Pain measurement and management in elderly patients : Clinical studies in long term hospital care and after cardiac surgery

The proportion of patients over 75 years of age, receiving all different types of healthcare, is constantly increasing. The elderly undergo surgery and anaesthetic procedures more often than middle-aged patients. Poor pain management in the elderly is still an issue. Although the elderly consumes the greatest proportion of prescribed medicines in Western Europe, most clinical pharmacological studies have been performed in healthy volunteers or middle-aged patients. The aim of this study was to investigate pain measurement and management in cognitively impaired patients in long term hospital care and in cognitively normal elderly patients after cardiac surgery. This thesis incorporated 366 patients, including 86 home-dwelling or hospitalized elderly with chronic pain and 280 patients undergoing cardiac surgery with acute pain. The mean age of patients was 77 (SD ± 8) years and approximately 8400 pain measurements were performed with four pain scales: Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), the Red Wedge Scale (RWS), and the Facial Pain Scale (FPS). Cognitive function, depression, functional ability in daily life, postoperative sedation and postoperative confusion were assessed with MMSE, GDS, Barthel Index, RASS, and CAM-ICU, respectively. The effects and plasma concentrations of fentanyl and oxycodone were measured in elderly (≥ 75 years) and middle-aged patients (≤ 60 years) and the opioid-sparing effect of pregabalin was studied after cardiac surgery. The VRS pain scores after movement correlated with the Barthel Index. The VRS was most successful in the groups of demented patients (MMSE 17-23, 11-16 and ≤ 10) and in elderly patients on the first day after cardiac surgery. The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients. The plasma concentrations of oxycodone were comparable between the groups. Pain intensity on the VRS was lower and the sedation scores were higher in the elderly. Total oxycodone consumption during five postoperative days was reduced by 48% and the CAM-ICU scores were higher on the first postoperative day in the pregabalin group. The incidence of postoperative pain during movement was lower in the pregabalin group three months after surgery. This investigation demonstrates that chronic pain did not seem to impair daily activities in home-dwelling Finnish elderly. The VRS appeared to be applicable for elderly patients with clear cognitive dysfunction (MMSE ≤17) and it was the most feasible pain scale for the early postoperative period after cardiac surgery. After cardiac surgery, plasma concentrations of fentanyl in elderly were elevated, although oxycodone concentrations were at similar level compared to middle-aged patients. The elderly had less pain and were more sedated after doses of oxycodone. Therefore, particular attention must be given to individual dosing of the opioids in elderly surgical patients, who often need a smaller amount for adequate analgesia than middle-aged patients. The administration of pregabalin reduced postoperative oxycodone consumption after cardiac surgery. Pregabalin-treated patients had less confusion, and additionally to less postoperative pain on the first postoperative day and during movement at three months post-surgery. Pregabalin might be a new alternative as analgesic for acute postoperative and chronic pain management in the elderly. Its clinical role and safety remains to be verified in large-scale randomized and controlled studies. In the future, many clinical trials in the older category of patients will be needed to facilitate improvements in health care methods.

Dissociation of monoclonal antibody-antigen complexes: Implications for ELISA procedures

A single step solid phase radioimmunoassay (SS-SPRIA) has been developed for human chorionic,gonadotropin (hCG) using monoclonal antibodies (MAb) from culture media adsorbed immunochemically on plastic tubes. The assays have been found to be very simple in terms of operation and do not demand purification of MAbs. Several MAbs which do not show any displacement in liquid phase RIA and ELISA provide a satisfactory SS-SPRIA. Our investigations revealed that the assumption regarding the stability of the primary Mab-Ag complex during incubation and washing steps in ELISAs is not strictly valid for dissociable MAbs. A comparison of different assay systems suggests that the single step SPRIA offers additional advantages over conventionally used multistep ELISA procedures and provides a quantitative probe for the analysis of epitope-paratope interactions.

Study of Layering Procedures in Finite-Element Analysis of RC Flexural and Torsional Elements

A new postcracking formulation for concrete, along with both implicit and explicit layering procedures, is used in the analysis of reinforced-concrete (RC) flexural and torsional elements. The postcracking formulation accounts for tension stiffening in concrete along the rebar directions, compression softening in cracked concrete based on either stresses or strains, and aggregate interlock based on crack-confining normal stresses. Transverse shear stresses computed using the layering procedures are included in material model considerations that permit the development of inclined cracks through the RC cross section. Examples of a beam analyzed by both the layering techniques, a torsional element, and a column-slab connection region analyzed by the implicit layering procedure are presented here. The study highlights the primary advantages and disadvantages of each layering approach, identifying the class of problems where the application of either procedure is more suitable.

Discrimination of Nuclear Grade Steel Samples Subjected to Different Heat Treatment Procedures Based on Acoustic Emission (AE) Data Profiling at Crack Initiation

The present work is an attempt to study crack initiation in nuclear grade, 9Cr-1Mo ferritic steel using AE as an online NDE tool. Laboratory experiments were conducted on 5 heat treated Compact Tension (CT) specimens made out of nuclear grade 9Cr-1Mo ferritic steel by subjecting them to cyclic tensile load. The CT Specimens were of 12.5 mm thickness. The Acoustic emission test system was setup to acquire the data continuously during the test by mounting AE sensor on one of the surfaces of the specimen. This was done to characterize AE data pertaining to crack initiation and then discriminate the samples in terms of their heat treatment processes based on AE data. The AE signatures at crack initiation could conclusively bring to fore the heat treatment distinction on a sample to sample basis in a qualitative sense.Thus, the results obtained through these investigations establish a step forward in utilizing AE technique as an on-line measurement tool for accurate detection and understanding of crack initiation and its profile in 9Cr-1Mo nuclear grade steel subjected to different processes of heat treatment.

A compliant mechanism kit with flexible beams and connectors along with analysis and optimal synthesis procedures

We present a compliant mechanism kit as a parallel to the kits available for rigid-body mechanisms. The kit consists of flexible beams and connectors that can be easily hand-assembled using snap fits. The mechanisms assembled using the kit accurately capture the aspects of the topology, shape, and size of joint-free compliant mechanisms. Thus, the kit enables designers to conceive and design new, practicable, single-piece compliant mechanisms that do not require assembly. The concept of the kit also resolves a discrepancy in the finite element (FE) modeling of beam-based compliant mechanisms. The discrepancy arises when two or more beams are joined at one point and thus leading to increased stiffness. After resolving this discrepancy, this work extends the topology optimization to automatically generate designs that can be assembled with the kit for quick and easy validation instead of time-consuming prototyping. Thus, the kit and the accompanying analysis and optimal synthesis procedures comprise a self-contained educational as well as a research and practice toolset for compliant mechanisms. The paper also illustrates how human creativity finds new ways of using the kit beyond the original intended use and how it enables even a novice to design compliant mechanisms. (C) 2011 Elsevier Ltd. All rights reserved.

Macromolecular Transport Through Porous Arterial Walls

Arteries are heterogeneous, composite structures that undergo large cyclic deformations during blood transport. Presence, build-up and consequent rupture of blockages in blood vessels, called atherosclerotic plaques, lead to disruption in the blood flow that can eventually be fatal. Abnormal lipid profile and hypertension are the main risk factors for plaque progression. Treatments span from pharmacological methods, to minimally invasive balloon angioplasty and stent procedures, and finally to surgical alternatives. There is a need to understand arterial disease progression and devise methods to detect, control, treat and manage arterial disease through early intervention. Local delivery through drug eluting stents also provide an attractive option for maintaining vessel integrity and restoring blood flow while releasing controlled amount of drug to reduce and alleviate symptoms. Development of drug eluting stents is hence interesting albeit challenging because it requires an integration of knowledge of mechanical properties with material transport of drug through the arterial wall to produce a desired biochemical effect. Although experimental models are useful in studying such complex multivariate phenomena, numerical models of mass transport in the vessel have proved immensely useful to understand and delineate complex interactions between chemical species, physical parameters and biological variables. The goals of this review are to summarize literature based on studies of mass transport involving low density lipoproteins in the arterial wall. We also discuss numerical models of drug elution from stents in layered and porous arterial walls that provide a unique platform that can be exploited for the design of novel drug eluting stents.

Evaluation of the Index-Flood Approach Related Regional Frequency Analysis Procedures

Index-flood related regional frequency analysis (RFA) procedures are in use by hydrologists to estimate design quantiles of hydrological extreme events at data sparse/ungauged locations in river basins. There is a dearth of attempts to establish which among those procedures is better for RFA in the L-moment framework. This paper evaluates the performance of the conventional index flood (CIF), the logarithmic index flood (LIF), and two variants of the population index flood (PIF) procedures in estimating flood quantiles for ungauged locations by Monte Carlo simulation experiments and a case study on watersheds in Indiana in the U.S. To evaluate the PIF procedure, L-moment formulations are developed for implementing the procedure in situations where the regional frequency distribution (RFD) is the generalized logistic (GLO), generalized Pareto (GPA), generalized normal (GNO) or Pearson type III (PE3), as those formulations are unavailable. Results indicate that one of the variants of the PIF procedure, which utilizes the regional information on the first two L-moments is more effective than the CIF and LIF procedures. The improvement in quantile estimation using the variant of PIF procedure as compared with the CIF procedure is significant when the RFD is a generalized extreme value, GLO, GNO, or PE3, and marginal when it is GPA. (C) 2015 American Society of Civil Engineers.

Monitoring hydrilla using two RAPD procedures and the Nonindigenous Aquatic Species database

Hydrilla ( Hydrilla verticillata (L.f.) Royle), an invasive aquatic weed, continues to spread to new regions in the United States. Two biotypes, one a female dioecious and the other monoecious have been identified. Management of the spread of hydrilla requires understanding the mechanisms of introduction and transport, an ability to map and make available information on distribution, and tools to distinguish the known U.S. biotypes as well as potential new introductions. Review of the literature and discussions with aquatic scientists and resource managers point to the aquarium and water garden plant trades as the primary past mechanism for the regional dispersal of hydrilla while local dispersal is primarily carried out by other mechanisms such as boat traffic, intentional introductions, and waterfowl. The Nonindigenous Aquatic Species (NAS) database is presented as a tool for assembling, geo-referencing, and making available information on the distribution of hydrilla. A map of the current range of dioecious and monoecious hydrilla by drainage is presented. Four hydrilla samples, taken from three discrete, non-contiguous regions (Pennsylvania, Connecticut, and Washington State) were examined using two RAPD assays. The first, generated using primer Operon G17, and capable of distinguishing the dioecious and monoecious U.S. biotypes, indicated all four samples were of the monoecious biotype. Results of the second assay using the Stoffel fragment and 5 primers, produced 111 markers, indicated that these samples do not represent new foreign introductions. The differences in the monoecious and dioecious growth habits and management are discussed.

MBARI procedures for automated nutrient analyses using a modified Alpkem Series 300 Rapid Flow Analyzer

This report documents the methods used at the Monterey Bay Aquarium Research Institute (MBARI) for analyzing seawater nutrient samples with an Alpkem Series 300 Rapid Flow Analyzer (RFA) system. The methods have been optimized for the particular requirements of this laboratory. The RFA system has been used to analyze approximately 20,000 samples during the past two years. The methods have been optimized to run nutrient analyses in a routine manner with a detection limit of better than -±1% and a within run precision of -±1% of the full scale concentration range. The normal concentration ranges are 0-200 ~M silicate, 0-5 ~M phosphate, 0-50 ~M nitrate, 0-3 ~M nitrite, and 0-10 ~M ammonium. The memorandum is designed to be used in a loose-leaf binder format. Each page is dated and as revisions are made, they should be inserted into the binder. The revisions should be added into the binder. Retain the old versions in order to maintain a historical record of the procedures. (88 pages)

WEMo (Wave Exposure Model): Formulation, Procedures and Validation

This report describes the working of National Centers for Coastal Ocean Service (NCCOS) Wave Exposure Model (WEMo) capable of predicting the exposure of a site in estuarine and closed water to local wind generated waves. WEMo works in two different modes: the Representative Wave Energy (RWE) mode calculates the exposure using physical parameters like wave energy and wave height, while the Relative Exposure Index (REI) empirically calculates exposure as a unitless index. Detailed working of the model in both modes and their procedures are described along with a few sample runs. WEMo model output in RWE mode (wave height and wave energy) is compared against data collected from wave sensors near Harkers Island, North Carolina for validation purposes. Computed results agreed well with the wave sensors data indicating that WEMo can be an effective tool in predicting local wave energy in closed estuarine environments. (PDF contains 31 pages)

Prognostic Role of Host Cyclooxygenase and Cytokine Genotypes in a Caucasian Cohort of Patients with Gastric Adenocarcinoma

11 p.