Pilot randomised controlled trial of focused narrative intervention for moderate to severe depression in palliative care patients: DISCERN trial.

BACKGROUND: Depression is poorly detected and sub-optimally managed in palliative care patients, and few trials of psychosocial interventions have been carried out in this group of patients. AIMS: A pilot trial to determine the effect of a focused narrative intervention on depression in palliative care patients when used in addition to usual care. DESIGN: Patients scoring 10 or higher on Patient Health Questionnaire-9 randomised to focused narrative intervention in addition to usual care or usual care only and followed up at 2, 4 and 6 weeks. A reduction of five points on Patient Health Questionnaire-9 was regarded as clinically significant response to treatment. SETTING/PARTICIPANTS: Palliative care patients aged over 18 recruited from hospice day care services - exclusion criteria included an estimated prognosis of 6 weeks or less, cognitive impairment and unable to understand written or spoken English. RESULTS: Out of 57 participating patients (71% female), with mean age 65.1 years (range 36-88 years), 33 patients were randomised to the intervention and 24 to usual care only. Mean Patient Health Questionnaire-9 score at baseline was 16.4. Patients receiving intervention had greater reduction in Patient Health Questionnaire-9 score at 6-week follow-up ( p = 0.04). Median survival was 157 days for intervention and 102 days for control group patients ( p = 0.07). CONCLUSION: This pilot trial suggests a focused narrative intervention in palliative care patients with moderate to severe depression can reduce depression scores more than usual care alone. Patients receiving intervention appeared to have longer survival. These results support the need for a fully powered trial.

Acceptance of chronic neuropathic pain in spinal cord injured persons: a qualitative approach.

Chronic neuropathic pain (CNP) in spinal cord injury (SCI) is a significant problem that has physical, functional, and psychosocial repercussions beyond the consequences of SCI. The notion that acceptance may be a viable alternative to suffering when resolution of pain is unattainable was explored. Studies indicate that acceptance of pain is associated with lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily active time, and improved work status in patients who have other types of chronic pain. This exploratory qualitative study examined acceptance of pain in SCI individuals who have CNP. Grounded theory was used to develop a conceptual framework to describe acceptance in people with CNP and SCI. Data were obtained from in-depth interviews with seven SCI individuals. Six phases were identified, including: "comprehending the perplexity of CNP," "seeking pain resolution," "acknowledging pain permanence," "redefining core values," "learning to live with the pain," and "integrating pain." Two driving forces, "increasing independence" and "evolving pain view," were noted to move the process of acceptance forward. The findings in this study suggest that acceptance of pain appeared to be beneficial in terms of reducing suffering and facilitating a more satisfying and fulfilling life in these SCI individuals. A decreased emphasis on continued searching for a cure for CNP and movement toward a self-management approach was associated with increased pain coping for these SCI individuals. Clinical implications suggest that early intervention to facilitate effective coping and an exploration of the notion of acceptance could be beneficial.

The experience of cough in patients diagnosed with lung cancer.

PURPOSE: The aim of this study was to explore the patient experience of cough in a population of patients with lung cancer. METHODS: A qualitative exploratory study design was developed and elicited the views of 26 patients with lung cancer who had current or past experience with cough. RESULTS: The data's four themes highlight the complex and distressing nature of cough, including its interaction with other symptoms, such as breathlessness, fatigue and sleep disturbance. A theme around descriptions of cough suggests typically a dry tickly cough and highlights mechanical and environmental triggers for cough. The theme around the effects of cough in daily life shows the impact of cough in socialising, the embarrassment from cough and the psychological effects experienced by patients. The last theme focuses on strategies for coping with and managing cough, showing the perceived ineffectiveness of current antitussives and the patients' use of a variety of approaches on an ad hoc basis to try to manage their cough often unsuccessfully. CONCLUSION: Cough has not received the same attention as other cancer symptoms, which means that patients' experience of a distressing and difficult symptom is often unnoticed by health care professionals. More clinical and research attention in this debilitating symptom is necessary.

Improved practices for safe administration of intravenous bolus morphine in a pediatric setting.

Postoperative pain control is a clinical imperative, for which morphine is a preferred opioid. However, interpatient variability and drug accumulation with repeated doses, as well as medication errors, may result in respiratory arrest with this medication. Early detection of respiratory depression is essential for safe use of morphine, following both initial and repeated doses. A multidisciplinary team contributed to development of an intravenous (IV) bolus morphine monitoring guideline that reflects current knowledge of morphine pharmacokinetics. Monitoring over a 22-week period in a postsurgical unit was then assessed via record review. A total of 270 postsurgical patients received a first dose of IV bolus morphine, with 784 subsequent doses also administered. Complete monitoring (heart rate, respiratory rate, blood pressure, sedation score, oxygen saturation, and pain score) after the morphine bolus was documented at baseline and 10 and 20 minutes for 34%, 30%, and 23%, respectively, of the patients; partial monitoring (respiratory rate and oxygen saturation) was documented for an additional 22%, 15%, and 9% of patients; 43% of subsequent morphine doses were followed with complete monitoring, and an additional 30% with at least partial monitoring. Adherence to the monitoring procedure fluctuated over the study period with no consistent upward or downward trend. A small number of children exhibited a reduced respiratory rate potentially indicating respiratory depression, but no child required antidote or respiratory support. Despite suboptimal guideline adherence, potential signs of respiratory depression were detected that might otherwise have gone unnoticed. This validates the improved guideline and suggests that some incidents may have remained undetected. Front-line staff must be involved to optimize change, champion the initiative, and promote patient safety.

Domain motion in cytochrome P450 reductase: conformational equilibria revealed by NMR and small-angle x-ray scattering.

NADPH-cytochrome P450 reductase (CPR), a diflavin reductase, plays a key role in the mammalian P450 mono-oxygenase system. In its crystal structure, the two flavins are close together, positioned for interflavin electron transfer but not for electron transfer to cytochrome P450. A number of lines of evidence suggest that domain motion is important in the action of the enzyme. We report NMR and small-angle x-ray scattering experiments addressing directly the question of domain organization in human CPR. Comparison of the (1)H-(15)N heteronuclear single quantum correlation spectrum of CPR with that of the isolated FMN domain permitted identification of residues in the FMN domain whose environment differs in the two situations. These include several residues that are solvent-exposed in the CPR crystal structure, indicating the existence of a second conformation in which the FMN domain is involved in a different interdomain interface. Small-angle x-ray scattering experiments showed that oxidized and NADPH-reduced CPRs have different overall shapes. The scattering curve of the reduced enzyme can be adequately explained by the crystal structure, whereas analysis of the data for the oxidized enzyme indicates that it exists as a mixture of approximately equal amounts of two conformations, one consistent with the crystal structure and one a more extended structure consistent with that inferred from the NMR data. The correlation between the effects of adenosine 2',5'-bisphosphate and NADPH on the scattering curve and their effects on the rate of interflavin electron transfer suggests that this conformational equilibrium is physiologically relevant.

Cold therapy for the management of pain associated with deep breathing and coughing post-cardiac surgery.

BACKGROUND: Coughing has been identified as the most painful experience post cardiac surgery. METHODS: Participants (n = 32), in a randomized crossover trial, applied a frozen gel pack to their sternal incision dressing before performing deep breathing and coughing (DB & C) exercises. Pain scores from 0 to 10 at rest were compared with pain scores post DB & C with and without the gel pack. Participants were also asked to describe their sensations with the frozen gel pack, as well as their preferences for gel pack application. RESULTS: The repeated measures analysis of variance revealed a significant reduction in pain scores between pre- and post-application of the gel pack (F = 28.69, p < .001). There were 22 (69%) participants who preferred the application of the gel pack compared with no gel pack. All 32 (100%) participants would reapply the gel pack in the future. CONCLUSION: This study demonstrates that cold therapy can be used to manage sternal incisional pain when DB & C.

A Randomized Controlled Trial on the Use of Virtual Reality for Needle-Related Procedures in Children and Adolescents in the Emergency Department.

Objective: A large number of children report fear and distress when undergoing blood work and intravenous placement. In pediatric departments, Child Life interventions are considered to be the gold standard in nonmedical pain management techniques. Virtual reality (VR) has also been identified as an effective tool for pain distraction in children undergoing painful medical procedures. The aim of this study was to document the efficacy of VR as a mode of distraction during a medical procedure compared with two comparison conditions: watching television (TV, minimal control condition) and distraction provided by the Child Life (CL, gold standard control condition) program. Materials and Methods: A total of 59 children aged 8-17 years (35% female) were recruited through the emergency department (ED) of the Children's Hospital of Eastern Ontario and randomly assigned to one of the three conditions. The key outcome measures were visual analog scale ratings of pain intensity and fear of pain, administrated before and right after the procedure. Patient satisfaction was also measured after the intervention. Results: A significant reduction in fear of pain and pain intensity was reported in all three conditions. A larger and statistically significant reduction in fear of pain was observed among children who used VR distraction compared with the CL and TV conditions, but this effect was not observed for pain intensity. The children's satisfaction with the VR procedure was significantly higher than for TV and comparable to CL. Discussion: The advantages of using VR in the ED to manage pain in children are discussed.

Concurrent action of purifying selection and gene conversion results in extreme conservation of the major stress-inducible Hsp70 genes in mammals.

Several evolutionary mechanisms alter the fate of mutations and genes within populations based on their exhibited functional effects. To understand the underlying mechanisms involved in the evolution of the cellular stress response, a very conserved mechanism in the course of organismal evolution, we studied the patterns of natural genetic variation and functional consequences of polymorphisms of two stress-inducible Hsp70 genes. These genes, HSPA1A and HSPA1B, are major orchestrators of the cellular stress response and are associated with several human diseases. Our phylogenetic analyses revealed that the duplication of HSPA1A and HSPA1B originated in a lineage proceeding to placental mammals, and henceforth they remained in conserved synteny. Additionally, analyses of synonymous and non-synonymous changes suggest that purifying selection shaped the HSPA1 gene diversification, while gene conversion resulted in high sequence conservation within species. In the human HSPA1-cluster, the vast majority of mutations are synonymous and specific genic regions are devoid of mutations. Furthermore, functional characterization of several human polymorphisms revealed subtle differences in HSPA1A stability and intracellular localization. Collectively, the observable patterns of HSPA1A-1B variation describe an evolutionary pattern, in which purifying selection and gene conversion act simultaneously and conserve a major orchestrator of the cellular stress response.

Implementing best practice pain management in a pediatric hospital.

PURPOSE: This study aims to evaluate the implementation of a comprehensive program to improve pain management practices in a pediatric hospital. METHODS: The pretest posttest design used questionnaires, patient record audits, and postimplementation focus groups with 366 nurses and 8 physicians. RESULTS: Positive changes occurred in the use of pain scales and in valuing good pain management. The program was less effective in improving procedural pain management and pain documentation. PRACTICE IMPLICATIONS: Important program strengths were the "local champions" (Pain Resource Nurses) and the ongoing support and expertise of the pain committee. Systematic evaluation was important to document successes as well as areas requiring further focus.

Information structure and organisation in change of shift reports: An observational study of nursing hand-offs in a Paediatric Intensive Care Unit.

Patient hand-offs involve the exchange of critical information. Ineffective hand-offs can result in reduced patient safety by leading to wrong treatment, delayed diagnoses or other outcomes that can negatively affect the healthcare system. The objectives of this study were to uncover the structure of the information conveyed during patient hand-offs and look for principles characterising the organisation of the information. With an observational study approach, data was gathered during the morning and evening nursing change of shift hand-offs in a Paediatric Intensive Care Unit. Content analysis identified a common meta-structure used for information transfer that contained categories with varying degrees of information integration and the repetition of high consequence information. Differences were found in the organisation of the hand-off structures, and these varied as a function of nursing experience. The findings are discussed in terms of the potential benefits of computerised tools which utilise standardised structure for information transfer and the implications for future education and critical care skill acquisition.

Pain in hospitalized pediatric patients: how are we doing?

OBJECTIVE: The purpose of this study was to provide a baseline description of the prevalence of pain and pain management strategies in a pediatric hospital and to compare the prevalence of pain in this hospital to that in published reports in the literature. METHODS: Two hundred thirty-seven children ranging in age from 10 days to 17 years and 223 parents participated in an 8-hour survey on 5 inpatient units. Information about pain intensity and pain affect was collected from the children older than 6 years of age and from parents of those who were younger at 4 2-hour intervals. Information about procedural pain was collected from children, parents, and health care professionals over this 8-hour period. The type and amount of analgesia were also noted. RESULTS: More than 20% of the children had clinically significant pain at each of the 2-hour intervals, and 7 had pain scores of 5/10 or greater for the majority of the study day. At least 50% of the children were found to be pain-free during the 4 intervals, and there was a high level of agreement between parents and children's pain-intensity ratings. One hundred fifty-seven children had medication ordered and 80 children had no analgesia ordered. There was no significant correlation between characteristics of the patients and amounts or types of medication given. No analgesia was administered via intramuscular or subcutaneous injection. DISCUSSION: Although these results are encouraging in that a significant portion of the children were pain-free during the study day, the number of children who had clinically significant pain was too high. The results of this study compare with others in that a significant number of children were inadequately treated for pain. Clinical implications are discussed.

Chronic neuropathic pain in spinal cord injury: the patient's perspective.

BACKGROUND: Chronic neuropathic pain (CNP) in spinal cord injury (SCI) is recognized as severely compromising, in both adjustment after injury and quality of life. Studies indicate that chronic pain in SCI is associated with great emotional distress over and above that of the injury itself. Currently, little is known about the SCI patient's perception of the impact of living with chronic neuropathic pain. OBJECTIVES: The purpose of this study was to explore the experience of CNP in SCI patients in relation with physical, emotional, psychosocial, environmental, informational, practical and spiritual domains, and to identify effective and ineffective pain coping strategies. METHODS: Three focus groups were conducted that included 24 SCI individuals living in the community. Participants were selected to maximize variation in terms of type of SCI, Frankel classification, years since onset of SCI, age and sex. The sessions were audiotaped and tapes were transcribed. A qualitative analysis of data involved a constant comparison approach, in which categories and themes were identified. RESULTS: Many complex themes emerged including: nature of pain; coping as process and product; medication failure; and the impact of CNP on physical, cognitive, emotional, interpersonal, social and life activities. CONCLUSIONS: Medication failure was identified as a common outcome, while strategies including use of warm water, swimming, increased activity and distraction provided temporary pain relief. Learning to live with the pain appeared to be related to acceptance of pain, which in turn seemed to facilitate adjustment. Further research is warranted to determine the process by which SCI patients learn to live with CNP and coping strategies that facilitate adjustment to CNP in SCI patients.

Recommendations for improved acute pain services: Canadian collaborative acute pain initiative.

The Canadian Collaborative Acute Pain Initiative, established in 2002, is a voluntary, multidisciplinary consortium of acute pain health professionals from across Canada whose goal is to improve acute pain management through discussion and consensus. The group met in January 2002 to define strategic areas related to the treatment of acute pain. The areas identified were: the definition of pain; the epidemiology of pain; the concept of an 'ideal' acute pain management service; education; therapeutic options; symptom management; and research and safety. In November 2002, a second meeting was held to develop objectives and recommendations for the management of acute pain based on the defined areas. The outcome of these discussions is summarized in this paper.

Pain prevalence in a pediatric hospital: raising awareness during Pain Awareness Week.

BACKGROUND: Despite the evidence and availability of numerous validated pain assessment tools and pain management strategies for infants and children, their use remains inconsistent in clinical practice. OBJECTIVES: To describe the prevalence of pain, pain assessment and pain management practices at a tertiary pediatric hospital in Canada. METHODS: The cross-sectional study design involved a combination of interviews with children and/or caregivers, and chart audits in five inpatient units. Information regarding pain intensity, painful procedures and pain management strategies was obtained from children and/or caregivers by interview. Patient charts were reviewed for information regarding pain assessment, pain scores, and pharmacological and nonpharmacological interventions. RESULTS: Sixty-two children (four days to 17 years of age) participated. Most children or their caregivers (n=51 [84%]) reported that pain was experienced during their hospitalization, with 40 (66%) reporting their worst pain as moderate or severe. Almost one-half reported analgesics were administered before or during their most recent painful procedure. Nineteen (32%) reported sucrose, topical anesthetics or nonpharmacological interventions were used; however, they were documented in only 17% of charts. Pain scores were documented in 34 (55%) charts in the previous 24 h. The majority of the children or their caregiver (n=44 [71%]) were satisfied with pain management at the study hospital. CONCLUSIONS: Most infants and children had experienced moderate or severe pain during their hospitalization. Analgesics were frequently used, and although nonpharmacological strategies were reported to be used, they were rarely documented. Most parents and children were satisfied with their pain management.

Redox-linked domain movements in the catalytic cycle of cytochrome p450 reductase.

NADPH-cytochrome P450 reductase is a key component of the P450 mono-oxygenase drug-metabolizing system. There is evidence for a conformational equilibrium involving large-scale domain motions in this enzyme. We now show, using small-angle X-ray scattering (SAXS) and small-angle neutron scattering, that delivery of two electrons to cytochrome P450 reductase leads to a shift in this equilibrium from a compact form, similar to the crystal structure, toward an extended form, while coenzyme binding favors the compact form. We present a model for the extended form of the enzyme based on nuclear magnetic resonance and SAXS data. Using the effects of changes in solution conditions and of site-directed mutagenesis, we demonstrate that the conversion to the extended form leads to an enhanced ability to transfer electrons to cytochrome c. This structural evidence shows that domain motion is linked closely to the individual steps of the catalytic cycle of cytochrome P450 reductase, and we propose a mechanism for this.

Establishing the psychometric properties and preferences for the Northern Pain Scale.

OBJECTIVES: A culturally relevant, evidence-based pain assessment scale in Inuktitut is needed. Psychometric properties and preferences for the Northern Pain Scale (NorthPS), a revised version of the Wong-Baker FACES scale, were examined. STUDY DESIGN: This repeated-measures, within-subjects study involved 2 face-to-face interviews held 2 weeks apart. METHODS: Participants were recruited from 2 schools and a community centre in Pangnirtung, Nunavut, Canada. Three pain scales (NorthPS, FACES and a numerical rating scale) were used to rate the pain portrayed in an adapted version of the Charleston Pediatric Pain Pictures (NorthCPPP, a series of 17 cartoon vignettes). RESULTS: The study involved 188 participants ranging in age from 5 to 83 years. Compared with the established FACES and numerical scales, the concurrent validity of the NorthPS was acceptable, with all 3 pain scales producing similar scores for the North CPPP vignettes. The youngest children were slightly more accurate during the second interview; otherwise, scoring accuracy was similar during both interviews. Accuracy was also similar across pain scales. Spearman correlations between NorthPS and other scales were lowest for the "No" pain vignettes, and for the youngest children. Internal consistency was acceptable for the NorthPS when compared with FACES and numerical scales. FACES was preferred by the majority of children and NorthPS was preferred by the majority of adults. CONCLUSIONS: NorthPS, a pain scale adapted to Inuit language and culture, was validated using the NorthCPPP with children and adults. The NorthPS is a well-understood, culturally and linguistically adapted option for the assessment of pain for Inuktitut speaking children and adults.

Review of prescribing practices for intermittent bolus administration of morphine.

BACKGROUND: Several changes to medication safety practices were proposed in a pediatric hospital, including changing the period of patient observation after administration of opioids and limiting the availability of various concentrations of morphine in the patient care unit. OBJECTIVE: To document and review postoperative pain management for children on a surgical ward, specifically with regard to intermittent IV bolus administration of morphine, to help in assessing the impact of the proposed nursing practice changes. METHODS: Data were collected from records for narcotics and controlled drugs for the surgical ward over a 3-month period (April to June 2006). For each patient, data had been recorded for up to 7 consecutive days after surgery. A patient's data were included in the review if he or she had received at least 2 doses of morphine by IV bolus, except for the review of weight-based dosing pattern (mg/kg), for which all patients who had received at least one dose of IV morphine were included. RESULTS: Charts for 193 patients were audited. Of these, 163 patients (84.5%) had recieved up to 0.1 mg/kg per dose, and 53 (27.5%) had received only one dose of morphine. Among patients who received more than one dose, the median dose was 0.080 mg/kg on day 1, with a decrease by day 5 to 0.065 mg/kg. Most patients received morphine over the first 2 days after surgery. The median time elapsed between doses was 4.3 h on day 1 and 6.2 h on day 2. Of the 1020 doses included in the analysis, most (801 [78.5%]) were 4 mg or less. CONCLUSION: The intermittent administration of IV bolus doses of morphine at the study hospital followed common standards for the treatment of postoperative pain. Most doses were no more than 4 mg. On the basis of this information, only 2-mg vials of morphine are now stocked on the ward. The hospital's change in monitoring practices will increase the surveillance of patients receiving IV bolus doses of morphine.

Impact of a school health coordinator intervention on health-related school policies and student behavior.

BACKGROUND: Health-related, school-based interventions may serve to prevent disease and improve academic performance. The Healthy Maine Partnerships (HMP) initiative funded local school health coordinators (SHCs) as a part of Maine's Coordinated School Health Program (CSHP) beginning in January 2001. SHCs established school health leadership teams and implemented annual work plans to address health risk behaviors. This study evaluates the impact of the Healthy Maine Partnerships SHC (HMPSHC) intervention on school policies and student risk behaviors after its first 5 years. METHODS: Data sources include the Maine School Health Profiles Survey and the Maine Youth Drug and Alcohol Use Survey/Youth Tobacco Survey. Cross-sectional analyses were performed on 2006 data to assess physical activity, nutrition, and tobacco-related policy associations with the HMPSHC intervention. Finally, policy and student behavior analyses were conducted to assess associations. RESULTS: Intervention schools were more likely to be associated with physical activity intramural offerings, improved nutritional offerings, and tobacco cessation programs. In intervention schools, supportive school policies were associated with decreased soda consumption, decreased inactivity, and decreased tobacco use. Required school health education curricula were more predictive of decreased risk behavior in intervention schools than in nonintervention schools. CONCLUSIONS: In schools with SHCs, there exists a stronger association with improved school programs. Improved policies and programs were associated with decreases in risk behavior among students in intervention schools. The HMPSHC intervention may be a viable CSHP model to replicate and evaluate in other settings.