assess the individual effects of these factors because labor is a dynamic process and pain intensity changes over the course of labor. Previous studies have used average pain scores. The aim of this study was to develop and validate a model that would allow for the statistical analysis of factors that affect pain throughout labor. METHODS: We conducted this study with a retrospective database drawn from the medical records of 200 consecutive nulliparous parturients who delivered at New York Presbyterian Hospital between October 2006 and January 2007. Numerical rating scale scores for pain with contractions (0-10 scale), cervical dilation, and oxytocin use before analgesia request were recorded. Nonlinear effects modeling with a sigmoid equation was used to describe the relationship between reported pain and cervical dilation. The modeling technique was developed with data from 91 parturients and validated with an independent set of 95 parturients (all parturients with pain scores more than zero). The resulting model was used to analyze the effect of a sample covariate, oxytocin administration, on reported pain in the entire data set. RESULTS: The model derived from our training set was predictive of the data from our validation set (P < 0.001). Predicted pain scores were on average two numerical rating scale points above or below measured pain scores. Analyzing oxytocin as a covariant showed that women treated with oxytocin reported 48% more pain at the start of labor but did not have a significantly more rapid increase in pain or higher maximal pain when compared with women not treated with oxytocin. Women treated with oxytocin had slower early labor and more rapid late labor. CONCLUSION: We have developed and validated a model for describing pain over the course of labor. Our model is suited to the statistical analysis of covariance and could potentially be used to compare the effects of covariants on labor pain and the rate of change of pain.