Assessment and management of pain in haemophilia patients.

Haemophilia patients experience acute pain during joint bleeds and chronic pain from haemophilic arthropathy. More than 50% of haemophilia patients have painful joints that cause disability and impair quality of life. Unfortunately, only a few clinical studies have investigated the non-pharmacological or pharmacological treatments for pain or the adverse effects of pain on the health and quality of life of children and adults with haemophilia. There are no detailed algorithms or guidelines for pain management in haemophilia patients, and treatment is largely empirical. Therefore, a standardized approach to the management of pain in haemophilia patients is needed. This approach should include a close relationship between pain specialists and the staffs at haemophilia treatment centres; validated instruments specific to haemophilia for assessing pain, quality of life and disability; and stepwise algorithms/protocols for treatment of chronic vs. acute pain and prophylactic vs early treatment. A pain treatment protocol should include a definition of the problem of pain and best practices for physicians. A call to action is needed to standardize treatment approaches to pain and to develop algorithms/protocols for the management of pain in haemophilia patients. This review will highlight the prevalence and devastating impact of pain in haemophilia patients, currently available treatment options and identify the unmet needs for pain management.

Development of the U.S. Army Ambulatory Care Data Base.

In providing more than 22 million outpatient visits per year, the U.S. Army Medical Department is one of the largest Health Maintenance Organizations in the world. Accordingly, the need for an Ambulatory Care Data Base (ACDB) to provide management, epidemiological, and cost indicators has long been recognized by the Army. As part of a multi-year study, the ACDB was developed to meet this need. Issues and problems faced in implementing such a wide-scale effort are discussed. Preliminary results from data collected on over 3 million outpatient visits include types of health care providers and clinic specialties, with the corresponding number of visits.

Postpartum hemorrhage. A 90s approach to an age-old problem.

Severe hemorrhage occurs in less than 1% of all pregnancies; however, it remains one of the important causes of maternal morbidity and mortality. Although the importance of hemorrhage has been recognized in obstetric circles for years, in the last decade or so, research has been conducted that has disproven long-held beliefs. Nurse-midwives must be knowledgeable about the etiology, management, and treatment of postpartum hemorrhage. This article presents an overview of postpartum hemorrhage and its pharmacologic and nurse-midwifery management. The overview includes definitions of postpartum hemorrhage, identifies risk factors for hemorrhage, and addresses problems associated with estimation of blood loss. The mechanisms of action of ergots, oxytocin, and prostaglandins are described, and criteria for selecting a medication are presented. Herbal remedies for hemorrhage are discussed briefly. Also discussed are the optimal time for drawing the hematocrit and what this laboratory value can tell the nurse-midwife.