Patient self-reports are the primary method for capturing the experience of pain, and diaries are often used to collect patient self-reports. This study was designed to determine if momentary ...monitoring of pain with an electronic diary affected pain levels over time, if it affected weekly recall of pain, and if daily sampling density affected compliance rates and patients’ reactions to the study. Ninety-one patients with chronic pain were randomized into four groups with differing levels of momentary monitoring over 2 weeks. Little support was found for reactivity defined as temporal shifts in pain over the study or as changes in recalled weekly pain due to momentary monitoring. Compliance with the electronic diary protocol was 94% or better, and was not related to sampling density. Patients reported little difficulty with the diary procedures and were not unduly burdened by the protocol.
To better understand the association between pain recalled over a previous week and the average of multiple momentary reports of pain taken during the same period, 68 patients with chronic pain ...completed both weekly recall and momentary reports over a 2-week period and assessed their change in pain over the 2 weeks. Pearson correlations and intraclass correlation coefficients were computed to index three different ways of comparing the measures on both a between-person and within-person basis. Between-person correspondence between weekly and momentary reports was generally moderate to high, but within-person correspondence was low. Judged change was only weakly related to changes over a week computed from weekly recall or from average momentary reports. Given the importance of within-person change for treatment studies, these results indicate a serious nonequivalence in weekly recall and averaged momentary reports of pain.
Paper diaries are commonly used in health care and clinical research to assess patient experiences. There is concern that patients do not comply with diary protocols, possibly invalidating the ...benefit of diary data. Compliance with paper diaries was examined with a paper diary and with an electronic diary that incorporated compliance-enhancing features. Participants were chronic pain patients and they were assigned to use either a paper diary instrumented to track diary use or an electronic diary that time-stamped entries. Participants were instructed to make three pain entries per day at predetermined times for 21 consecutive days. Primary outcome measures were reported vs actual compliance with paper diaries and actual compliance with paper diaries (defined by comparing the written times and the electronically-recorded times of diary use). Actual compliance was recorded by the electronic diary. Participants submitted diary cards corresponding to 90% of assigned times (±15 min). However, electronic records indicated that actual compliance was only 11%, indicating a high level of faked compliance. On 32% of all study days the paper diary binder was not opened, yet reported compliance for these days exceeded 90%. For the electronic diary, the actual compliance rate was 94%. In summary, participants with chronic pain enrolled in a study for research were not compliant with paper diaries but were compliant with an electronic diary with enhanced compliance features. The findings call into question the use of paper diaries and suggest that electronic diaries with compliance-enhancing features are a more effective way of collecting diary information.
Self-report ratings of pain intensity are ubiquitous in research and clinical practice. In addition to rating their current pain, patients are often asked to provide ratings to represent pain ...intensity over several days or weeks. Few data are available that provide insight into how people understand and accomplish this recall task. This study describes the results of structured interviews with 106 rheumatology patients with chronic pain about how they arrived at their ratings of pain intensity on a visual analog scale referenced to the past week. Most patients were unable to coherently articulate how they derived their ratings. Moreover, there was no consistency across patients. A variety of different strategies were identified that guided their responses. These results support the concern about the meaning and validity of retrospective recall ratings. Recall of pain, a seemingly simple task, is a deceptively more complex phenomenon. Efforts to improve the measurement of recalled pain need to be explored. Improving instructional sets, clearer specification of the dimensions of pain being targeted, avoiding use of a single item to measure pain, improved description of intended reference groups, and determining the length of time that patients are able to remember pain and limiting recall periods are reasonable methods that need to be explored.
These results emphasize our lack of a full understanding of the meaning of the information elicited by commonly used pain recall questions. They point to the potential importance of clearly specifying what qualities of pain are sought and how the patient should summarize them over the reporting period.
Compliance with a paper diary protocol would be improved by using auditory signaling.
Prior research has demonstrated that compliance with the reporting schedule in paper diary protocols is poor.
...Adults with chronic pain (N = 27) were recruited from the community to participate in a 24-day experience sampling protocol of 3 pain assessments per day (10:00 a.m., 4:00 p.m., 8:00 p.m.). Diaries were instrumented to record openings and closings, thereby permitting determination of date and time when the participant could have made diary entries. Participants were signaled with a programmed wristwatch at the onset of each 30-min assessment window. Two compliance windows were defined: -/+ 15 min and -/+ 45 min of the targeted assessment time.
Self-reported compliance based on participants' paper diaries was 85% and 91% for the 30- and 90-min windows. Verified compliance was 29% and 39% for the two windows. Signaling produced a significant increment in verified compliance when compared with an identical trial without signaling. A significant eroding of verified compliance was observed across the 3 weeks of the study.
Self-report dating of diary entries may be misleading investigators about compliance with diary protocols. Although auditory signaling enhances compliance, the result is still unsatisfactory.
Patients with systemic lupus are at increased risk for myocardial infarction. In this study, the extent of carotid atherosclerosis was investigated by ultrasonography in patients with lupus and ...matched controls. Patients with lupus had premature atherosclerosis that was not related to traditional cardiovascular risk factors.
Premature atherosclerosis not related to traditional risk factors.
The diagnostic criteria for systemic lupus erythematosus, the prototypical autoimmune disease, focus on its major clinical manifestations, particularly renal, neurologic, and hematologic disease. In 1976, Urowitz et al. noted premature myocardial infarction among patients with lupus,
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a finding confirmed by subsequent studies.
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,
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However, the reported cardiovascular outcomes are based on relatively few events, and the prevalence of atherosclerosis among patients with lupus and its relation to that in a control population are unknown. Furthermore, controversy remains regarding the mechanism of premature atherosclerosis. The prevailing hypothesis holds that premature atherosclerosis in lupus is attributable to an increased frequency of conventional . . .
Patients were instructed to complete daily entries at 10 am, 4 pm, and 8 pm within 15 minutes of the target times. With the electronic diary, entries could not be initiated outside the designated 30 ...minute windows. We considered paper diary entries to be compliant if they were made within the 30 minute windows. A more liberal secondary outcome allowed a 90 minute window around the target times. Reported compliance was based on the time and date that patients recorded on their paper diary cards.
Cardiovascular events occur most frequently in the morning hours. We prospectively studied the association between the morning blood pressure (BP) surge and stroke in elderly hypertensives.
We ...studied stroke prognosis in 519 older hypertensives in whom ambulatory BP monitoring was performed and silent cerebral infarct was assessed by brain MRI and who were followed up prospectively. The morning BP surge (MS) was calculated as follows: mean systolic BP during the 2 hours after awakening minus mean systolic BP during the 1 hour that included the lowest sleep BP. During an average duration of 41 months (range 1 to 68 months), 44 stroke events occurred. When the patients were divided into 2 groups according to MS, those in the top decile (MS group; MS > or =55 mm Hg, n=53) had a higher baseline prevalence of multiple infarcts (57% versus 33%, P=0.001) and a higher stroke incidence (19% versus 7.3%, P=0.004) during the follow-up period than the others (non-MS group; MS <55 mm Hg, n=466). After they were matched for age and 24-hour BP, the relative risk of the MS group versus the non-MS group remained significant (relative risk=2.7, P=0.04). The MS was associated with stroke events independently of 24-hour BP, nocturnal BP dipping status, and baseline prevalence of silent infarct (P=0.008).
In older hypertensives, a higher morning BP surge is associated with stroke risk independently of ambulatory BP, nocturnal BP falls, and silent infarct. Reduction of the MS could thus be a new therapeutic target for preventing target organ damage and subsequent cardiovascular events in hypertensive patients.
The objectives of this study were to assess whether socioeconomic status (SES) is associated with dysregulation of the cortisol diurnal rhythm and whether this association is independent of race and ...occurs equally in whites and blacks; and to determine if an association between SES and cortisol can be explained (is mediated) by behavioral, social, and emotional differences across the SES gradient.
Seven hundred eighty-one subjects from a multisite sample representing both whites and blacks provided six saliva cortisol samples over the course of the day: at awakening, 45 minutes, 2.5 hours, 8 hours, and 12 hours after awakening, and at bedtime.
Both lower SES (education and income) and being black were associated with higher evening levels of cortisol. These relationships were independent of one another and SES associations with cortisol were similar across racial categories. The evidence was consistent with poorer health practices (primarily smoking), higher levels of depressive symptoms, poorer social networks and supports, and feelings of helplessness (low mastery) mediating the link between SES and cortisol. However, we found no evidence for psychosocial or behavioral mediation of the association between race and cortisol response.
Lower SES was associated in a graded fashion with flatter diurnal rhythms as a result of less of a decline during the evening. This association occurred independent of race and the data were consistent with mediation by health practices, emotional and social factors. Blacks also showed a flatter rhythm at the end of the day. This association was independent of SES and could not be explained by behavioral, social, or emotional mediators.
The authors measured mRNA for the T-cell marker
FOXP3,
as well as for CD25, CD3ε, perforin, and 18S ribosomal RNA in the urine of patients who had undergone renal transplantation, correlating results ...with biopsy findings and renal function. Only
FOXP3
mRNA correlated inversely with serum creatinine levels in patients with acute rejection, thus providing a potentially noninvasive means of predicting outcome in acute rejection.
FOXP3
mRNA correlated inversely with serum creatinine levels in patients with acute rejection, thus providing a potentially noninvasive means of predicting outcome in acute rejection.
Kidney transplantation is the treatment of choice for most patients with end-stage renal disease (ESRD), but a shortage of organs limits its availability.
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Renal-allograft failure is the fourth most common cause of ESRD in the United States
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and contributes to the shortage of organs.
Acute rejection is an important risk factor for allograft failure.
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–
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The current approach to treatment of acute rejection is uniform, although it is well recognized that some rejection episodes are not fully reversible and lead to long-term graft dysfunction and failure, whereas others are easily treatable and benign.
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The outcome of acute rejection is difficult . . .
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