Evaluation of the Determinants of Satisfaction With Postoperative Pain Control After Thoracoscopic Surgery: A Single-Center, Survey-Based Study.

BACKGROUND: The need to measure, compare, and improve the quality of pain management is important to patients, payers, and health care providers. Pain after thoracic surgery can be severe, and thoracoscopic approaches have not had the favorable impact on pain as anticipated. The aim of this study was to evaluate the determinants of patient satisfaction with acute pain management and the effectiveness of pain control after video-assisted thoracoscopic surgery using a modified version of the Revised American Pain Society Patient Outcome Questionnaire. METHODS: We performed a single-center, prospective, survey-based study of 300 patients who had undergone elective video-assisted thoracoscopic surgery. Patients were enrolled and completed the survey on postoperative day 1 or 2. The primary outcome variable was patient-reported satisfaction with acute postoperative pain treatment measured on a 1-4 scale. The relationship between the items on the survey and patient satisfaction was analyzed to determine the factors significantly associated with satisfaction. RESULTS: Fifty-one percent of the patients had the highest satisfaction level with pain treatment, and 4% of the patients had the lowest satisfaction level. The mean reported acceptable pain level was 3.8 ± 1.9 (numeric rating scale [NRS], 0-10). The average pain intensity score at the time of the survey was 2.8 ± 2.1 (NRS, 0-10). The median for the most pain in the prior 24 hours was 7 (NRS, 0-10; interquartile range, 5-9). Five items from the survey were significantly associated with the satisfaction level. The predictor with the highest associated odds ratio (OR) with satisfaction was the ability to participate in pain management decisions (OR, 1.45; P < .0001). Another positively associated predictor was receiving helpful information about pain treatment options (OR, 1.31; P = .002). Negatively associated predictors of patient satisfaction included level of pain intensity at time of survey (OR, 0.76; P = .002), lowest pain score in the prior 24 hours (OR, 0.70; P = .0006), and having pain interfere with sleep in the postoperative period (OR, 0.72; P = .037). CONCLUSIONS: Our findings highlight several factors associated with patient satisfaction with acute postoperative pain management. Interventions focused on achieving acceptable pain levels for the majority of the time, ensuring that patients are able to get sleep, providing patients with helpful information about their pain treatment, and, most importantly, allowing patients to participate in decisions about their pain management may improve patient satisfaction with postoperative pain management.

Genetic discrimination and the need for federal legislation.

The advent of the Human Genome Project signaled a new era in preventative care. However, this Project threatens to create a new form of employment discrimination, which legislation has yet to sufficiently address. Courts are attempting to utilize a variety of currently enacted laws to combat such discrimination but it is clear that this may be an inadequate deterrence. To combat this problem, a new set of laws and regulations will need to be enacted to ensure that the interests of employers are upheld while maintaining proper protection of employees from genetic discrimination. This paper focuses on genetic testing in the workplace and the need for Federal legislation.

The role of a murine transplantation model of atherosclerosis regression in drug discovery.

Atherosclerosis is the leading cause of death worldwide. To date, the use of statins to lower LDL levels has been the major intervention used to delay or halt disease progression. These drugs have an incomplete impact on plaque burden and risk, however, as evidenced by the substantial rates of myocardial infarctions that occur in large-scale clinical trials of statins. Thus, it is hoped that by understanding the factors that lead to plaque regression, better approaches to treating atherosclerosis may be developed. A transplantation-based mouse model of atherosclerosis regression has been developed by allowing plaques to form in a model of human atherosclerosis, the apoE-deficient mouse, and then placing these plaques into recipient mice with a normolipidemic plasma environment. Under these conditions, the depletion of foam cells occurs. Interestingly, the disappearance of foam cells was primarily due to migration in a CCR7-dependent manner to regional and systemic lymph nodes after 3 days in the normolipidemic (regression) environment. Further studies using this transplant model demonstrated that liver X receptor and HDL are other factors likely to be involved in plaque regression. In conclusion, through the use of this transplant model, the process of uncovering the pathways regulating atherosclerosis regression has begun, which will ultimately lead to the identification of new therapeutic targets.

Functional characterization of filamin a interacting protein 1-like, a novel candidate for antivascular cancer therapy.

Inhibiting angiogenesis has become a major therapeutic strategy for cancer treatment. To identify common intracellular mediators, we previously analyzed gene expression profiles of endothelial cells after treatment with angiogenesis inhibitors. Filamin A interacting protein 1-like (FILIP1L; previously known as down-regulated in ovarian cancer 1) was identified as one of the genes up-regulated in endothelial cells in response to these inhibitors. However, the expression and function of FILIP1L protein is uncharacterized. Here, we provide the first description of the expression and specific subcellular localization of FILIP1L protein in human tissue. Overexpression of FILIP1L resulted in inhibition of cell proliferation and migration and increased apoptosis. In addition, overexpression of FILIP1L truncation mutants showed differential antiproliferative activity. A COOH terminal truncation mutant (FILIP1LDeltaC103) was more potent than wild-type FILIP1L in mediating this activity. Targeted expression of FILIP1LDeltaC103 in tumor vasculature inhibited tumor growth in vivo. Overall, these findings suggest that the novel protein FILIP1L may be an important mediator of the effects of angiogenesis inhibitors and that FILIP1L has the potential to be an antivascular reagent for cancer therapy.

Idiopathic interstitial pneumonia: do community and academic physicians agree on diagnosis?

RATIONALE: Treatment and prognoses of diffuse parenchymal lung diseases (DPLDs) varies by diagnosis. Obtaining a uniform diagnosis among observers is difficult. OBJECTIVES: Evaluate diagnostic agreement between academic and community-based physicians for patients with DPLDs, and determine if an interactive approach between clinicians, radiologists, and pathologists improved diagnostic agreement in community and academic centers. METHODS: Retrospective review of 39 patients with DPLD. A total of 19 participants reviewed cases at 2 community locations and 1 academic location. Information from the history, physical examination, pulmonary function testing, high-resolution computed tomography, and surgical lung biopsy was collected. Data were presented in the same sequential fashion to three groups of physicians on separate days. MEASUREMENTS AND MAIN RESULTS: Each observer's diagnosis was coded into one of eight categories. A kappa statistic allowing for multiple raters was used to assess agreement in diagnosis. Interactions between clinicians, radiologists, and pathologists improved interobserver agreement at both community and academic sites; however, final agreement was better within academic centers (kappa = 0.55-0.71) than within community centers (kappa = 0.32-0.44). Clinically significant disagreement was present between academic and community-based physicians (kappa = 0.11-0.56). Community physicians were more likely to assign a final diagnosis of idiopathic pulmonary fibrosis compared with academic physicians. CONCLUSIONS: Significant disagreement exists in the diagnosis of DPLD between physicians based in communities compared with those in academic centers. Wherever possible, patients should be referred to centers with expertise in diffuse parenchymal lung disorders to help clarify the diagnosis and provide suggestions regarding treatment options.

Six rapid tests for direct detection of Clostridium difficile and its toxins in fecal samples compared with the fibroblast cytotoxicity assay.

Clostridium difficile is one of the most frequent causes of nosocomial gastrointestinal disease. Risk factors include prior antibiotic therapy, bowel surgery, and the immunocompromised state. Direct fecal analysis for C. difficile toxin B by tissue culture cytotoxin B assay (CBA), while only 60 to 85% sensitive overall, is a common laboratory method. We have used 1,003 consecutive, nonduplicate fecal samples to compare six commercially available immunoassays (IA) for C. difficile detection with CBA: Prima System Clostridium difficile Tox A and VIDAS Clostridium difficile Tox A II, which detect C. difficile toxin A; Premier Cytoclone A/B and Techlab Clostridium difficile Tox A/B, which detect toxins A and B; and ImmunoCard Clostridium difficile and Triage Micro C. difficile panels, which detect toxin A and a species-specific antigen. For all tests, Triage antigen was most sensitive (89.1%; negative predictive value [NPV] = 98.7%) while ImmunoCard was most specific (99.7%; positive predictive value [PPV] = 95.0%). For toxin tests only, Prima System had the highest sensitivity (82.2%; NPV = 98.0%) while ImmunoCard had the highest specificity (99.7%; PPV = 95.0%). Hematopoietic stem cell transplant (HSCT) patients contributed 44.7% of all samples tested, and no significant differences in sensitivity or specificity were noted between HSCT and non-HSCT patients. IAs, while not as sensitive as direct fecal CBA, produce reasonable predictive values, especially when both antigen and toxin are detected. They also offer significant advantages over CBA in terms of turnaround time and ease of use.