Pain Intensity and Misconceptions Among Hospice Patients With Cancer and Their Caregivers: Status After 2 Decades.

There is little evidence about barriers to pain management or their relationships with pain outcomes of hospice patients with cancer. The purpose of the study was to determine the barriers reported by hospice patients with cancer and their caregivers and the relationships with demographic characteristics and the patients' pain. In this cross-sectional study, we used selected baseline data from an ongoing randomized clinical trial of patient and lay caregiver dyads receiving home-level hospice care. Participants used an Internet-enabled tablet to complete the valid, reliable measures of pain intensity, pain management barriers (Barriers Questionnaire 13 items [BQ-13]), and demographic characteristics. The responses indicate that the 2 areas of highest concern (mean scores >3) to both patients and caregivers were "pain means disease progression" and "constipation." Additionally, 3 other areas of highest concern (mean scores >3) to caregivers were "addiction" pain medicine causing "one to do embarrassing things" and "confusion." The mean BQ-13 scores ranged from 0.2 to 4.9 and averaged 2.6 ± 0.9 for the patients and ranged from 0.5 to 4.7 and averaged 2.7 ± 0.9 for the caregivers. Mean barrier scores remain high and were not different between patients and their caregivers or significantly related to the patients' pain intensity. However, there were differences in race, ethnic, and hospice setting in the barrier scores. Patients with Hispanic heritage reported higher barrier scores than non-Hispanic patients. Together, these findings not only support prior research findings but also contribute new insights about pain intensity and pain barriers that are relevant to hospices serving minorities with cancer.

The plusoptiX S08 photoscreener as a vision screening tool for children with autism.

PURPOSE: Children with autism and related disorders reportedly have an increased prevalence (40%) of ocular disorders, and comprehensive eye examinations by a pediatric ophthalmologist are recommended. Examinations can be very time consuming, expensive, and stressful for the child. A photoscreener such as the plusoptiX S08 may be a cost-effective, time-saving, and less invasive method for testing patients with autism. The purpose of this study was to determine the efficacy of photoscreening with the plusoptiX S08 in detecting amblyopia risk factors in children with autism. METHODS: Photoscreening and complete ophthalmologic examinations were performed on 43 children with autism. Prevalence, sensitivity, specificity, positive predictive value, and negative predictive value were calculated using ophthalmologic examination as the gold standard. RESULTS: The gold standard examination used American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee guidelines for the definition of amblyopia risk factors. The plusoptiX S08 referred 29 (67%) of 43 children. On examination, 16 patients (37%) had amblyopia risk factors. The plusoptiX S08 had a sensitivity of 94% (95% CI, 0.68-0.99). The specificity was 48% (95% CI, 0.29-0.68), the positive predictive value was 52% (95% CI, 0.33-0.70), and the negative predictive value was 93% (95% CI, 0.64-0.99). CONCLUSIONS: The plusoptiX S08 is sensitive but less specific at detecting treatable ocular conditions in children with autism. The majority of children with autism and amblyopia risk factors were detected on screening; however, about half of all referrals had no amblyopia risk factors. The plusoptiX S08 reduced the need for a full examination in one-third of the children screened.

Totally laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon disease of elderly patients who present with bowel obstruction. Mortality and severe complications are common, even in modern series, due to the comorbidities in the affected patient population. A number of less invasive ways to treat this disease are described. We report on a case where enterolithotomy was performed laparoscopically. The patient is a 60-year-old diabetic woman who presented with a bowel obstruction and pneumobilia on abdominal radiographs. She underwent exploratory laparoscopy using three reusable ports, an enterolithotomy, and her remaining bowel was examined. The benefits to a minimal access approach to this rare disorder are discussed. The ability to suture laparoscopically is emphasized.

Pheochromocytoma.

Causes of hypertension that are amenable to surgical treatment constitute a very small but potentially important segment of the hypertensive population. These causes (which constitute frequently asked questions for medical students) include coarctation of the aorta, aldosterone and corticosteroid-producing tumors of the adrenal glands, lesions producing decreased renal blood flow, and pheochromocytoma. This latter tumor is quite uncommon, with a frequency of roughly one per million, but often produces dramatic hypertensive episodes. Due to its rarity, physicians in practice may not consider the diagnosis and appropriately evaluate the patient. We present the case histories of three patients with pheochromocytoma who demonstrate important features of this disease. Diagnostic evaluation and principles of treatment will be discussed.

Immunologic responses to pneumonia.

Pneumonia in the critically ill surgical patient often results from the bombardment of a previously normal pulmonary system with therapeutic foreign bodies, hospital pathogens, and impairment of the host defenses. Despite its long history as a significant clinical problem, a woefully inadequate amount of study has been directed toward therapy. We created an experimental model of a differential pulmonary infection using a strain of Klebsiella pneumoniae. We then compared the progressively affected pneumonic process versus the normal parenchyma. We measured neutrophil and monocyte complement antibody receptor expression and monocyte and macrophage class II major histocompatibility antigens (HLA-DR) via percent of cells and mean fluorescent intensity outcomes from flow cytometry. The main difference between infected versus noninfected tissues was monocyte DR expression, which was consistently depressed in cells from infected parenchyma. What follows is a discussion of the implications of this work as well as other work in the immunology of pneumonia and cytokine expression. Possible therapeutic modalities are included.

Antibiotic efficacy against Staphylococcus epidermidis adherent to vascular grafts.

Antibiotic bonded grafts may improve the treatment results of vascular graft infections. The purpose of this study was to determine the antibiotic and antibiotic concentration needed to be effective against Staphylococcus epidermidis-infected vascular grafts. The efficacy of four antibiotics (minocycline, cefazolin, vancomycin, and rifampin) against S. epidermidis adherent to Dacron or Teflon vascular grafts was studied in vitro. Kill kinetic studies were performed with 18 and 42 hr of exposure of Dacron-adherent and Teflon-adherent S. epidermidis at 1, 4, 16, and 64 times the minimum inhibitory concentration (MIC) of each antibiotic. Antibiotic efficacy against graft-adherent S. epidermidis at 42 hr was best at concentrations 64x MIC for minocycline, cefazolin, and vancomycin and 4x MIC for rifampin. None of the antibiotics totally eradicated the graft-adherent bacteria. Antibiotics were equally effective for S. epidermidis adherent to Dacron and Teflon grafts. Antibiotic concentrations several times that predicted by the MIC were needed for all antibiotics to achieve significant killing of graft-adherent bacteria, with rifampin the most effective at the lowest concentration.

Immunosuppression augments growth of graft-adherent Staphylococcus epidermidis.

OBJECTIVE: To determine if systemic suppression of host defenses during graft implantation alters the initial adherence and subsequent growth of Staphylococcus epidermidis on vascular prostheses. DESIGN: Dacron grafts 1 cm2 were implanted in the back subcutaneous tissue of Swiss-Webster mice (n = 247), followed by topical inoculation with 2 x 10(7), 2 x 10(5), 2 x 10(3), or 2 x 10(1) colony-forming units of S epidermidis. Half of the mice were immunosuppressed with cyclophosphamide (150 mg/kg intraperitoneally), to achieve a consistent, significant decrease in the white blood cell count and major histocompatibility complex class II (Ia) expression. Control mice received an equal volume of saline solution. Graft bacterial biofilm concentrations were determined at 1 day for adherence and within 2 weeks for bacterial growth, by using sonication and quantitative agar culture. RESULTS: Immunosuppression did not significantly alter the initial adherence of bacteria to vascular grafts. Immunosuppressed animals that were inoculated with 2 x 10(7) and 2 x 10(5) colony-forming units of S epidermidis had significantly higher bacterial biofilm concentrations as compared with those in control animals. Graft infection persisted at 14 days in all animals, with and without immunosuppression. CONCLUSIONS: Suppression of immune function during graft implantation augmented growth of adherent bacteria. The effect of short-term perioperative immunosuppression on late-appearing S epidermidis graft infection needs further study.

Canadian Bacterial Diseases Network: a new approach to university-industry relationships.

Bacterial diseases are a substantial problem worldwide. Their diagnosis and therapy form the basis of a multibillion dollar industry. This industry is dynamic and is continuously revitalized by research. The Canadian Bacterial Diseases Network (CBDN) was established to capitalize on the enhanced opportunities that now exist for the rapid progression of an idea from conceptualization to implementation and, ultimately, commercialization. CBDN is one of 15 Networks of Centres of Excellence, a Federal Government initiative whose intention is to improve Canada's economic competitiveness in the global market. CBDN research involves fundamental science, is broadly-based, and encompasses all aspects of bacterial diseases. Current projects include the investigations of strategies to block Pseudomonas aeruginosa binding to epithelial cells and a novel anti-toxin approach for Escherichia coli. Also CBDN is investigating the basis for antibiotic resistance in Gram-negative bacteria, and is devising improved procedures for overcoming such resistance mechanisms. CBDN is only 28 months into its first 4-year mandate; however, considerable successes have been enjoyed to date.