Pain is an understudied problem in frail elderly patients, especially those with cognitive impairment, delirium, or dementia. The focus of this study was to describe the pain experienced by patients ...in skilled nursing homes, which have a high prevalence of cognitive impairment. A random sample of 325 subjects was selected from ten community skilled nursing homes. Subjects underwent a cross-sectional interview and chart review for the prevalence of pain complaints, etiology, and pain management strategies. Pain was assessed using the McGill Pain Questionnaire and four unidimensional scales previously utilized in younger adults. Thirty-three percent (33%) of subjects were excluded because they were either comatose (21%), non-English speaking (3.7%), temporarily away (sick in hospital) (4.3%), or refused to participate (3.7%). Of 217 subjects in the final analysis, the mean age was 84.9 years, 85% were women, and most were dependent in all activities of daily living. Subjects demonstrated substantial cognitive impairment (mean Folstein Mini-Mental State exam score was 12.1 ± 7.9), typically having deficits in memory, orientation, and visual spatial skills. Sixty-two percent reported pain complaints, mostly related to musculoskeletal and neuropathic causes. Pain was not consistently documented in records, and pain management strategies appeared to be limited in scope and only partially successful in controlling pain. None of the four unidimensional pain-intensity scales studied in this investigation had a higher completion rate than the Present Pain Intensity Scale of the McGill Pain Questionnaire (65% completion rate). However, 83% of subjects who had pain could complete at least one of the scales. We conclude that cognitive impairment among elderly nursing home residents presents a substantial barrier to pain assessment and management. Nonetheless, most patients with mild to moderate cognitive impairment can be assessed using at least one of the available bedside assessment scales.
Summary
Pyoderma gangrenosum (PG) is a neutrophil‐predominant inflammatory disease that initially presents as a sterile pustule and may progress to ulcerations. Its root cause is unknown, but the ...presentation is commonly associated with systemic inflammatory conditions such as inflammatory bowel disease, arthritis and haematological abnormalities. On the other hand, pregnant women show a progressive neutrophilia during gestation, which culminates in a major inflammatory event to help drive labour. Although uncommonly, PG has been associated with pregnancy, which provides an additional link to systemic inflammation as an underlying cause of PG. We reviewed documented presentations of PG in gravid and post‐partum patients, and have speculated on the possible pathogenesis based on their clinical presentations. Also, we summarize the reported treatments and their outcomes in these patients.
What's already known about this topic?
Pyoderma gangrenosum (PG) is rarely associated with pregnancy.
What does this study add?
We reviewed 26 cases of pregnancy‐associated PG and speculated on the pathogenesis.
Alterations in the immune system during pregnancy may predispose certain patients to PG.
Understanding the pathogenesis of PG and its associated conditions is important for proper diagnosis and targeted therapy.
Treatment can be challenging due to the possible detrimental side‐effects from medications, not only to the mother's health but also to the fetus.
Undertreatment of pain and lack of knowledge about pain management have been evident for approximately two decades. Because nurses are often the cornerstone of pain management, nurses' knowledge in ...this area is especially important. This paper explores indications of progress in the level of nursing knowledge about basic aspects of pain management. The literature is reviewed and findings from recent (1995) surveys of nurses' knowledge are compared with results of similar surveys conducted beginning in 1988. Improvements in nurses' knowledge of pain assessment, opioid dosing, and likelihood of addiction seem to have occurred. However, knowledge deficits continue. Fewer than one-half of the nurses surveyed understand that the patient's self report of pain is the single most reliable indicator of pain and that the nurse should increase a previously safe but ineffective dose of opioid. Findings from surveys on addiction reveal that the longer the patient receives opioids the more concerned nurses become about causing addiction. Nevertheless, results of current knowledge surveys of nurses suggest that educational efforts probably have been beneficial and should continue. To maximize the impact of educational efforts, content in basic and continuing education courses should be prioritized and critically evaluated for relevance and accuracy, especially content related to addiction. Early in the education of nurses, responsibility for pain assessment and use of analgesics must be instilled.
A QOL instrument was developed to measure the specific concerns of long term cancer survivors. The QOL-CS is based on previous versions of the QOL instrument developed by researchers at the City of ...Hope National Medical Centre (Grant, Padilla, and Ferrell). This instrument was revised over a one year pilot by Hassey-Dow and Ferrell. The revised instrument included 41 items representing the four domains of quality of life incorporating physical, psychological, social, and spiritual well being. The present study was conducted as a mail survey to the membership (n = 1,200) of the National Coalition for Cancer Survivorship with 686 subjects responding to the survey. This survey included a Demographic tool, QOL-CS and the FACT-G tool developed by Cella. Psychometric analysis, performed on 686 respondents, included measures of reliability and validity. Two measures of reliability included test-retest and internal consistency. The overall QOL-CS tool test-retest reliability was 0.89 with subscales of Physical r = 0.88, Psychological r = 0.88, Social r = 0.81, and Spiritual, r = 0.90. The second measure of reliability was computation of internal consistency using Cronbach's α coefficient as a measure of agreement between items and subscales. Analysis revealed an overall r = 0.93. Subscale alphas average ranged from r = 0.71 for spiritual well being, r = 0.77 for physical, r = 0.81 for social, and r = 0.89 for psychological. Several measures of validity were used to determine the extent to which the instrument measured the concept of QOL in cancer survivors. The first method of content validity was based on a panel of QOL researchers and nurses with expertise in oncology. The second measure used stepwise multiple regression to determine factors most predictive of overall QOL in cancer survivors. Seventeen variables were found to be statistically significant accounting for 91% of the variance in overall QOL. The fourth measure of validity used Pearson's correlations to estimate the relationships between the subscales of QOL-CS and the subscales of the established FACT-G tool. There was moderate to strong correlation between associated subscales including QOL-CS physical to FACT physical (r = 0.74), QOL-CS Psych to FACT Emotional (r = 0.65), QOL Social to FACT Social (r = 0.44). The overall QOL-CS correlation with the FACT-G was 0.78. Additional measures of validity included correlations of individual items of the QOL-CS tool, factor analysis, and construct validity discriminating known groups of cancer survivors. Findings demonstrated that the QOL-CS and its subscales adequately measured QOL in this growing population of cancer survivors.
Racial disparities in health are largely unexplained. Because many diseases causing premature mortality among African Americans are mediated by the immune system, the authors explored the ...race-specific distribution of allelic variants in cytokine genes known to stimulate inflammation. The authors studied women seeking prenatal care and delivering singletons in uncomplicated first births at a US hospital in 1997–2001. A total of 179 African-American women and 396 White women were evaluated for functionally relevant allelic variants in cytokine genes. African-American women were significantly more likely to carry allelic variants known to up-regulate proinflammatory cytokines; odds ratios increased with allele dose. Odds ratios for African Americans versus Whites in genotypes up-regulating proinflammatory interleukin (IL) 1 (IL1A-4845G/G, IL1A-889T/T, IL1B-3957C/C, and IL1B-511A/A) ranged from 2.1 to 4.9. The proinflammatory cytokine interleukin-6 IL6-174 G/G genotype was 36.5 times (95% confidence interval (CI): 8.8, 151.9) more common among African Americans. Genotypes known to down-regulate the antiinflammatory interleukin-10 (IL10-819 T/T and IL10-1082 A/A) were elevated 3.5-fold (95% CI: 1.8, 6.6) and 2.8-fold (95% CI: 1.6, 4.9) in African Americans. Cytokine genotypes found to be more common in African-American women were consistently those that up-regulate inflammation.
Hereditary lymphedemas are developmental disorders of the lymphatics resulting in edema of the extremities due to altered lymphatic flow. One such disorder, the lymphedema-distichiasis syndrome, has ...been reported to be caused by mutations in the forkhead transcription factor, FOXC2. We sequenced the FOXC2 gene in 86 lymphedema families to identify mutations. Eleven families were identified with mutations predicted to disrupt the DNA binding domain and/or C-terminal alpha-helices essential for transcription activation by FOXC2. Broad phenotypic heterogeneity was observed within these families. The phenotypes observed overlapped four phenotypically defined lymphedema syndromes. FOXC2 appears to be the primary cause of lymphedema-distichiasis syndrome and is also a cause of lymphedema in families displaying phenotypes attributed to other lymphedema syndromes. Our data demonstrates that the phenotypic classification of autosomal dominant lymphedema does not reflect the underlying genetic causation of these disorders.
This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. ...Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.
Pain in the nursing home Ferrell, B A; Ferrell, B R; Osterweil, D
Journal of the American Geriatrics Society (JAGS),
April 1990, Volume:
38, Issue:
4
Journal Article
Peer reviewed
Pain is an understudied problem in geriatric medicine and especially among nursing home residents. The focus of this study was to describe the scope of the problem of pain in a long-term care ...facility. Ninety-seven subjects from a 311-bed multilevel teaching nursing home were interviewed, and charts were reviewed for pain problems and management strategies. Functional status, depression, and cognitive impairment were also evaluated. Results indicate that 71% of residents had at least one pain complaint (range, 1-4). Of subjects with pain, 34% described constant (continuous) pain and 66% described intermittent pain. Of 43 subjects with intermittent pain, 51% described pain on a daily basis. Major sources of pain included low back pain (40%), arthritis of appendicular joints (24%), previous fracture sites (14%), and neuropathies (11%). Moderately strong correlations were found between pain and infrequent attendance at recreational and social activities (r = .50). However, little correlation was observed between pain and the Yesavage Depression Scale, the Folstein Mini-Mental State Scale, or basic ADLs measured by the Katz Scale. Pain-management strategies consisted of analgesic drugs, physical therapy, and heating pads. Only 15% of patients with pain had received medication within the previous 24 hours. The findings suggest that pain is a major problem in long-term care. Strategies for pain management appear to be limited in scope and application in this setting. Important barriers were identified that influence the reporting and management of pain in this setting.
Attention to the quality of life (QOL) among long-term of breast cancer is long overdue. Modest improvements in overall survival have led to a greater emphasis on how women are living with the ...disease. The purpose of this paper is to report the results of a descriptive study that evaluated the quality of life of 294 breast cancer survivors, and to review the continuum of positive and negative QOL outcomes in this population. Members of the National Coalition for Cancer Survivorship (NCCS) were surveyed and received two QOL instruments: the Quality of Life-Cancer Survivors Tool (QOL-CS) and the Functional Assessment of Cancer Therapy (FACT-G), and a demographic data tool. The main research variables were the subscales (Physical, Psychological, Social, and Spiritual Well-being) and individual items of the QOL-CS and the FACT-G. Results indicated that: a) fatigue, aches and pains, and sleep problems were persistent after treatment ended; b) psychological distress from cancer diagnosis and treatment, and fear of recurrent, metastatic, and recurrent disease were problematic over time; c) family distress, sexuality, and family burden issues were of greatest social concern; and d) uncertainty over the future plagued breast cancer survivors long-term. Breast cancer survivors also reported good outcomes in hopefulness, having a life purpose, and having a positive change after the treatment.
breast cancer survivors experienced long-term changes after completion of treatment which affected overall quality of life. However, many positive benefits were also gained which helped to balance the worse outcomes.
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