A new instrument for pain assessment in the immediate postoperative period

Perceptual-cognitive impairment after general anaesthesia may affect the ability to reliably report pain severity with the standard visual analog scale (VAS). To minimise these limitations, we developed 'PAULA the PAIN-METER' (PAULA): it has five coloured emoticon faces on the forefront, it is twice as long as a standard VAS scale, and patients use a slider to mark their pain experience. Forty-eight postoperative patients rated descriptive pain terms on PAULA and on a standard VAS immediately after admission and before discharge from the postanaesthesia care unit. Visual acuity was determined before both assessments. The values obtained with PAULA showed less variance than those obtained with the standard VAS, even at the first assessment, where only 23% of the patients had regained their visual acuity. Furthermore, the deviations of the absolute VAS values in individual patients for each descriptive pain term were significantly smaller with PAULA than with the standard VAS.

Development of a screening tool predicting the transition from acute to chronic low back pain for patients in a GP setting: protocol of a multinational prospective cohort study

BACKGROUND: Low back pain (LBP) is by far the most prevalent and costly musculoskeletal problem in our society today. Following the recommendations of the Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement, our study aims to define outcome assessment tools for patients with acute LBP and the time point at which chronic LBP becomes manifest and to identify patient characteristics which increase the risk of chronicity. METHODS: Patients with acute LBP will be recruited from clinics of general practitioners (GPs) in New Zealand (NZ) and Switzerland (CH). They will be assessed by postal survey at baseline and at 3, 6, 12 weeks and 6 months follow-up. Primary outcome will be disability as measured by the Oswestry Disability Index (ODI); key secondary endpoints will be general health as measured by the acute SF-12 and pain as measured on the Visual Analogue Scale (VAS). A subgroup analysis of different assessment instruments and baseline characteristics will be performed using multiple linear regression models. This study aims to examine: 1. Which biomedical, psychological, social, and occupational outcome assessment tools are identifiers for the transition from acute to chronic LBP and at which time point this transition becomes manifest. 2. Which psychosocial and occupational baseline characteristics like work status and period of work absenteeism influence the course from acute to chronic LBP. 3. Differences in outcome assessment tools and baseline characteristics of patients in NZ compared with CH. DISCUSSION: This study will develop a screening tool for patients with acute LBP to be used in GP clinics to access the risk of developing chronic LBP. In addition, biomedical, psychological, social, and occupational patient characteristics which influence the course from acute to chronic LBP will be identified. Furthermore, an appropriate time point for follow-ups will be given to detect this transition. The generalizability of our findings will be enhanced by the international perspective of this study. TRIAL REGISTRATION: [Clinical Trial Registration Number, ACTRN12608000520336].

Adapting health-risk communication to the specific cultural contexts of diverse populations : an assessment of malaria-treatment programs in Liberia

Drawing on theories of technical communication, rhetoric, literacy, language and culture, and medical anthropology, this dissertation explores how local culture and traditions can be incorporated into health-risk-communication-program design and implementation, including the design and dissemination of health-risk messages. In a modern world with increasing global economic partnerships, mounting health and environmental risks, and cross-cultural collaborations, those who interact with people of different cultures have “a moral obligation to take those cultures seriously, including their social organization and values” (Hahn and Inhorn 10). Paradoxically, at the same time as we must carefully adapt health, safety, and environmental-risk messages to diverse cultures and populations, we must also recognize the increasing extent to which we are all becoming part of one, vast, interrelated global village. This, too, has a significant impact on the ways in which healthcare plans should be designed, communicated, and implemented. Because communicating across diverse cultures requires a system for “bridging the gap between individual differences and negotiating individual realities” (Kim and Gudykunst 50), both administrators and beneficiaries of malaria-treatment-and-control programs (MTCPs) in Liberia were targeted to participate in this study. A total of 105 people participated in this study: 21 MTCP administrators (including designers and implementers) completed survey questionnaires on program design, implementation, and outcomes; and 84 MTCP beneficiaries (e.g., traditional leaders and young adults) were interviewed about their knowledge of malaria and methods for communicating health risks in their tribe or culture. All participants showed a tremendous sense of courage, commitment, resilience, and pragmatism, especially in light of the fact that many of them live and work under dire socioeconomic conditions (e.g., no electricity and poor communication networks). Although many MTCP beneficiaries interviewed for this study had bed nets in their homes, a majority (46.34 percent) used a combination of traditional herbal medicine and Western medicine to treat malaria. MTCP administrators who participated in this study rated the impacts of their programs on reducing malaria in Liberia as moderately successful (61.90 percent) or greatly successful (38.10 percent), and they offered a variety of insights on what they might do differently in the future to incorporate local culture and traditions into program design and implementation. Participating MTCP administrators and beneficiaries differed in their understanding of what “cultural incorporation” meant, but they agreed that using local indigenous languages to communicate health-risk messages was essential for effective health-risk communication. They also suggested that understanding the literacy practices and linguistic cultures of the local people is essential to communicating health risks across diverse cultures and populations.

Postoperative hypoesthesia and pain: qualitative assessment after open and laparoscopic inguinal hernia repair

BACKGROUND: Chronic pain is an important outcome variable after inguinal hernia repair that is generally not assessed by objective methods. The aim of this study was to objectively investigate chronic pain and hypoesthesia after inguinal hernia repair using three types of operation: open suture, open mesh, and laparoscopic. METHODS: A total of 96 patients were included in the study with a median follow-up of 4.7 years. Open suture repair was performed in 40 patients (group A), open mesh repair in 20 patients (group B), and laparoscopic repair in 36 patients (group C). Hypoesthesia and pain were assessed using von Frey monofilaments. Quality of life was investigated with Short Form 36. RESULTS: Pain occurring at least once a week was found in 7 (17.5%) patients of group A, in 5 (25%) patients of group B, and in 6 (16.6%) patients of group C. Area and intensity of hyposensibility were increased significantly after open nonmesh and mesh repair compared to those after laparoscopy (p = 0.01). Hyposensibility in patients who had laparoscopic hernia repair was significantly associated with postoperative pain (p = 0.03). Type of postoperative pain was somatic in 19 (61%), neuropathic in 9 (29%), and visceral in 3 (10%) patients without significant differences between the three groups. CONCLUSIONS: The incidence of hypoesthesia in patients who had laparoscopic hernia repair is significantly lower than in those who had open hernia repair. Hypoesthesia after laparoscopic but not after open repair is significantly associated with postoperative pain. Von Frey monofilaments are important tools for the assessment of inguinal hypoesthesia and pain in patients who had inguinal hernia repair allowing quantitative and qualitative comparison between various surgical techniques.

Assessment of osteoarthritis in hips with femoroacetabular impingement using delayed gadolinium enhanced MRI of cartilage

PURPOSE: To determine the feasibility of assessing early osteoarthritis (OA) in hips with femoroacetabular impingement (FAI) using delayed Gadolinium enhanced MRI of Cartilage (dGEMRIC). MATERIALS AND METHODS: Thirty-seven hips in 30 patients who had a dGEMRIC scan and radiographic evidence of FAI were identified. Clinical symptoms were assessed. Radiographic measurements were performed to determine acetabular and femoral morphology. The severity of radiographic OA was determined using Tönnis grade and minimum joint space width (JSW). On MRI, the alpha angle was measured on the sagittal oblique slices. Correlations between dGEMRIC index, patient symptoms, morphologic measurements, radiographic OA, and age were determined. RESULTS: Significant correlations were observed between dGEMRIC index, pain (P < 0.05), and alpha angle (P < 0.05). The correlation of dGEMRIC with alpha angle suggests that hips with more femoral deformity show signs of early OA. CONCLUSION: The results of osteoplasty for FAI depend on the amount of pre-existing OA in the joint. dGEMRIC may be a useful technique for diagnosis and staging of early osteoarthritis in hips with impingement.

Endoleak detection with CT angiography in an abdominal aortic aneurysm phantom: effect of tube energy, simulated patient size, and physical properties of endoleaks

To analyze the detection of endoleaks with low-tube-voltage computed tomographic (CT) angiography.

The prevalence of widespread central hypersensitivity in chronic pain patients

BACKGROUND Chronic pain is associated with generalized hypersensitivity and impaired endogenous pain modulation (conditioned pain modulation; CPM). Despite extensive research, their prevalence in chronic pain patients is unknown. This study investigated the prevalence and potential determinants of widespread central hypersensitivity and described the distribution of CPM in chronic pain patients. METHODS We examined 464 consecutive chronic pain patients for generalized hypersensitivity and CPM using pressure algometry at the second toe and cold pressor test. Potential determinants of generalized central hypersensitivity were studied using uni- and multivariate regression analyses. Prevalence of generalized central hypersensitivity was calculated for the 5th, 10th and 25th percentile of normative values for pressure algometry obtained by a previous large study on healthy volunteers. CPM was addressed on a descriptive basis, since normative values are not available. RESULTS Depending on the percentile of normative values considered, generalized central hypersensitivity affected 17.5-35.3% of patients. 23.7% of patients showed no increase in pressure pain threshold after cold pressor test. Generalized central hypersensitivity was more frequent and CPM less effective in women than in men. Unclearly classifiable pain syndromes showed higher frequencies of generalized central hypersensitivity than other pain syndromes. CONCLUSIONS Although prevalent in chronic pain, generalized central hypersensitivity is not present in every patient. An individual assessment is therefore required in order to detect altered pain processing. The broad basic knowledge about central hypersensitivity now needs to be translated into concrete clinical consequences, so that patients can be offered an individually tailored mechanism-based treatment.

Transcatheter aortic valve implantation: patient selection

Transcatheter aortic valve implantation (TAVI) is a disruptive technology as it satisfies a previously unmet need which is associated with a profound therapeutic benefit. In randomized clinical trials, TAVI has been shown to improve survival compared with medical treatment among patients considered not suitable candidates for surgical aortic valve replacement (SAVR), and to provide similar outcomes as SAVR in selected high-risk patients. Currently, TAVI is limited to selected elderly patients with symptomatic severe aortic stenosis. As this patient population frequently suffers from comorbid conditions, which may influence outcomes, the selection of patients to undergo TAVI underlies a complex decision process. Several clinical risk score algorithms are routinely used, although they fall short to fully appreciate the true risk among patients currently referred for TAVI. Beyond traditional risk scores, the clinical assessment by an interdisciplinary Heart Team as well as detailed imaging of the aortic valve, aortic root, descending and abdominal aorta as well as peripheral vasculature are important prerequisites to plan a successful procedure. This review will familiarize the reader with the concepts of the interdisciplinary Heart team, risk scores as well as the most important imaging algorithms suited to select appropriate TAVI patients.

Communication Across Cultures - Use of Video to Promote Culturally Competent Patient Management

Diverse belief systems exist among dental and medical patients related to health, healing and wellness. Culturally competent health care may be defined as the ability to provide care to patients with diverse values, beliefs and behaviors, including modifying delivery of care to meet patients’ social and cultural needs. [See PDF for complete abstract]

Persuasive email messages for patient communication.

To improve health and reduce costs, we need to encourage patients to make better health care decisions. Since email is widely available, it may be useful for patient-directed interventions. However, we know little about how the contents of an email message can influence a health-related decision. We propose a model to understand how patients may process persuasive email messages.

Comparison of cost and outcome of care in patients with low back pain who are managed by physicians or physical therapists in private practice

The purpose of this study was to determine if there were differences in the cost and outcome of care in patients with low back pain who were managed by physicians or physical therapists in private practice in the state of Arizona. A secondary purpose was to describe the current status of private practice physical therapy clinicians who treat patients with low back pain.^ A Survey on Practice was mailed to 194 physical therapists who were listed by the American Physical Therapy Association as being in private practice in Arizona. Eighty-three percent of the surveys were returned after three attempts. Of those which were returned, 72 were complete and included in the analysis.^ The 72 practices were screened to determine those eligible for the second phase of the study. Those eligible for the second phase numbered 52 clinics. Twenty-six practices agreed to participate; however, only 21 did participate. Clinics which participated were sent packets of information which were to be kept on each patient seen with a complaint of low back pain during a three month period. Packets contained a patient-oriented survey on functional activity to be completed before and after the physical therapy course of treatment, as well as a log which was completed by the physical therapist on the type of care given to the patient and an assessment of the outcome of treatment. The patient was asked to fill out a satisfaction survey relative to the care received from the physical therapist and physician, if applicable.^ Although 259 patients were entered into the study, 210 patient logs were available for analysis. Results indicated that generally, there was no difference in cost or outcome as measured by the final functional score, change between the initial and final functional scores, or the therapist-rated outcome between the patients who were managed by physicians or physical therapists when controlling for age and length of time the patient was experiencing pain. Patients were more satisfied with care received from physical therapists as compared to physicians. Age and length of pain were good predictors of the type of referral patients received according to a logistic regression procedure. The initial disability score (IRS) and the time spent in the facility predicted therapist-rated outcome, a good or poor final disability score (FRS), and a good or poor change score. In addition, age predicted FRS and change scores. The time that the therapist spent in direct contact with the patient also predicted the change score.^ These findings of no difference in the cost and outcome of care were discussed as they relate to the practice of medicine and physical therapy. ^

Patient satisfaction and nursing staff work satisfaction in an urban public teaching hospital

This study examined the level of patient satisfaction and nursing staff work satisfaction at an urban public hospital in the Southwestern United States. The primary objectives of this study were to determine: (1) the level of overall patient satisfaction and satisfaction with specific dimensions of hospital care; (2) the differences in patient satisfaction according to demographic characteristics (age, gender, ethnicity, and education completed) and predispositional factors (perceived health status, perceived level of pain, prior contact with the hospital, and hospital image) and the relative importance of each variable on patient satisfaction; (3) the level of overall work satisfaction and satisfaction with specific dimensions of work experienced by the medical/surgical nursing staff; (4) the differences in work satisfaction experienced by the nursing staff based on demographic variables (age, gender, ethnicity, and marital status) and professional factors (education completed, staff position, the number of years employed with the hospital, and number of years employed in nursing) and the relative importance of each variable on work satisfaction; and (5) to determine the effect of the nursing work milieu on patient and staff satisfaction.^ The study findings showed that patients experienced a moderate to low level of satisfaction with the dimensions of hospital care (admission process, daily care, information, nursing care, physician care, other hospital staff, living arrangements, and overall care). Of the eight dimensions of care, patients reported a relatively positive level of satisfaction (75 percent or better) with only one dimension: physician care. Ethnicity, perceived health status, and hospital image were significantly related to patient satisfaction. Hispanic patients, those who were in good health, and those who felt the hospital had a good image in their community were most satisfied with hospital care. Patients also reported areas of hospital care that needed the most improvement. Responses included: rude staff, better nursing care, and better communication.^ Findings from the nursing satisfaction survey indicated a low level of satisfaction with the dimensions of work (autonomy, pay, professional status, interaction, task requirements, and organizational policies). Only one dimension of work, professional status, received a mean satisfaction score in the positive range. Additionally, staff members were unanimously dissatisfied with their salaries. Frequently mentioned work-related problems reported by the staff included: staffing shortages, heavy patient loads. and excessive paperwork.^ The nursing milieu appeared to have had a significant effect on the satisfaction levels of patients nursing staff employees. The nursing staff were often short staffed, which increased the patient-to-nurse ratio. Consequently, patients did not receive the amount of attention and care they expected from the nursing staff. Crowded patient rooms allowed for little personal space and privacy. Dissatisfaction with living conditions served to influence patients' attitudes and satisfaction levels. These frustrations were often directed toward their primary caregivers, the nursing staff. Consequently, the nursing milieu appeared to directly affect and influence the satisfaction levels of both patients and staff. (Abstract shortened by UMI). ^