To provide a focused, detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients' symptom ...reports.
Prospective, observational study of patients' symptoms.
Two intensive care units in a tertiary medical center in the western United States.
One hundred seventy-one intensive care unit patients at high risk of dying.
None.
Patients were interviewed every other day for up to 14 days. Patients rated the presence, intensity (1 = mild; 2 = moderate; 3 = severe), and distress (1 = not very distressing; 2 = moderately distressing; 3 = very distressing) of ten symptoms (that is, pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method-Intensive Care Unit was used to ascertain the presence of delirium. A total of 405 symptom assessments were completed by 171 patients. Patients' average age was 58 ± 15 yrs; 64% were males. Patients were mechanically ventilated during 34% of the 405 assessments, and 22% died in the hospital. Symptom prevalence ranged from 75% (tired) to 27% (confused). Thirst was moderately intense, and shortness of breath, scared, confusion, and pain were moderately distressful. Delirium was found in 34.2% of the 152 patients who could be evaluated. Delirious patients were more acutely ill and received significantly higher doses of opioids. Delirious patients were significantly more likely to report feeling confused (43% vs. 22%, p = .004) and sad (46% vs. 31%, p = .04) and less likely to report being tired (57% vs. 77%, p = .006) than nondelirious patients.
Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients, including those with delirium. Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering.
Background
Loneliness and social isolation are significant public health problems that are being exacerbated during the coronavirus disease 2019 pandemic. Little is known about the associations ...between loneliness and symptom burden in oncology patients before and during the pandemic. Study purposes include determining the prevalence of loneliness in a sample of oncology patients; evaluating for differences in demographic, clinical, and symptom characteristics between lonely and nonlonely patients; and determining which demographic, clinical, and symptom characteristics were associated with membership in the lonely group.
Methods
A convenience sample (n = 606) completed online surveys that evaluated the severity of loneliness, social isolation, and common symptoms (ie, anxiety, depression, fatigue, sleep disturbance, cognitive dysfunction, and pain) in oncology patients. Parametric and nonparametric tests were used to evaluate for differences in scores between the lonely and nonlonely groups. Logistic regression analysis was used to determine risk factors for membership in the loneliness group.
Results
Of the 606 patients, 53.0% were categorized in the lonely group. The lonely group reported higher levels of social isolation, as well as higher symptom severity scores for all of the symptoms evaluated. In the multivariate model, being unmarried, having higher levels of social isolation, as well as higher levels of anxiety and depressive symptoms were associated with membership in the lonely group.
Conclusions
Study findings suggest that a significant number of oncology patients are experiencing loneliness, most likely as a result of mandate social distancing and isolation procedures. The symptom burden of these patients is extremely high and warrants clinical evaluation and interventions.
Little is known about the experience of loneliness in oncology patients during COVID‐19. Of the 606 patients in this study, 53% report a clinically meaningful level of loneliness. Associations are found between loneliness and higher levels of social isolation, anxiety, and depressive symptoms.
No information is available on oncology patients' level of stress and symptom burden during the coronavirus disease 2019 (COVID-19) pandemic.
To evaluate for differences in demographic and clinical ...characteristics, levels of social isolation and loneliness, and the occurrence and severity of common symptoms between oncology patients with low vs. high levels of COVID-19 and cancer-related stress. In addition, to determine which of these characteristics were associated with membership in the high-stressed group.
Patients were 18 years and older; had a diagnosis of cancer; and were able to complete an online survey.
Of the 187 patients in this study, 31.6% were categorized in the stressed group (Impact of Event Scale—Revised score of ≥24). Stressed group's Impact of Event Scale—Revised score exceeds previous benchmarks in oncology patients and equates with probable post-traumatic stress disorder. In this stressed group, patients reported occurrence rates for depression (71.2%), anxiety (78.0%), sleep disturbance (78.0%), evening fatigue (55.9%), cognitive impairment (91.5%), and pain (75.9%). Symptom severity scores equate with clinically meaningful levels for each symptom.
We identified alarmingly high rates of stress and an extraordinarily high symptom burden among patients with cancer, exceeding those previously benchmarked in this population and on par with noncancer patients with post-traumatic stress disorder. Given that the COVID-19 pandemic will likely impact cancer care for an indefinite period, clinicians must exhibit increased vigilance in their assessments of patients' level of stress and symptom burden. Moreover, an increase in referrals to appropriate supportive care resources must be prioritized for high-risk patients.
Background We previously reported rapid mood elevation following an experimental magnetic resonance imaging procedure in depressed patients with bipolar disorder (BPD). This prompted the design, ...construction, and testing of a portable electromagnetic device that reproduces only the rapidly oscillating (1 kHz, <1 V/m) electromagnetic field of the experimental procedure, called low field magnetic stimulation (LFMS). Methods We used a randomized, double blind, sham controlled treatment protocol to study the effects of LFMS in a large group of stably medicated, depressed patients with either BPD ( n = 41) or major depressive disorder ( n = 22). Subjects received a single, 20-minute treatment. Change in mood was assessed immediately afterward using a visual analog scale (VAS), the 17-item Hamilton Depression Rating Scale (HDRS-17), and the Positive and Negative Affect Schedule scales. Results Substantial improvement (>10% of baseline) in mood was observed following LFMS treatment relative to sham treatment for both diagnostic subgroups for our primary outcomes, the VAS and the HDRS-17. These differences were not statistically significant in primary analyses stratifying by diagnosis but were significant in secondary analyses combining data across the two diagnostic groups ( p = .01 VAS, p = .02 HDRS-17). Rapid improvement in mood was also observed using the Positive and Negative Affect Schedule scales as secondary measures (positive affect scale p = .02 BPD, p = .002 combined group). A finite element method calculation indicates a broad penetration of the LFMS electric field throughout the cerebral cortex. Conclusions Low field magnetic stimulation may produce rapid changes in mood using a previously unexplored range of electromagnetic fields.
Purpose
No information is available on cancer patients’ knowledge of and experiences with COVID-19. We undertook an evaluation of differences in COVID-19 symptom occurrence rates, COVID-19 testing ...rates, clinical care activities, knowledge of COVID-19, and use of mitigation procedures between patients who were and were not receiving active cancer treatment.
Methods
Patients enrolled were
>
18 years of age; had a diagnosis of cancer; and were able to complete the emailed study survey online.
Results
Of the 174 patients who participated, 27.6% (
n
= 48) were receiving active treatment, 13.6% were unemployed because of COVID-19, 12.2% had been tested for COVID-19, and 0.6% had been hospitalized for COVID-19. Patients who were not on active treatment reported a higher mean number of COVID-19 symptoms (3.1 (± 4.2) versus 1.9 (± 2.6)), and patients who reported a higher number of COVID-19 symptoms were more likely to be tested. Over 55% of the patients were confident that their primary care provider could diagnose COVID-19, and the majority of the patients had high levels of adherence with the use of precautionary measures (e.g., social distancing, use of face coverings).
Conclusion
The high level of COVID-19 symptoms and the significant overlap of COVID-19 and cancer-related symptoms pose challenges for clinicians who are assessing and triaging oncology patients for COVID-19 testing. For patients on active treatment, clinicians face challenges with how to assess and manage symptoms that, prior to COVID-19, would be ascribed to acute toxicities associated with cancer treatments or persistent symptoms in cancer survivors.
Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients' symptoms and compare levels of mean intensity (i.e., ...the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters.
Prospective study of proxy reporters of symptoms in seriously ill patients.
Two intensive care units in a tertiary medical center in the Western United States.
Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians.
None.
On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients' and family members' ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients' and physicians' ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients' and nurses' ratings. Two symptoms had symptom-distress correlation coefficients between patients' and physicians' ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively.
Patient-family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients' symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians' and patients' symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients' symptoms. Proxy overestimation of patients' symptom scores warrants further study because this may influence decisions about treating patients' symptoms.
Managing Pain Brummett, Chad M
2013, 2013-03-12
eBook
Including a review of therapies and case-based chapters, Managing Pain: Essentials of Diagnosis and Treatment is a fundamental guide to on the diagnosis and therapy of frequently encountered pain ...conditions for non-pain specialists.
Chronic shoulder pain (CSP) is a common condition with various etiologies including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with ...substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy (PT) constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no prior RCT has compared fully-remote digital physical therapy (DGPT) to in-person rehabilitation for non-operative CSP.
The aim of this study is to compare clinical outcomes between DGPT and conventional in-person physical therapy in patients with CSP.
Single-center, parallel-group, randomized controlled trial (RCT) involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy including exercises, manual therapy, education, and CBT. Primary outcome was the change (baseline to 8-weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH). Secondary outcome measures included self-reported pain, surgery intent, analgesics intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically.
Ninety participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function (QuickDASH), with no differences between groups (-1.8, 95%CI -13.5 to 9.8, P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which given the small effect sizes (least pain: 0.15; average pain: 0.16) are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups with no adverse events.
This study shows fully-remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage, in-person rehabilitation.
ClinicalTrials.gov (NCT04636528).
Abstract
Objective
Low back pain is the leading cause of worldwide disability, with lumbosacral radiculopathy accounting for over one-third of these cases. There are limited data on the relationship ...between etiologies and lumbosacral radiculopathy, and it is unknown whether specific causes predict treatment outcomes.
Design, Setting, and Subjects
This study explores patient-reported etiologies for lumbosacral radiculopathy in a chronic pain clinic between January 2007 and December 2015 and examines whether these causes affected epidural steroid injection outcomes.
Methods
We reviewed the medical records of 1,242 patients with lumbosacral radiculopathy who received epidural steroid injections. The recording of an inciting event was done contemporaneously based on note templates. A positive outcome following an epidural steroid injection was defined as ≥30% pain relief sustained for six or more weeks without additional intervention. Factors associated with epidural steroid injection outcome were analyzed by multivariable logistic regression.
Results
Fifty point seven percent reported an inciting event, and 59.9% of patients experienced a positive epidural steroid injection outcome. The most commonly reported causes were falls (13.1%), motor vehicle collisions (10.7%), and lifting (7.8%). Individuals with a herniated disc (56.3%) were more likely to report a precipitating cause than those with stenosis (44.7%) or degenerative discs (47.8%, P = 0.012). An inciting event did not predict treatment outcome. Factors associated with negative treatment outcome included opioid consumption (odds ratio OR = 0.61, 95% confidence interval CI = 0.39–0.95, P = 0.027), secondary gain (OR = 0.69, 95% CI = 0.50–0.96, P = 0.030), and baseline pain score (OR = 0.90, 95% CI = 0.84–0.97, P = 0.006). The number of levels injected was associated with a positive outcome (OR = 2.72, 95% CI = 1.28–6.47, P = 0.008).
Conclusions
Reported inciting events are common in patients with lumbosacral radiculopathy but are not associated with outcome following epidural steroid injection, and their occurrence is not always consistent with the purported mechanism of injury.
Purpose
Pain, fatigue, sleep disturbance, and depression are four of the most common symptoms in patients with gynecologic cancer. The purposes were to identify subgroups of patients with distinct ...co-occurring pain, fatigue, sleep disturbance, and depression profiles (i.e., pre-specified symptom cluster) in a sample of patients with gynecologic cancer receiving chemotherapy and assess for differences in demographic and clinical characteristics, as well as the severity of other common symptoms and QOL outcomes among these subgroups.
Methods
Patients completed symptom questionnaires prior to their second or third cycle of chemotherapy. Latent profile analysis was used to identify subgroups of patients using the pre-specified symptom cluster. Parametric and nonparametric tests were used to evaluate for differences between the subgroups.
Results
In the sample of 233 patients, two distinct latent classes were identified (i.e., low (64.8%) and high (35.2%)) indicating lower and higher levels of symptom burden. Patients in high class were younger, had child care responsibilities, were unemployed, and had a lower annual income. In addition, these women had a higher body mass index, a higher comorbidity burden, and a lower functional status. Patients in the high class reported higher levels of anxiety, as well as lower levels of energy and cognitive function and poorer quality of life scores.
Conclusions
This study identified a number of modifiable and non-modifiable risk factors associated with membership in the high class. Clinicians can use this information to refer patients to dieticians and physical therapists for tailored interventions.
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