Population-Level Analysis of Appropriateness of End-of-Life Care for Children with Neurologic Conditions
terminal care; analysis of variance; article; Belgium; child; cohort analysis; comfort; drawing; female; financial management; follow up; general practitioner; human; intensive care unit; major clinical study; male; nationality; palliative therapy; phlebotomy; physician; retrospective study; sibling; surgery; Terminal Care; total quality management
Abstract Objective: The objective of this study was to measure the appropriateness of end-of-life care for children who died with neurologic conditions. Study design: Based on linked routinely collected databases, we conducted a population-level decedent retrospective cohort study of children with neurologic conditions who died in Belgium between 2010 and 2017. We measured a set of 22 face-validated quality indicators. The set concerns 12 indicators of potentially appropriate end-of-life care (eg, specialized comfort medication, physician contact, continuous care) and 10 indicators of potentially inappropriate end-of-life care (eg, diagnostic tests, phlebotomy). We performed ANOVA for predictors (age, sex, disease category, nationality, having siblings, year of death) for scales of appropriate and inappropriate care. Results: Between 2010 and 2017, 139 children with neurologic conditions died in Belgium. For potentially appropriate care, in the last 30 days, 76% of children received clinical care, 55% had continuous care relationships, 17% had contact with a general physician, 8% of children received specialized comfort medication, and 14% received care from a palliative care team. For potentially inappropriate care, in the last 14 days, 45% had blood drawn and 27% were admitted to intensive care unit. Conclusions: Our study found indications of appropriate as well as inappropriate end-of-life care for children who died with neurologic conditions. These findings reveal a substantial margin for potential quality improvement, in regard to palliative care provision, multidisciplinary care, financial support, specialized comfort medication, clinical follow-up, general physician contact, diagnostics, and blood drawing.
Piette V; Smets T; Deliens L; van Berlaer G; Beernaert K; Cohen J
The Journal of Pediatrics
2023
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<a href="http://doi.org/10.1016/j.jpeds.2022.10.037" target="_blank" rel="noreferrer noopener">10.1016/j.jpeds.2022.10.037</a>
Parental knowledge and opinions on palliative care for children
ambulatory care; analysis of variance; awareness; Caucasian; child; conference abstract; controlled study; convenience sample; data analysis software; ethnic group; female; high school; human; Illinois; institutional review; legal guardian; Likert scale; major clinical study; male; New York; palliative therapy; physician; randomized controlled trial; terminal care
Purpose: A pilot study to ascertain awareness and understanding of palliative care among parents of pediatric patients at a single academic medical center.
Zawistowski C A; Black C; Spruill T M; Granowetter L
Pediatrics
2018
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Quantifying physical decline in juvenile neuronal ceroid lipofuscinosis (Batten disease)
Cross-Sectional Studies; Disease Progression; Young Adult; Child; Humans; Adult; Prospective Studies; Adolescent; Child Preschool; Regression Analysis; Reproducibility of Results; Analysis of Variance; Neuropsychological Tests; Mutation; Disabled Persons; Genotype; Homozygote; Membrane Glycoproteins; Molecular Chaperones; Neuronal Ceroid-Lipofuscinoses; tone and motor problems; NCL3; tool development; scale development; UBDRS
OBJECTIVE: To use the Unified Batten Disease Rating Scale (UBDRS) to measure the rate of decline in physical and functional capability domains in patients with juvenile neuronal ceroid lipofuscinosis (JNCL) or Batten disease, a neurodegenerative lysosomal storage disorder. We have evaluated the UBDRS in subjects with JNCL since 2002; during that time, the scale has been refined to improve reliability and validity. Now that therapies are being proposed to prevent, slow, or reverse the course of JNCL, the UBDRS will play an important role in quantitatively assessing clinical outcomes in research trials. METHODS: We administered the UBDRS to 82 subjects with JNCL genetically confirmed by CLN3 mutational analysis. Forty-four subjects were seen for more than one annual visit. From these data, the rate of physical impairment over time was quantified using multivariate linear regression and repeated-measures analysis. RESULTS: The UBDRS Physical Impairment subscale shows worsening over time that proceeds at a quantifiable linear rate in the years following initial onset of clinical symptoms. This deterioration correlates with functional capability and is not influenced by CLN3 genotype. CONCLUSION: The UBDRS is a reliable and valid instrument that measures clinical progression in JNCL. Our data support the use of the UBDRS to quantify the rate of progression of physical impairment in subjects with JNCL in clinical trials.
Kwon J M; Adams H; Rothberg P G; Augustine E F; Marshall F J; Deblieck E A; Vierhile A; Beck C A; Newhouse N J; Cialone J; Levy E; Ramirez-Montealegre D; Dure L S; Rose K R; Mink J W
Neurology
2011
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<a href="http://doi.org/10.1212/WNL.0b013e318237f649" target="_blank" rel="noreferrer noopener">10.1212/WNL.0b013e318237f649</a>
Correlates of maladaptive behavior in individuals with 5p- (cri du chat) syndrome
Male; Surveys and Questionnaires; Child; Humans; Adult; Adolescent; Female; Child Preschool; Analysis of Variance; Risk Factors; Psychiatric Status Rating Scales; Adjustment Disorders/etiology; Child Behavior Disorders/etiology; Cri-du-Chat Syndrome/genetics/psychology; Gene Deletion; Intellectual Disability/psychology; Mental Disorders/etiology; Translocation Genetic; behavioral problems; Cri-du-chat; trajectory; characteristics; self-injury; aggression; pain behaviors; mood; low mood; hyperactivity; impulsivity; repetitive language use
This study examined the range, distinctiveness, and correlates of maladaptive behavior in 146 subjects with 5p- (cri du chat) syndrome using the Aberrant Behavior Checklist as a standardized measure. Hyperactivity was the most significant and frequent problem in the sample. Subjects with 5p- syndrome also showed aggression, tantrums, self-injurious behavior, and stereotypies; some of these problems were more pronounced in individuals with lower cognitive-adaptive levels, as well as in those with histories of previous medication trials. Autistic-like features and social withdrawal were more characteristic of individuals with translocations as opposed to deletions, even when controlling for the lower adaptive level of the translocation group. These findings encourage further research on the behavior of individuals with 5p- syndrome.
Dykens E M; Clarke D J
Developmental Medicine and Child Neurology
1997
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<a href="http://doi.org/10.1111/j.1469-8749.1997.tb07377.x" target="_blank" rel="noreferrer noopener">10.1111/j.1469-8749.1997.tb07377.x</a>
Children Enrolled in Hospice Care Under Commercial Insurance: A Comparison of Different Age Groups
Data Analysis Software; Age Factors; Male; Human; Sex Factors; Length of Stay; Child; Prospective Studies; Female; Child Preschool; Analysis of Variance; Infant; Adolescence; Health Care Costs; Insurance Health; Pediatric Care; Pennsylvania; Descriptive Statistics; Retrospective Design; Funding Source; Chi Square Test; Cross Sectional Studies; Health Resource Utilization; Academic Medical Centers -- Pennsylvania; Chronic Disease -- Classification -- In Infancy and Childhood; Comparative Studies; Geographic Factors; Hospice Care -- Economics -- In Infancy and Childhood; Hospice Patients -- Psychosocial Factors; Pearson's Correlation Coefficient
Background: Although most children at end of life have commercial insurance, little is known about their demographic and clinical characteristics, what care they are receiving, and how much it costs. Objectives: To describe commercially insured children who enrolled in hospice care during their last year of life and to examine differences across age-groups. Methods: A retrospective cohort study was conducted using 2005 to 2014 data from the MarketScan Commercial Claims and Encounters database from Truven Health Analytics. Variables were created for demographics, health, utilization, and spending. Analyses included χ2 and analysis of variance tests of differences. Results: Among the 17 062 children who utilized hospice, 49% had a preferred provider organization (PPO). Hospice length of stay averaged less than 5 days. Over 80% of children visited their primary care physician. Eight percent had hospital readmissions, and 38% had emergency department (ED) visits. Average expenditures were US$3686 per month or US$44 232 annually. The most common condition for children less than 1 year was cardiovascular (21.96%). Neuromuscular conditions were the most frequent (7.89%) in children aged 1 to 5 years, while malignancies (10.53% and 11.32%, respectively) were prevalent in ages 6 to 14 and 15 to 17. Children less than 1 year had the highest frequency of hospital readmissions (16.25%) with the lowest ED visits (28.67%) while incurring the highest expenses (US$11 211/month). Conclusions: The findings suggest that commercially insured children, who enroll in hospice, have flexible coverage with a PPO. Hospital readmissions and ED visits were relatively low for a population who was seriously ill. There were significant age-group differences.
Lindley Lisa C; Cohrs A C; Keim-Malpass J; Leslie D L
American Journal of Hospice & Palliative Medicine
2019
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<a href="http://doi.org/10.1177/1049909118789868" target="_blank" rel="noreferrer noopener"> 10.1177/1049909118789868</a>
Proxy-Reported Quality of Life and Family Impact for Children Followed Longitudinally by a Pediatric Palliative Care Team
Quality of Life; palliative therapy; Child; Longitudinal Studies; Only Child; Palliative Care; major clinical study; statistical significance; longitudinal study; prospective study; child; attention; human; female; male; quality of life; article; diagnosis; analysis of variance; daily life activity; Metronidazole; minimal clinically important difference; physical model
Background: One goal of pediatric palliative care is to maintain quality of life for children and their families. Quality-of-life investigations may be enhanced by considering clinically important metrics in addition to statistical significance. Objective: The purpose of this study was to longitudinally evaluate the effect of time on quality of life and family impact for pediatric palliative care patients across all diagnoses and ages. Design: This prospective quality-of-life study included administration of a 23-item PedsQLTM Measurement Model to evaluate for physical, emotional, social, and cognitive dimensions of the child's quality of life and a 36-item PedsQL Family Impact Module to assess for the familial impact at time of initial palliative care consultation, Month 6, and Month 12. Setting/Subjects: All pediatric patients who received a palliative care consultation in our Midwestern free-standing children's hospital over a five-year period were included in the longitudinal study (n = 87). Measurements: Repeated measures ANOVA was used to investigate how proxy-reported quality of life and family impact changed with time with attentiveness to also follow trends in minimal clinically important difference (MCID) metrics. Results: The emotional domain showed a statistically significant positive trend over the first six months of palliative care involvement (p = 0.049), while the physical domain (p = 0.028) and daily activity (p = 0.039) showed a positive improvement for the full year. In using a standard of MCID, the physical, emotional, and cognitive domains improved in the quality-of-life scale and the communication, worry, and daily activity domains improved in the family impact scale over 12 months. Conclusions: In considering quality-of-life analyses for pediatric palliative care programmatic improvements, providers may consider analyzing not only for statistical significance in collective data sets but also for clinically important difference over time.
Weaver M; Wichman C; Darnall C; Bace S; Vail C; Macfadyen A
Journal of Palliative Medicine
2018
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<a href="http://doi.org/10.1089/jpm.2017.0092" target="_blank" rel="noreferrer noopener">10.1089/jpm.2017.0092</a>
Meditation experience predicts less negative appraisal of pain: electrophysiological evidence for the involvement of anticipatory neural responses
Female; Humans; Male; Young Adult; Adult; Middle Aged; Analysis of Variance; Regression Analysis; Brain Mapping; Dose-Response Relationship; Evoked Potentials; Pain Threshold/physiology; Electroencephalography/methods; Pain Measurement/methods; Cerebral Cortex/physiology; Lasers/adverse effects; Meditation/methods; Pain/etiology/physiopathology/psychology/rehabilitation; Radiation; Somatosensory/physiology
The aim of mindfulness meditation is to develop present-focused, non-judgmental, attention. Therefore, experience in meditation should be associated with less anticipation and negative appraisal of pain. In this study we compared a group of individuals with meditation experience to a control group to test whether any differences in the affective appraisal of pain could be explained by lower anticipatory neural processing. Anticipatory and pain-evoked ERPs and reported pain unpleasantness were recorded in response to laser stimuli of matched subjective intensity between the two groups. ERP data were analysed after source estimation with LORETA. No group effects were found on the laser energies used to induce pain. More experienced meditators perceived the pain as less unpleasant relative to controls, with meditation experience correlating inversely with unpleasantness ratings. ERP source data for anticipation showed that in meditators, lower activity in midcingulate cortex relative to controls was related to the lower unpleasantness ratings, and was predicted by lifetime meditation experience. Meditators also reversed the normal positive correlation between medial prefrontal cortical activity and pain unpleasantness during anticipation. Meditation was also associated with lower activity in S2 and insula during the pain-evoked response, although the experiment could not disambiguate this activity from the preceding anticipation response. Our data is consistent with the hypothesis that meditation reduces the anticipation and negative appraisal of pain, but effects on pain-evoked activity are less clear and may originate from preceding anticipatory activity. Further work is required to directly test the causal relationship between meditation, pain anticipation, and pain experience.
2010
Brown CA; Jones AK
Pain
2010
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Journal Article
<a href="http://doi.org/10.1016/j.pain.2010.04.017" target="_blank" rel="noreferrer">10.1016/j.pain.2010.04.017</a>
Miglustat for treatment of Niemann-Pick C disease: a randomised controlled study
Child; Female; Humans; Male; Cohort Studies; Adult; Age Factors; Severity of Illness Index; Analysis of Variance; Double-Blind Method; Drug Administration Schedule; adolescent; Preschool; Q3 Literature Search; retrospective studies; Niemann-Pick Disease; 1-Deoxynojirimycin/analogs & derivatives/therapeutic use; Deglutition/drug effects; Enzyme Inhibitors/therapeutic use; Saccades/drug effects; Type C/drug therapy/physiopathology
BACKGROUND: Niemann-Pick type C disease (NPC) is an inherited neurodegenerative disorder characterised by an intracellular lipid-trafficking defect with secondary accumulation of glycosphingolipids. Miglustat, a small iminosugar, reversibly inhibits glucosylceramide synthase, which catalyses the first committed step of glycosphingolipid synthesis. Miglustat is able to cross the blood-brain barrier, and is thus a potential therapy for neurological diseases. We aimed to establish the effect of miglustat on several markers of NPC severity. METHODS: Patients aged 12 years or older who had NPC (n=29) were randomly assigned to receive either miglustat 200 mg three times a day (n=20) or standard care (n=9) for 12 months. 12 children younger than 12 years of age were included in an additional cohort; all received miglustat at a dose adjusted for body surface area. All participants were then treated with miglustat for an additional year in an extension study. The primary endpoint was horizontal saccadic eye movement (HSEM) velocity, based on its correlation with disease progression. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN26761144. FINDINGS: At 12 months, HSEM velocity had improved in patients treated with miglustat versus those receiving standard care; results were significant when patients taking benzodiazepines were excluded (p=0.028). Children showed an improvement in HSEM velocity of similar size at 12 months. Improvement in swallowing capacity, stable auditory acuity, and a slower deterioration in ambulatory index were also seen in treated patients older than 12 years. The safety and tolerability of miglustat 200 mg three times a day in study participants was consistent with previous trials in type I Gaucher disease, where half this dose was used. INTERPRETATION: Miglustat improves or stabilises several clinically relevant markers of NPC. This is the first agent studied in NPC for which there is both animal and clinical data supporting a disease modifying benefit.
2007
Patterson MC; Vecchio D; Prady H; Abel L; Wraith JE
Lancet Neurology
2007
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Journal Article
<a href="http://doi.org/10.1016/S1474-4422(07)70194-1" target="_blank" rel="noreferrer">10.1016/S1474-4422(07)70194-1</a>
A D2 antagonist enhances the rewarding and priming effects of a gambling episode in pathological gamblers.
Female; Humans; Male; Pain Measurement; Adult; Middle Aged; Semantics; Analysis of Variance; Motivation; Double-Blind Method; IM; Psychiatric Status Rating Scales; Neuropsychological Tests; Blood Pressure/de [Drug Effects]; Dopamine Antagonists/ad [Administration & Dosage]; Dopamine Antagonists/ae [Adverse Effects]; Gambling/px [Psychology]; Haloperidol/ad [Administration & Dosage]; Haloperidol/ae [Adverse Effects]; Reaction Time/de [Drug Effects]; Reward
Previous research indicated shared neurochemical substrates for gambling and psychostimulant reward. This suggests that dopamine substrates may directly govern the reinforcement process in pathological gambling. To investigate this issue, the present study assessed the effects of the relatively selective dopamine D2 antagonist, haloperidol (3 mg, oral) on responses to actual gambling (15 min on a slot machine) in 20 non-comorbid pathological gamblers and 18 non-gambler controls in a placebo-controlled, double-blind, counterbalanced design. In gamblers, haloperidol significantly increased self-reported rewarding effects of gambling, post-game priming of desire to gamble, facilitation of reading speed to Gambling words, and gambling-induced elevation in blood pressure. In controls, haloperidol augmented gambling-induced elevation in blood pressure, but had no effect on other indices. The findings provide direct experimental evidence that the D2 substrate modulates gambling reinforcement in pathological gamblers.
2007
Zack M; Poulos CX
Neuropsychopharmacology
2007
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Journal Article
<a href="http://doi.org/10.1038/sj.npp.1301295" target="_blank" rel="noreferrer">10.1038/sj.npp.1301295</a>
Increase of plasmatic beta-endorphin immunoreactive material in children in the perioperative period: the influence of the site of surgery
Child; Female; Humans; Male; Time Factors; Linear Models; Analysis of Variance; adolescent; Preschool; Adaptation; Stress/immunology; Ambulatory Surgical Procedures/adverse effects/statistics & numerical data; beta-Endorphin/blood/immunology; Perioperative Care/statistics & numerical data; Physiological/immunology
BACKGROUND: The primary aim of the study was to confirm the increase of plasmatic IR beta-endorphin material during the perioperative period in children. The second was to search for the factors responsible for this increment. METHODS: Seventy-two consecutive children undergoing a surgical procedure were recruited. Pre-anaesthesia and anaesthesia were standardised. Plasmatic IR beta-endorphin material was measured at three timepoints: at baseline (t (0)), before induction (t (1)), and at the end of anaesthesia (t (2)). Two general linear models were set up to analyse the influence of demographics and clinics on the IR beta-endorphin variation between t (0) and t (1). A third model was established to process the possible surgical factors contributing to the IR beta-endorphin variation between t (1) and t (2). RESULTS: ANOVA showed that IR beta-endorphin concentrations increased significantly across the three timepoints (p < 0.0001). Wilcoxon test proved that the difference was significant both for t (0) vs. t (1) and for t (1) vs. t (2). None of the factors taken into account in the pre-operative period influenced the increase in IR beta-endorphin between t (0) and t (1). Of the factors taken into account in the surgical period, only the type of procedure was significant (p = 0.005). The t-test showed that IR beta-endorphin significantly increased during spermatic and epigastric anastomosis (p = 0.000), orchidopexy (p = 0.02), Van der Meulen urethroplasty (p = 0.004), and Duckett urethroplasty (p = 0.003). CONCLUSION: Plasmatic beta-endorphin increases during the perioperative period in children. The site of surgery is responsible for this increment during intervention.
2008
Bachiocco V; Mastrolia A; Gentili A; Pipitone E; Lima M
European Journal Of Pediatric Surgery
2008
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Journal Article
<a href="http://doi.org/10.1055/s-2007-989274" target="_blank" rel="noreferrer">10.1055/s-2007-989274</a>
Parent resuscitation preferences for young people with severe developmental disabilities.
Child; Female; Humans; Male; Adult; Attitude to Health; Choice Behavior; Massachusetts; Program Evaluation; Analysis of Variance; Organizational Policy; adolescent; Preschool; retrospective studies; Parents/education/psychology; DNAR; Attitude to Health; Developmental Disabilities/th [Therapy]; Health Education/og [Organization & Administration]; Parents; Resuscitation Orders/px [Psychology]; Advance Care Planning/og [Organization & Administration]; Advance Care Planning/organization & administration; Consent Forms; Developmental Disabilities/co [Complications]; Developmental Disabilities/complications/therapy; documentation; Health Education/organization & administration; Parents/ed [Education]; Parents/px [Psychology]; Resuscitation Orders/psychology; Skilled Nursing Facilities/og [Organization & Administration]; Skilled Nursing Facilities/organization & administration; Treatment Refusal/psychology; Treatment Refusal/px [Psychology]
OBJECTIVE: To determine the relationship of providing explanatory information regarding resuscitation to DNR status for parents and guardians of young people who reside in a pediatric skilled nursing facility., DESIGN: Retrospective, quasi-experimental study of policy change, with each individual serving as his or her own control. Interval comparisons were made between resuscitation choices before and after information was provided to families. For those who were originally in the full resuscitation group, comparisons were also made between those who changed to DNR and those who did not., SETTING: Pediatric skilled nursing facility in Massachusetts., PARTICIPANTS: Sixty individuals with severe mental retardation and complex medical problems, between the ages of approximately 2 and 32 years., MEASUREMENTS: Review of records regarding resuscitation choices and changes, with each person serving as his or her own control. Both univariate and multivariate analyses were performed on individuals who were in the full resuscitation group at the initiation of the study to determine distinguishing characteristics between those who remained in that group from those who changed to DNR., RESULTS: The families of 11 (18%) of 60 patients had requested DNR orders prior to requirement of written preference for resuscitation or DNR in the event of cardiopulmonary arrest. After provision of informative material, there was an increase to 26 patients (43%) who were designated DNR (P < . 001). There was no significant difference in characteristics between the groups that changed to DNR and those that remained full resuscitation, although there was a marginal trend of children in the group with an acquired etiology for their developmental disabilities were more apt to have their resuscitation status changed than those with congenital diagnoses (P = .053)., CONCLUSION: When families are provided with explanatory information regarding resuscitation in a nonacute, pediatric skilled nursing home setting, there is a significant increase in request for DNR.
2006
Friedman SL
Journal Of The American Medical Directors Association
2006
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Journal Article
<a href="http://doi.org/10.1016/j.jamda.2005.06.004" target="_blank" rel="noreferrer">10.1016/j.jamda.2005.06.004</a>
Brief report: family-based group intervention for young siblings of children with chronic illness and developmental disability
adolescent; Child; Female; Humans; infant; Male; Adult; Chronic disease; Follow-Up Studies; Siblings; Social Adjustment; Developmental Disabilities; Family Therapy; Analysis of Variance; Practice; Preschool; Adaptation; Psychological; Attitudes; PedPal Lit; Health Knowledge; Intervention; Interventions; sibling bereavement
OBJECTIVE: To evaluate the impact of a family-based group intervention for young siblings of children with chronic illness and developmental disability (CI/DD). METHODS: Forty-three healthy siblings (ages 4-7 years) of children with CI/DD and their parents participated in an intervention designed to address sibling challenges that cut across types of diagnostic conditions. The intervention consisted of six sessions of collateral and integrated sibling-parent groups. Measures of sibling knowledge, sibling sense of connectedness with other children in similar family circumstances, and sibling global functioning were collected before and after intervention. A subsample of 17 families completed a 3-month follow-up. RESULTS: Siblings' knowledge of the child's disorder and sibling connectedness increased significantly from pre- to posttreatment for both boys and girls, regardless of the nature of the brother or sister's condition. Sibling perceptions of self-competence increased from pre- to posttreatment, whereas parent reports of sibling behavioral functioning remained within the normal range. Improvements in sibling knowledge and connectedness maintained at follow-up. Parent satisfaction with the program was high. CONCLUSIONS: Results support more controlled evaluations of family-based intervention to improve young sibling adaptation to CI/DD.
2005-12
Lobato DJ; Kao BT
Journal of Pediatric Psychology
2005
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Journal Article
<a href="http://doi.org/10.1093/jpepsy/jsi054" target="_blank" rel="noreferrer">10.1093/jpepsy/jsi054</a>
Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death
Female; Humans; Male; Hospital Mortality; Prospective Studies; Aged; Middle Aged; Comorbidity; Resuscitation Orders; Severity of Illness Index; Survival Analysis; Risk Factors; Hospitals; Analysis of Variance; Predictive Value of Tests; Proportional Hazards Models; Teaching; 80 and over; Empirical Approach; Death and Euthanasia; decision making; ICU Decision Making; Intensive Care Units/statistics & numerical data; APACHE; Critical Care/statistics & numerical data; Life Support Care/statistics & numerical data; Paris/epidemiology; Withholding Treatment/statistics & numerical data
OBJECTIVE: More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality. DESIGN AND SETTING: Prospective multicenter 2-year study in six ICUs in France. PATIENTS: The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs. MEASUREMENTS AND RESULTS: The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887). CONCLUSIONS: DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.
2003
Azoulay E; Pochard F; Garrouste-Orgeas M; Moreau D; Montesino L; Adrie C; deLassence A; Cohen Y; Timsit JF; Outcomerea Study Group
Intensive Care Medicine
2003
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Journal Article
<a href="http://doi.org/10.1007/s00134-003-1989-3" target="_blank" rel="noreferrer">10.1007/s00134-003-1989-3</a>
Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study
Female; Humans; Male; Intensive Care Units; Adult; Aged; Middle Aged; Australia; Analysis of Variance; adolescent; 80 and over; Family/psychology; ICU Decision Making; social support; Intervention; Interventions; Patient Transfer; Anxiety/prevention & control; Pamphlets
INTRODUCTION: This intervention study examines anxiety and uncertainty in illness in families transferring from intensive care to a general ward. METHODS: The pre-test, post-test design purposively allocated family members to a control (n = 80) and intervention group (n = 82). The intervention group experienced a structured individualised transfer method whereas the control group received existing ad hoc transfer methods. Families were surveyed before and after transfer. RESULTS: Families' uncertainty was significantly related to their state anxiety (P < 0.000), the relationship to the patient (P = 0.022), and the unexpected nature of patients' admission (P < 0.000). Anxiety increased significantly with reduced social support (P = 0.002). Following transfer, anxiety reduced significantly for both groups whereas uncertainty reduced significantly for the intervention group (P = 0.03). CONCLUSION: Families at the time of transfer experience uncertainty and anxiety, which are significantly related in this study. The intervention significantly reduced uncertainty scores. When the family member was a parent, when admissions were unexpected, and those with fewer social supports represent potential 'at risk' groups whose adaptation to transfer may limit their coping ability. The structured individualised method of transfer is recommended with further research of ICU families to further examine the dimension of uncertainty and how it affects patient outcomes.
2004
Mitchell ML; Courtney M
Intensive and Critical Care Nursing
2004
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Journal Article
<a href="http://doi.org/10.1016/j.iccn.2004.05.008" target="_blank" rel="noreferrer">10.1016/j.iccn.2004.05.008</a>
Control of inflammatory pain by chemokine-mediated recruitment of opioid-containing polymorphonuclear cells
Male; Pain Measurement; Analysis of Variance; Animals; Rats; Non-U.S. Gov't; Research Support; Comparative Study; Dose-Response Relationship; Drug; Receptors; Naloxone/pharmacology; Freund's Adjuvant; Wistar; Flow Cytometry/methods; Antibodies/pharmacology; Cell Count/methods; Cell Movement/physiology; Chemokines; Chemokines/immunology/physiology; Corticotropin-Releasing Hormone/therapeutic use; CXC/immunology/metabolism; Drug Administration Routes; Enzyme-Linked Immunosorbent Assay/methods; Gene Expression Regulation/physiology; Immunohistochemistry/methods; Intercellular Signaling Peptides and Proteins/immunology/metabolism; Interleukin-8B/metabolism; Narcotics/metabolism; Neurogenic Inflammation/chemically induced/complications/therapy; Neutrophils/metabolism; Pain Threshold/drug effects; Pain/etiology/therapy
Opioid-containing leukocytes can counteract inflammatory hyperalgesia. Under stress or after local injection of corticotropin releasing factor (CRF), opioid peptides are released from leukocytes, bind to opioid receptors on peripheral sensory neurons and mediate antinociception. Since polymorphonuclear cells (PMN) are the predominant opioid-containing leukocyte subpopulation in early inflammation, we hypothesized that PMN and their recruitment by chemokines are important for peripheral opioid-mediated antinociception at this stage. Rats were intraplantarly injected with complete Freund's adjuvant (CFA). Using flow cytometry, immunohistochemistry, and ELISA, leukocyte subpopulations, chemokine receptor (CXCR2) expression on opioid-containing leukocytes and the CXCR2 ligands keratinocyte-derived chemokine (KC), macrophage inflammatory protein-2 (MIP-2) and cytokine-induced neutrophil chemoattractant-2 (CINC-2) were quantified. Paw pressure threshold (PPT) was determined before and after intraplantar and subcutaneous injection of CRF with or without naloxone. PMN depletion was achieved by intravenous injection of an antiserum. Chemokines were blocked by intraplantar injection of anti-MIP-2 and/or anti-KC antiserum. We found that at 2 h post CFA (i) intraplantar but not subcutaneous injection of CRF produced dose-dependent and naloxone-reversible antinociception (P0.05, ANOVA). In summary, in early inflammation peripheral opioid-mediated antinociception is critically dependent on PMN and their recruitment by CXCR2 chemokines.
2004
Brack A; Rittner HL; Machelska H; Leder K; Mousa SA; Schafer M; Stein C
Pain
2004
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1016/j.pain.2004.08.029" target="_blank" rel="noreferrer">10.1016/j.pain.2004.08.029</a>
The parents' postoperative pain measure: replication and extension to 2-6-year-old children
Child; Female; Humans; Male; Pain; Adult; Parent-Child Relations; Psychometrics; Analysis of Variance; Preschool; Non-U.S. Gov't; Research Support; Comparative Study; Pain Measurement/methods; Postoperative/diagnosis
Pain assessment is a difficult task for parents at home following children's surgery. The purpose of the present study was to confirm the psychometric properties of a behavioural measure of postoperative pain developed to assist parents with pain assessment in children aged 7-12 years following day surgery. The study also examined the reliability and validity of the measure with children aged 2-6 years. Participants were 51 parents of children aged 7-12 years and 107 parents of children aged 2-6 years. For the 2 days following surgery, parents completed a pain diary that included global ratings of their children's pain and the 15-item Parents' Postoperative Pain Measure (PPPM). The older children provided self-reports of their pain intensity. The PPPM items showed good internal consistency on the two postoperative days for both samples (alpha's=0.81-0.88) and scores on the PPPM were highly correlated with children's (for the older children) and parents' (for the young children) global ratings of pain (r's=0.53-0.72). As global pain ratings decreased from Days 1 to 2, so did scores on the PPPM. Scores on the PPPM were successful in discriminating between children who had undergone low/moderate and high pain surgeries. The results of this study provide evidence of the reliability and validity of the PPPM as a measure of postoperative pain among children aged 2 through to 12 years.
2003
Chambers CT; Finley GA; McGrath PJ; Walsh TM
Pain
2003
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1016/s0304-3959(03)00256-2" target="_blank" rel="noreferrer">10.1016/s0304-3959(03)00256-2</a>
Parental stress and burden following traumatic brain injury amongst children and adolescents.
Child; Female; Humans; Male; Adult; England; Questionnaires; Follow-Up Studies; Health Status; Longitudinal Studies; Mental Health; Cost of Illness; Analysis of Variance; Health Education; Family Health; Family Characteristics; Stress; adolescent; Preschool; Non-U.S. Gov't; Research Support; Adaptation; Psychological; Comparative Study; Parents/psychology; poverty; Brain Injuries/economics/psychology; Psychological/etiology
PRIMARY OBJECTIVES: To assess parental stress following paediatric traumatic brain injury (TBI), and examine the relationship between self-reported problems, parental stress and general health. RESEARCH DESIGN: Parents of 97 children admitted with a TBI (49 mild, 19 moderate, 29 severe) to North Staffordshire National Health Service Trust, and parents of 31 uninjured children were interviewed and assessed. METHODS AND PROCEDURES: Structured interviews were carried out with families, and parents assessed on the Parenting Stress Index (PSI/SF) and General Health Questionnaire (GHQ-12) at recruitment, and repeated 12 months later. MAIN OUTCOMES AND RESULTS: Forty parents (41.2%) of children with TBI exhibited clinically significant stress. Regardless of injury severity, parents of injured children suffered greater stress than control parents as measured by the PSI/SF (p = 0.001). There was a highly significant relationship between number of problems reported and level of parental stress (p = 0.001). Financial burden was related to severity of TBI. At follow-up, one third of parents of children with severe TBI scored > or =18 on the GHQ-12, signifying poor psychological health. CONCLUSIONS: The parents of a child with serious TBI should be screened for abnormal levels of stress. Parental stress and family burden may be alleviated by improved information, follow-up and support.
2003
Hawley CA; Ward AB; Magnay AR; Long J
Brain Injury
2003
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Journal Article
<a href="http://doi.org/10.1080/0269905021000010096" target="_blank" rel="noreferrer">10.1080/0269905021000010096</a>
Sense of coherence: a relevant resource in the coping process of mothers of deaf and hard-of-hearing children?
Female; Humans; Questionnaires; Analysis of Variance; Stress; Adaptation; Psychological; Models; Mothers/psychology; Psychological/psychology; Theoretical; Deafness/psychology
This study examined the importance of reported sense of coherence (Antonovsky, 1987) in mothers of children with hearing impairment. Sense of coherence was explored as a factor in relation to the experience of stress and subjective life satisfaction and in the context of other relevant variables in coping (e.g., social support, additional handicaps of the child, child's hearing status, means of communication). Two hundred thirty-five mothers completed a questionnaire, and path analysis corroborated a theoretical model in which sense of coherence was delineated as a factor contributing directly to stress perception. Both sense of coherence and the experience of social support were identified as resources that reduced reported stress and improved quality of life, with sense of coherence especially important in reducing stress. Child variables, including additional handicaps and extent of hearing impairment, intensified reported stress for the mothers, but mode of communication with the deaf child did not affect stress experience. The findings are discussed within the context of socialization theory. Recommendations for further research (e.g., longitudinal data, control designs, socio-economic status, applicability to fathers) are made.
2004
Hintermair M
Journal Of Deaf Studies And Deaf Education
2004
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Journal Article
<a href="http://doi.org/10.1093/deafed/enh005" target="_blank" rel="noreferrer">10.1093/deafed/enh005</a>
Acute and chronic paediatric intensive care patients: current trends and perspectives on resource utilization
Child; Female; Humans; infant; Male; Intensive Care Units; Hospital Mortality; Prospective Studies; Length of Stay; Respiration; Severity of Illness Index; Analysis of Variance; adolescent; Preschool; infant; Newborn; Pediatric/utilization; ICU Decision Making; Greece; Acute Disease/mortality/therapy; Artificial/methods; Chronic Disease/mortality/therapy; Health Resources/trends/utilization
BACKGROUND: Advances in paediatric critical care have resulted in increased survival of critically ill patients, many of whom require long-term ventilation as a means of life support. AIM: To determine current trends in resource utilization, and problems in the care of acute and chronic paediatric intensive care patients. DESIGN: Open observational study. METHODS: We evaluated consecutive admissions (n = 1629) to a 10-bed paediatric intensive care unit (PICU) over a 5-year period. Three previously defined criteria for resource utilization were used: mean length of stay (LOS); length of mechanical ventilation (LOMV); and LOMV/LOS ratio. RESULTS: A total of 10 310 patient bed days and 5223 ventilator days were used. Mean LOS increased from 5.3 +/- 12 days in 1998 to 8.7 +/- 27 days in 2001 (p 2 weeks (n = 320, 20%) used 55% of LOS and 57% of LOMV, in contrast to the 1298 (80%) hospitalized for 3 months (11, 0.7%) consumed 17% of LOS and 23% of LOMV. Five of these (45%) were eventually discharged home, two on ventilators. CONCLUSION: The increasing trend of occupation of PICU bed and ventilator days by critically ill children may be related to the increasing trend for hospitalization of chronic care patients. Severity scoring systems were predictive of resource consumption, but not of the overall trend in mortality rate.
2004
Briassoulis G; Filippou O; Natsi L; Mavrikiou M; Hatzis T
Monthly Journal Of The Association Of Physicians
2004
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Journal Article
<a href="http://doi.org/10.1093/qjmed/hch087" target="_blank" rel="noreferrer">10.1093/qjmed/hch087</a>
Intensive care unit admission has minimal impact on long-term mortality
Female; Humans; Male; Survival Rate; Adult; Hospital Mortality; Aged; Middle Aged; Outcome Assessment (Health Care); Survival Analysis; Analysis of Variance; Risk; Regression Analysis; Non-U.S. Gov't; Research Support; Comparative Study; retrospective studies; Intensive Care Units/utilization; British Columbia/epidemiology; Risk Adjustment
OBJECTIVE: To measure the association between intensive care unit (ICU) admission and both hospital and long-term mortality, separate from the effect of hospital admission alone. DESIGN: Retrospective cohort study. SETTING: All hospitals in British Columbia, Canada, during 3 fiscal years, 1994 to 1996. PATIENTS: A total of 27,103 patients admitted to ICU and 41,308 (5% random sample) patients admitted to hospital but not to ICU. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Although ICU admission was an important factor associated with hospital mortality (odds ratio: 9.12; 95% confidence interval: 8.34-9.96), the association between ICU admission and mortality after discharge was relatively minimal (hazard ratio: 1.21; 95% confidence interval: 1.17-1.27) and was completely overshadowed by the effect of age, gender, and diagnosis. CONCLUSIONS: After controlling for the effect of hospital admission, admission to ICU has minimal independent effect on mortality after discharge.
2002
Keenan SP; Dodek P; Chan K; Hogg RS; Craib KJ; Anis AH; Spinelli JJ
Critical Care Medicine
2002
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Journal Article
<a href="http://doi.org/10.1097/00003246-200203000-00002" target="_blank" rel="noreferrer">10.1097/00003246-200203000-00002</a>
A survey of IRB process in 68 U.S. hospitals
Humans; United States; Questionnaires; Guidelines as Topic; Time Factors; Patient Advocacy; Analysis of Variance; Empirical Approach; Ethics Committees; Biomedical and Behavioral Research; Multi-site Ethics; Guideline Adherence/standards; Professional Competence/standards; Research/organization & administration; Human Experimentation; Conflict of Interest; Documentation/methods/standards; Hospital Bed Capacity/statistics & numerical data; Organizational Affiliation; Outcome and Process Assessment (Health Care)/organization & administration
PURPOSE: To compare IRB processes in 68 U.S. hospitals for the same multicenter study. DESIGN: Survey of IRB processes in 68 U.S. hospitals during 2001-2002. METHODS: Requirements of IRB submission including type and duration of review and qualifications of principal investigator were compared by hospital bed size, region, and academic affiliation. FINDINGS: The majority of hospitals (63.2%) were on the East coast, and mean bed size was 465 (range: 77-2,112). About one-third (33.8%) required that the principal investigator listed on the application be from within the institution, 26.5% required evidence of human subjects research training, 10.3% required a conflict of interest statement. Mean number of pages for the application was 5.24 (1-31) and up to eight copies were requested. Time from submission of the IRB application to approval averaged 45.4 days (range, 1-303 days), and the majority of reviews were "expedited" (61.8%). Expedited reviews required more time (mean, 54.8 days) than did either exempt (mean, 10.8 days) or full (mean, 47.1 days) reviews. CONCLUSIONS: Current IRB review processes are cumbersome and nonstandardized, and review time varies widely. The absence of efficient and streamlined review might unnecessarily impede national clinical research projects without improving participant safety.
2004
Larson E; Bratts T; Zwanziger J; Stone P
Journal Of Nursing Scholarship
2004
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Journal Article
<a href="http://doi.org/10.1111/j.1547-5069.2004.04047.x" target="_blank" rel="noreferrer">10.1111/j.1547-5069.2004.04047.x</a>
Emotionally focused interventions for couples with chronically ill children: a 2-year follow-up
Child; Female; Humans; Male; Follow-Up Studies; Treatment Outcome; Ontario; Time Factors; Cost of Illness; Analysis of Variance; Family Characteristics; Stress; Preschool; Adaptation; Psychological; Parents/psychology; Intervention; Interventions; Chronic Disease/psychology; Spouses/psychology; Marriage/psychology; Psychological/etiology; Marital Therapy/methods
Couples with chronically ill children are particularly at risk for experiencing marital distress. The study presented here is a 2-year follow-up of a randomized control trial that assessed the efficacy of Emotionally Focused Therapy (EFT) in decreasing marital distress in a sample of couples with a chronically ill child. Thirteen couples with chronically ill children who received treatment were assessed to determine if the significant improvement in relationship distress observed at posttreatment and 5-month follow-up would be maintained at 2-year follow-up. Results demonstrated that improvements in marital functioning were not only maintained but, in some cases, enhanced at the 2-year follow-up. This uncontrolled follow-up study provides initial evidence of the longer-term benefits of EFT.
2002
Cloutier PF; Manion IG; Walker JG; Johnson SM
Journal Of Marital And Family Therapy
2002
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Journal Article
<a href="http://doi.org/10.1111/j.1752-0606.2002.tb00364.x" target="_blank" rel="noreferrer">10.1111/j.1752-0606.2002.tb00364.x</a>
A systematic review of physicians' survival predictions in terminally ill cancer patients.
Humans; Terminally Ill; Survival Analysis; Longitudinal Studies; Reproducibility of Results; Analysis of Variance; Regression Analysis; Empirical Approach; Death and Euthanasia; decision making; Charting the Territory; Neoplasms/mortality; Clinical Competence/standards; Physicians/standards
OBJECTIVE: To systematically review the accuracy of physicians' clinical predictions of survival in terminally ill cancer patients. DATA SOURCES: Cochrane Library, Medline (1996-2000), Embase, Current Contents, and Cancerlit databases as well as hand searching. STUDY SELECTION: Studies were included if a physician's temporal clinical prediction of survival (CPS) and the actual survival (AS) for terminally ill cancer patients were available for statistical analysis. Study quality was assessed by using a critical appraisal tool produced by the local health authority. DATA SYNTHESIS: Raw data were pooled and analysed with regression and other multivariate techniques. RESULTS: 17 published studies were identified; 12 met the inclusion criteria, and 8 were evaluable, providing 1563 individual prediction-survival dyads. CPS was generally overoptimistic (median CPS 42 days, median AS 29 days); it was correct to within one week in 25% of cases and overestimated survival by at least four weeks in 27%. The longer the CPS the greater the variability in AS. Although agreement between CPS and AS was poor (weighted kappa 0.36), the two were highly significantly associated after log transformation (Spearman rank correlation 0.60, P < 0.001). Consideration of performance status, symptoms, and use of steroids improved the accuracy of the CPS, although the additional value was small. Heterogeneity of the studies' results precluded a comprehensive meta-analysis. CONCLUSIONS: Although clinicians consistently overestimate survival, their predictions are highly correlated with actual survival; the predictions have discriminatory ability even if they are miscalibrated. Clinicians caring for patients with terminal cancer need to be aware of their tendency to overestimate survival, as it may affect patients' prospects for achieving a good death. Accurate prognostication models incorporating clinical prediction of survival are needed.
2003
Glare P; Virik K; Jones M; Hudson M; Eychmuller S; Simes J; Christakis NA
Bmj (clinical Research Ed.)
2003
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Journal Article
<a href="http://doi.org/10.1136/bmj.327.7408.195" target="_blank" rel="noreferrer">10.1136/bmj.327.7408.195</a>
Activation of peripheral NMDA receptors contributes to human pain and rat afferent discharges evoked by injection of glutamate into the masseter muscle
Female; Humans; Male; Adult; Analysis of Variance; Animals; Double-Blind Method; Cross-Over Studies; Rats; Non-U.S. Gov't; Research Support; Nonparametric; Statistics; Dose-Response Relationship; Drug; Receptors; Sprague-Dawley; Afferent Pathways/drug effects/physiology; Glutamic Acid/pharmacology; Masseter Muscle/drug effects/physiology; N-Methyl-D-Aspartate/agonists/antagonists & inhibitors/metabolism; Pain/chemically induced/physiopathology
Peripheral N-methyl-d-aspartate (NMDA) receptors are found in deep tissues and may play a role in deep tissue pain. Injection of the endogenous NMDA receptor agonist glutamate into the masseter muscle excites deep craniofacial afferent fibers in rats and evokes pain in human subjects. It is not clear whether peripheral NMDA receptors play a role in these effects of glutamate. Accordingly, the effect of NMDA on afferent activity as well as the effect of locally administered NMDA receptor antagonists on glutamate-evoked afferent discharges in acutely anesthetized rats and muscle pain in human subjects was examined. Injection of NMDA into the masseter muscle evoked afferent discharges in a concentration-related manner. It was found that the NMDA receptor antagonists 2-amino-5-phosphonvalerate (APV, 10 mM), ketamine (10 mM), and dextromethorphan (40 mM) significantly decreased glutamate-evoked afferent discharges. The effects of APV and ketamine, but not dextromethorphan, were selective for glutamate-evoked afferent discharges and did not affect hypertonic saline-evoked afferent discharges. In human experiments, it was found that 10 mM ketamine decreased glutamate-evoked muscle pain but had no effect on hypertonic saline-evoked muscle pain. These results indicate that injection of glutamate into the masseter muscle evokes afferent discharges in rats and muscle pain in humans in part through activation of peripheral NMDA receptors. It is conceivable that activation of peripheral NMDA receptors may contribute to masticatory muscle pain and that peripherally acting NMDA receptor antagonists could prove to be effective analgesics for this type of pain.
2003
Cairns BE; Svensson P; Wang K; Hupfeld S; Graven-Nielsen T; Sessle BJ; Berde CB; Arendt-Nielsen L
Journal Of Neurophysiology
2003
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Journal Article
<a href="http://doi.org/10.1152/jn.00353.2003" target="_blank" rel="noreferrer">10.1152/jn.00353.2003</a>
Peripheral opioid receptors mediating antinociception in inflammation. Activation by endogenous opioids and role of the pituitary-adrenal axis
Male; Analysis of Variance; Animals; Rats; Biomarkers of Pain; Dose-Response Relationship; Drug; Receptors; Naloxone/pharmacology; Foot; Biomarkers Reference List; Adrenalectomy; Cold; Endorphins/physiology; Hypophysectomy; Inbred Strains; Inflammation/physiopathology; Naltrexone/pharmacology; Nociceptors/physiopathology; Opioid/physiology; Pituitary-Adrenal System/physiology; Stress/physiopathology; Swimming
This study investigated the involvement of endogenous opioid peptides in mediating cold water swim (CWS) stress-induced antinociception (SIA) in rats with unilateral hind paw inflammation induced by Freund's complete adjuvant (FCA). Following 0.5, 1 and 2 min of CWS, there was a duration-dependent elevation of paw pressure threshold (PPT) in both inflamed and non-inflamed paws which was maximal immediately after CWS and returned to control values within 15 min. The antinociception elicited in the inflamed paw was significantly greater than that elicited in the non-inflamed paw. The antinociception induced by a 1 min CWS was dose dependently antagonized by tertiary naloxone (0.125-1 mg/kg s.c.) and completely reversed by tertiary naltrexone (0.5 mg/kg). Quaternary naltrexone (5-40 mg/kg s.c.) was similarly effective in reversing the elevation of inflamed PPT induced by a 1 min CWS stress. In contrast, similar doses of quaternary naltrexone had no effect against centrally mediated morphine antinociception in non-inoculated rats. Adrenalectomy was without effect on the pattern of SIA seen in FCA-treated rats. Surgical hypophysectomy completely abolished the differential antinociception induced by 0.5 and 1 min durations of CWS but had little effect on that following 2 min of CWS stress. Inhibition of hypophysial corticotrophic cell secretion with dexamethasone (300 micrograms/kg) injected s.c. 120 min prior to CWS completely abolished the differential SIA at all durations of CWS tested. beta-Endorphin 12.5 micrograms/kg administered i.v. in non-stressed rats also caused a greater elevation of PPT in inflamed than in non-inflamed paws. This effect was not reversed by concomitant i.v. administration of (-) tertiary naloxone 5 mg/kg or quaternary naltrexone 20 mg/kg.
1990
Parsons CG; Czlonkowski A; Stein C; Herz A
Pain
1990
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Journal Article
<a href="http://doi.org/10.1016/0304-3959(90)91112-v" target="_blank" rel="noreferrer">10.1016/0304-3959(90)91112-v</a>
Sublingual absorption of selected opioid analgesics
Humans; Adult; Analgesics; Time Factors; Analysis of Variance; Non-U.S. Gov't; P.H.S.; Research Support; U.S. Gov't; Comparative Study; Administration; Biological Availability; Buprenorphine/pharmacokinetics; Fentanyl/pharmacokinetics; Heroin/pharmacokinetics; Hydromorphone/pharmacokinetics; Levorphanol/pharmacokinetics; Methadone/pharmacokinetics; Morphine/blood/pharmacokinetics; Mouth/metabolism; Naloxone/pharmacokinetics; Opioid/administration & dosage/pharmacokinetics; Oxycodone/pharmacokinetics; Sublingual
Ongoing interest in the improvement of pain management with opioid analgesics had led to the investigation of sublingual opioid absorption. The present report determined the percent absorption of selected opioid analgesics from the oral cavity of normal subjects under conditions of controlled pH and swallowing when a 1.0 ml aliquot of the test drug was placed under the tongue for a 10-minute period. Compared with morphine sulfate at pH 6.5 (18% absorption), buprenorphine (55%), fentanyl (51%), and methadone (34%) were absorbed to a significantly greater extent (p less than 0.05), whereas levorphanol, hydromorphone, oxycodone, heroin, and the opioid antagonist naloxone were not. Overall, lipophilic drugs were better absorbed than were hydrophilic drugs. Plasma morphine concentration-time profiles indicate that the apparent sublingual bioavailability of morphine is only 9.0% +/- 11.9% (SD) of that after intramuscular administration. In the same subjects the estimated sublingual absorption was 22.4% +/- 9.2% (SD), indicating that the sublingual absorption method may overestimate apparent bioavailability. When the oral cavity was buffered to pH 8.5, methadone absorption was increased to 75%. Thus, an alkaline pH microenvironment that favors the unionized fraction of opioids increased sublingual drug absorption. Although absorption was found to be independent of drug concentration, it was contact time dependent for methadone and fentanyl but not for buprenorphine. These results indicate that although the sublingual absorption and apparent sublingual bioavailability of morphine are poor, the sublingual absorption of methadone, fentanyl, and buprenorphine under controlled conditions is relatively high.
1988
Weinberg DS; Inturrisi CE; Reidenberg B; Moulin DE; Nip TJ; Wallenstein S; Houde RW; Foley KM
Clinical Pharmacology And Therapeutics
1988
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Journal Article
<a href="http://doi.org/10.1038/clpt.1988.159" target="_blank" rel="noreferrer">10.1038/clpt.1988.159</a>
Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. A randomized controlled trial
Female; Humans; Male; Physician-Patient Relations; Truth Disclosure; California; Analysis of Variance; Disclosure; Regression Analysis; adolescent; Empirical Approach; Professional Patient Relationship; Adolescent Transitions; Adolescent Health Services/utilization; Confidentiality
CONTEXT: Adolescents' concerns about privacy in clinical settings decrease their willingness to seek health care for sensitive problems and may inhibit their communication with physicians. OBJECTIVE: To investigate the influence of physicians' assurances of confidentiality on adolescents' willingness to disclose information and seek future health care. DESIGN: Randomized controlled trial. SETTING: Three suburban public high schools in California. PARTICIPANTS: The 562 participating adolescents represented 92% of students in mandatory classes. INTERVENTION: After random assignment to 1 of 3 groups, the adolescents listened to a standardized audiotape depiction of an office visit during which they heard a physician who assured unconditional confidentiality, a physician who assured conditional confidentiality, or a physician who did not mention confidentiality. MAIN OUTCOME MEASURES: Adolescents' willingness to disclose general information, willingness to disclose information about sensitive topics, intended honesty, and likelihood of return visits to the physician depicted in the scenario were assessed by anonymous written questionnaire. RESULTS: Assurances of confidentiality increased the number of adolescents willing to disclose sensitive information about sexuality, substance use, and mental health from 39% (68/175) to 46.5% (178/383) (beta=.10, P=.02) and increased the number willing to seek future health care from 53% (93/175) to 67% (259/386) (beta=.17, P
1997
Ford CA; Millstein SG; Halpern-Felsher BL; Irwin CE
Jama
1997
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Journal Article
<a href="http://doi.org/10.1001/jama.1997.03550120089044" target="_blank" rel="noreferrer">10.1001/jama.1997.03550120089044</a>
Limitations and withdrawals of medical intervention in pediatric critical care
Child; Female; Humans; Male; Survival Rate; United States; Intensive Care Units; Withholding Treatment; Hospital Mortality; Resuscitation Orders; Patient Selection; Analysis of Variance; Outcome and Process Assessment (Health Care); Preschool; Empirical Approach; Death and Euthanasia; infant; ICU Decision Making; Intervention; Interventions; Life Support Care/utilization; Pediatric/standards/statistics & numerical data
OBJECTIVE--To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care. DESIGN--Consecutive patients admitted between December 1989 and January 1992. SETTING--A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination. MAIN OUTCOME MEASURES--Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices. PATIENTS--All pediatric admissions undergoing restrictions (n = 119) drawn from 5415 consecutive PICU admissions. RESULTS--A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%. CONCLUSIONS--Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.
1994
Levetown M; Pollack MM; Cuerdon TT; Ruttimann UE; Glover JJ
Jama
1994
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Journal Article
<a href="http://doi.org/10.1001/jama.272.16.1271" target="_blank" rel="noreferrer">10.1001/jama.272.16.1271</a>
Gene expression and localization of opioid peptides in immune cells of inflamed tissue: functional role in antinociception
Male; Pain Measurement; Analysis of Variance; Animals; Nucleic Acid Hybridization; Rats; Non-U.S. Gov't; Research Support; Biomarkers of Pain; RNA; Biomarkers Reference List; Inbred Strains; beta-Endorphin/genetics/metabolism; Calcitonin Gene-Related Peptide/analysis/metabolism; Endorphins/analysis/genetics/metabolism; Freund's Adjuvant; Gene Expression/radiation effects; Hindlimb; Inflammation/immunology/physiopathology; Messenger/genetics/metabolism; Nerve Fibers/physiology/ultrastructure; Oligonucleotide Probes; Pain/immunology/physiopathology; T-Lymphocytes/immunology/pathology; Whole-Body Irradiation
Our previous studies indicate that endogenous opioids (primarily beta-endorphin) released during stressful stimuli can interact with peripheral opioid receptors to inhibit nociception in inflamed tissue of rats. This study sought to localize opioid precursor mRNAs and opioid peptides deriving therefrom in inflamed tissue, identify opioid containing cells and demonstrate their functional significance in the inhibition of nociception. In rats with Freund's adjuvant-induced unilateral hindpaw inflammation we show that: (i) pro-opiomelanocortin and proenkephalin-mRNAs (but not prodynorphin mRNA) are abundant in cells of inflamed, but absent in non-inflamed tissue; (ii) numerous cells infiltrating the inflamed subcutaneous tissue are stained intensely with beta-endorphin and [Met]enkephalin (but only few scattered cells with dynorphin) antibodies; (iii) beta-endorphin is present in T- and B-lymphocytes, monocytes and macrophages; and (iv) whole-body irradiation suppresses stress-induced antinociception in the inflamed paw. Taken together, these data suggest that endogenous opioid peptides are synthesized and processed within various types of immune cells at the site of inflammation. Immunosuppression abolishes the intrinsic antinociception in inflammatory tissue confirming the functional significance of these cells.
1992
Przewlocki R; Hassan AH; Lason W; Epplen C; Herz A; Stein C
Neuroscience
1992
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1016/0306-4522(92)90509-z" target="_blank" rel="noreferrer">10.1016/0306-4522(92)90509-z</a>
The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress
Female; Humans; Male; Pain Measurement; Adult; Prevalence; Aged; Middle Aged; Reproducibility of Results; Analysis of Variance; Karnofsky Performance Status; 80 and over; Psychological; Stress; Neoplasms/complications; quality of life; Severity of Illness Index
The Memorial Symptom Assessment Scale (MSAS) is a new patient-rated instrument that was developed to provide multidimensional information about a diverse group of common symptoms. This study evaluated the reliability and validity of the MSAS in the cancer population. Randomly selected inpatients and outpatients (n = 246) with prostate, colon, breast or ovarian cancer were assessed using the MSAS and a battery of measures that independently evaluate phenomena related to quality of life. Symptom prevalence in the 218 evaluable patients ranged from 73.9% for lack of energy to 10.6% for difficulty swallowing. Based on a content analysis, three symptoms were deleted and two were added; the revised scale evaluates 32 physical and psychological symptoms. A factor analysis of variance yielded two factors that distinguished three major symptom groups and several subgroups. The major groups comprised psychological symptoms (PSYCH), high prevalence physical symptoms (PHYS H), and low prevalence physical symptoms (PHYS L). Internal consistency was high in the PHYS H and PSYCH groups (Cronback alpha coefficients of 0.88 and 0.83, respectively), and moderate in the PHYS L group (alpha = 0.58). Although the severity, frequency and distress dimensions were highly intercorrelated, canonical correlations and other analyses demonstrated that multidimensional assessment (frequency and distress) augments information about the impact of symptoms. High correlations with clinical status and quality of life measures support the validity of the MSAS and indicate the utility of several subscale scores, including PSYCH, PHYS, and a brief Global Distress Index. The MSAS is a reliable and valid instrument for the assessment of symptom prevalence, characteristics and distress. It provides a method for comprehensive symptom assessment that may be useful when information about symptoms is desirable, such as clinical trials that incorporate quality of life measures or studies of symptom epidemiology.
1994
Portenoy RK; Thaler HT; Kornblith AB; Lepore JM; Friedlander-Klar H; Kiyasu E; Sobel K; Coyle N; Kemeny N; Norton L; et al
European Journal Of Cancer
1994
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Journal Article
<a href="http://doi.org/10.1016/0959-8049(94)90182-1" target="_blank" rel="noreferrer">10.1016/0959-8049(94)90182-1</a>
Patient-controlled analgesia for mucositis pain in children: a three-period crossover study comparing morphine and hydromorphone
Child; Humans; Pain Measurement; Analgesics; Treatment Outcome; Therapeutic Equivalency; Analgesia; Analysis of Variance; Double-Blind Method; Cross-Over Studies; adolescent; Non-U.S. Gov't; Research Support; Comparative Study; Pain/drug therapy/etiology; Inflammation/complications; Patient-Controlled; Hydromorphone/adverse effects/pharmacokinetics/therapeutic use; Morphine/adverse effects/pharmacokinetics/therapeutic use; Mucous Membrane; Opioid/adverse effects/pharmacokinetics/therapeutic use
OBJECTIVES: (1) To test the safety and efficacy of a clinical protocol for administering opioid by using patient-controlled analgesia (PCA) for the management of mucositis pain in children after bone marrow transplantation, (2) to compare the efficacy, side-effect profile, and potency ratio of morphine with those of hydromorphone by using PCA as the method of opioid administration, and (3) to obtain pharmacokinetic data on hydromorphone and morphine in this population of children. METHODS: In this double-blind, three-period crossover study, patients were randomly assigned to receive either morphine (group 1) or hydromorphone (group 2) initially by means of PCA on days 1, 2, and 3 (period 1), to be followed on days 4, 5, and 6 (period 2) with the alternative opioid, followed by the opioid used at the commencement of the study on days 7, 8, and 9 (period 3). A clinical protocol for calculating the PCA commencement opioid dose and subsequent opioid-dose escalation was tested by measures of safety and efficacy. Measures of pain intensity and opioid side effects were made during the three periods. On the last study day (day 10), patients received a continuous infusion of opioid derived from the previous 24-hour PCA opioid requirement, and blood specimens were collected and stored for subsequent opioid analysis. RESULTS: Ten patients were enrolled in this study. Rapid escalation in opioid requirement commonly occurred at the commencement of PCA, followed by a variable plateau phase and then deescalation of opioid requirement after mucositis resolution. The measures demonstrated the safety and efficacy of the clinical protocol. In the concentrations used, there was no statistical difference between the mean daily pain, sedation, nausea and vomiting, and pruritus scores for both opioids (Friedman test). The analysis of variance of the log-total opioid doses per patient during periods 1, 2, and 3 indicated that patients used 27% more hydromorphone than expected from its presumed 7:1 ratio relative to morphine potency used in the PCA infusions. The mean plasma hydromorphone concentration was 4.7 ng/ml (range, 1.9 to 8.9 ng/ml), and the mean clearance was 51.7 ml/min per kilogram of body weight (range, 28.6 to 98.2 ml/min per kilogram). The mean plasma morphine, morphine-6-glucuronide, and morphine-3-glucuronide concentrations were 40.0 ng/ml (range, 15 to 62.5), 168.2 ng/ml (range, 54.4 to 231.9), and 391.0 ng/ml (range, 149.4 to 921.7), respectively. The mean morphine clearance was 34.3 ml/min per kilogram of body weight (range, 19.3 to 58.3). The mean molar ratios of morphine-6-glucuronide/morphine, morphine-3-glucoronide/morphine, and morphine-3-glucuronide/morphine-6-glucuronide were 2.48 (range, 1.4 to 3.3), 5.82 (range, 3.4 to 9.1), and 2.46 (range, 1.1 to 3.3), respectively. CONCLUSIONS: The safety and efficacy of a clinical protocol for the administration of opioids by means of PCA for mucositis pain after bone marrow transplantation was demonstrated. In this small study, hydromorphone was not superior to morphine in terms of analgesia or the side-effect profile: a larger study would be needed to show a difference. The clearances of hydromorphone and morphine in the children studied were generally greater than those previously recorded, but this finding may be related to disease or treatment variables. Apart from clearance, the morphine pharmacokinetics in the study population were similar to those previously recorded. Hydromorphone may be less potent in this population of children than indicated by adult equipotency tables.
1996
Collins J J; Geake J; Grier HE; Houck CS; Thaler HT; Weinstein HJ; Twum-Danso NY; Berde CB
The Journal Of Pediatrics
1996
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Journal Article
<a href="http://doi.org/10.1016/s0022-3476(96)70156-7" target="_blank" rel="noreferrer">10.1016/s0022-3476(96)70156-7</a>
A randomized, controlled trial of intravenous clodronate in patients with metastatic bone disease and pain
Female; Humans; Male; Pain; Adult; Analgesics; Aged; Middle Aged; Treatment Outcome; Analysis of Variance; Chi-Square Distribution; Cross-Over Studies; 80 and over; Comparative Study; Injections; Intravenous; Dose-Response Relationship; Drug; Clodronate; Pain Measurement/drug effects; Clodronic Acid/administration & dosage; Non-Narcotic/administration & dosage; Intractable/drug therapy/etiology; Bone Neoplasms/complications/secondary
To evaluate the effectiveness of intravenous clodronate in ameliorating refractory bone pain in patients with metastatic bone disease, 60 patients with established osseous metastases and persistent bone pain were randomized to receive either clodronate (600 mg or 1500 mg in 500 mL of normal saline) or 500 mL of saline as placebo. After 2 weeks, the patients were crossed over to receive the alternate treatment. After another 2 weeks, each patient and investigator made a blinded choice. Daily visual analogue scales (VAS) and analgesic diaries were recorded throughout the study period. Forty-six patients were evaluable (77%). A treatment x period interaction was identified in the VAS and daily morphine equivalent dose (DMED) scores. First period analysis of the VAS scores for general pain, pain at rest, and pain upon movement demonstrated an average reduction of 13, 14, and 24 mm, respectively, from baseline, but were not significantly different from changes following placebo. The average change in DMED was -6.4 (SE = 2.9) following clodronate and was +24.6 (SE = 14.9) following placebo (p = 0.03). In the blinded choice of which agent resulted in improvement in pain, 26 (57%) patients chose clodronate, 12 (26%) chose placebo, and eight (17%) had no preference (p = 0.0021). For the investigators who also made a blinded selection, clodronate was chosen in 30 (65%) patients, placebo in ten (22%) patients, and no difference was apparent in six (13%) (p < 0.0001). Intravenous clodronate appeared to have analgesic effect in patients with refractory bone pain due to metastatic bone disease. The optimal dose and duration of effect require further evaluation, particularly in patients with stable disease and persistent bone pain.
1997
Ernst DS; Brasher P; Hagen N; Paterson AH; MacDonald RN; Bruera E
Journal Of Pain And Symptom Management
1997
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Journal Article
<a href="http://doi.org/10.1016/s0885-3924(97)00075-4" target="_blank" rel="noreferrer">10.1016/s0885-3924(97)00075-4</a>
Making sense of loss and benefiting from the experience: two construals of meaning
Female; Humans; Male; Grief; Adult; Interpersonal Relations; Middle Aged; Social Adjustment; Cognition; Life Change Events; Spirituality; Analysis of Variance
Theoretical models of the adjustment process following loss and trauma have emphasized the critical role that finding meaning plays. Yet evidence in support of these models is meager, and definitions of meaning have been too broad to facilitate a clear understanding of the psychological process involved. Using a prospective and longitudinal study of people coping with the loss of a family member, we differentiate 2 construals of meaning--making sense of the event and finding benefit in the experience--and demonstrate that both independently play roles in the adjustment process following the loss. Results indicate that making sense of the loss is associated with less distress, but only in the 1st year postloss, whereas reports of benefit finding are most strongly associated with adjustment at interviews 13 and 18 months postloss.
1998
Davis CG; Nolen-Hoeksema S; Larson J
Journal Of Personality And Social Psychology
1998
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Journal Article
<a href="http://doi.org/10.1037//0022-3514.75.2.561" target="_blank" rel="noreferrer">10.1037//0022-3514.75.2.561</a>
Interleukin 1 beta and corticotropin-releasing factor inhibit pain by releasing opioids from immune cells in inflamed tissue
Humans; Male; Analysis of Variance; Animals; Regression Analysis; Rats; Biomarkers of Pain; Injections; Dose-Response Relationship; Drug; Naloxone/pharmacology; Enkephalin; Inflammation/immunology/physiopathology; Wistar; Antibodies/pharmacology; beta-Endorphin/immunology/physiology; Corticotropin-Releasing Hormone/administration & dosage/pharmacology/therapeutic use; Cyclosporine/pharmacology; Dynorphins/immunology/physiology; Endorphins/immunology/physiology/secretion; Interleukin-1/administration & dosage/pharmacology/therapeutic use; Leucine/analogs & derivatives/pharmacology; Methionine/immunology/physiology; Pain/immunology/physiopathology/prevention & control; Recombinant Proteins/pharmacology/therapeutic use; Somatostatin/analogs & derivatives/pharmacology
Local analgesic effects of exogenous opioid agonists are particularly prominent in painful inflammatory conditions and are mediated by opioid receptors on peripheral sensory nerves. The endogenous ligands of these receptors, opioid peptides, have been demonstrated in resident immune cells within inflamed tissue of animals and humans. Here we examine in vivo and in vitro whether interleukin 1 beta (IL-1) or corticotropin-releasing factor (CRF) is capable of releasing these endogenous opioids and inhibiting pain. When injected into inflamed rat paws (but not intravenously), IL-1 and CRF produce antinociception, which is reversible by IL-1 receptor antagonist and alpha-helical CRF, respectively, and by the immunosuppressant cyclosporine A. In vivo administration of antibodies against opioid peptides indicates that the effects of IL-1 and CRF are mediated by beta-endorphin and, in addition, by dynorphin A and [Met]enkephalin, respectively. Correspondingly, IL-1 effects are inhibited by mu-, delta-, and kappa-opioid antagonists, whereas CRF effects are attenuated by all except a kappa-antagonist. Finally, IL-1 and CRF produce acute release of immunoreactive beta-endorphin in cell suspensions freshly prepared from inflamed lymph nodes. This effect is reversible by IL-1 receptor antagonist and alpha-helical CRF, respectively. These findings suggest that IL-1 and CRF activate their receptors on immune cells to release opioids that subsequently occupy multiple opioid receptors on sensory nerves and result in antinociception. beta-Endorphin, mu- and delta-opioid receptors play a major role, but IL-1 and CRF appear to differentially release additional opioid peptides.
1994
Schafer M; Carter L; Stein C
Proceedings Of The National Academy Of Sciences Of The United States Of America
1994
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Journal Article
<a href="http://doi.org/10.1073/pnas.91.10.4219" target="_blank" rel="noreferrer">10.1073/pnas.91.10.4219</a>
Stressors and well-being among caregivers to older adults with dementia: the in-home versus nursing home experience
Female; Humans; Male; Aged; Middle Aged; Mental Health; Multivariate Analysis; Analysis of Variance; Homes for the Aged; Nursing Homes; Stress; Non-U.S. Gov't; Research Support; Comparative Study; Psychological/etiology; Home Nursing/psychology; Alzheimer Disease/nursing
We examined differences in stressors and well-being for caregivers who care for a relative with dementia at home and those who had placed their relative in a nursing home. The groups did not differ in depression or somatic complaints, but nursing home caregivers had fewer social and interpersonal disruptions. Controlling for caregiving problems, nursing home caregivers reported more stressors due to ADL (activities of daily living) assistance, their relatives' behavioral and cognitive functioning, and lack of caregiving support from family and friends.
1991
Stephens MA; Kinney JM; Ogrocki PK
The Gerontologist
1991
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Journal Article
<a href="http://doi.org/10.1093/geront/31.2.217" target="_blank" rel="noreferrer">10.1093/geront/31.2.217</a>
Factors influencing family participation in a longitudinal study: comparison of pediatric and healthy samples.
Humans; Severity of Illness Index; Longitudinal Studies; Analysis of Variance; Family Health; Chi-Square Distribution; Regression Analysis; Case-Control Studies; infant; Parents/psychology; Heart Defects; Congenital/psychology; Cystic Fibrosis/psychology; Patient Dropouts/statistics & numerical data; Patient Participation/statistics & numerical data; Research/statistics & numerical data
Compared participation levels in a longitudinal study of parent-child relationships from infancy to 4 years in families of children with cystic fibrosis, congenital heart disease, and with no chronic illness. Demographic (parent's age, education) and child, parent, and family variables (medical status, family environment) were investigated for their predictive value of families' participation. 34% of families (71/209) were lost to the study at a later date. Families of children with cystic fibrosis were the least likely to be lost. Parents' age and/or education predicted participation in all groups. Families in both pediatric samples participated less when parental well-being was less optimal, and the level of mother-infant attachment organization was lower. Unlike demographic factors, family factors have differential impact on participation in families in pediatric and nonpediatric samples.
1997
Janus M; Goldberg S
Journal Of Pediatric Psychology
1997
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Journal Article
<a href="http://doi.org/10.1093/jpepsy/22.2.245" target="_blank" rel="noreferrer">10.1093/jpepsy/22.2.245</a>
Long-stay patients in the pediatric intensive care unit
Child; Female; Humans; Male; Intensive Care Units; Hospital Mortality; Logistic Models; Treatment Outcome; Comorbidity; Health Services Research; Severity of Illness Index; Risk Factors; Quality of Health Care; Sensitivity and Specificity; Analysis of Variance; Predictive Value of Tests; Cost Savings; Preschool; infant; algorithms; Pediatric/utilization; ICU Decision Making; United States/epidemiology; Age Distribution; Discriminant Analysis; Patient Admission/statistics & numerical data; Length of Stay/statistics & numerical data; Emergencies; Decision Trees; Intensive Care/economics/standards
OBJECTIVE: Length of stay in the pediatric intensive care unit (PICU) is a reflection of patient severity of illness and health status, as well as PICU quality and performance. We determined the clinical profiles and relative resource use of long-stay patients (LSPs) and developed a prediction model to identify LSPs for early quality and cost saving interventions. DESIGN: Nonconcurrent cohort study. SETTING: A total of 16 randomly selected PICUs and 16 volunteer PICUs. PATIENTS: A total of 11,165 consecutive admissions to the 32 PICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: LSPs were defined as patients having a length of stay greater than the 95th percentile (>12 days). Logistic regression analysis was used to determine which clinical characteristics, available within the first 24 hrs after admission, were associated with LSPs and to create a predictive algorithm. Overall, LSPs were 4.7% of the population but represented 36.1% of the days of care. Multivariate analysis indicated that the following factors are predictive of long stays: age <12 months, previous ICU admission, emergency admission, no CPR before admission, admission from another ICU or intermediate care unit, chronic care requirements (total parenteral nutrition and tracheostomy), specific diagnoses including acquired cardiac disease, pneumonia, and other respiratory disorders, having never been discharged from the hospital, need for ventilatory support or an intracranial catheter, and a Pediatric Risk of Mortality III score between 10 and 33. The performance of the prediction algorithm in both the training and validation samples for identifying LSPs was good for both discrimination (area under the receiver operating characteristics curve of 0.83 and 0.85, respectively), and calibration (goodness of fit, p = .33 and p = .16, respectively). LSPs comprised from 2.1% to 8.1% of individual ICU patients and occupied from 15.2% to 57.8% of individual ICU bed days. CONCLUSIONS: LSPs have less favorable outcomes and use more resources than non-LSPs. The clinical profile of LSPs includes those who are younger and those that require chronic care devices. A predictive algorithm could help identify patients at high risk of prolonged stays appropriate for specific interventions.
2001
Marcin JP; Slonim AD; Pollack MM; Ruttimann UE
Critical Care Medicine
2001
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Journal Article
<a href="http://doi.org/10.1097/00003246-200103000-00035" target="_blank" rel="noreferrer">10.1097/00003246-200103000-00035</a>
End-of-life care in the pediatric intensive care unit: attitudes and practices of pediatric critical care physicians and nurses
Child; Cross-Sectional Studies; Humans; United States; Intensive Care Units; Adult; Attitude of Health Personnel; Medical Staff; Questionnaires; Middle Aged; Attitude to Death; Multivariate Analysis; Hospitals; Analysis of Variance; Child Advocacy; Ethics; Medical; Nursing Staff; Practice; Pediatric; Empirical Approach; Death and Euthanasia; Attitudes; decision making; Health Knowledge; ICU Decision Making; Nursing; Pediatrics/methods; Critical Care/organization & administration/psychology; Hospital/education/psychology; Physician's Practice Patterns/organization & administration; Terminal Care/organization & administration/psychology
OBJECTIVE: To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN: Cross-sectional survey. SETTING: A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS: Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.
2001
Burns JP; Mitchell C; Griffith JL; Truog RD
Critical Care Medicine
2001
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Journal Article
<a href="http://doi.org/10.1097/00003246-200103000-00036" target="_blank" rel="noreferrer">10.1097/00003246-200103000-00036</a>
Immune cell-derived beta-endorphin. Production, release, and control of inflammatory pain in rats
Humans; Male; Time Factors; Analysis of Variance; Animals; Regression Analysis; Rats; Biomarkers of Pain; RNA; Genetic; Biomarkers Reference List; Inflammation/physiopathology; Freund's Adjuvant; Hindlimb; Pain/immunology/physiopathology; Corticotropin-Releasing Hormone/pharmacology; Wistar; Messenger/biosynthesis; beta-Endorphin/biosynthesis; Interleukin-1/pharmacology; Lymph Nodes/metabolism; Pro-Opiomelanocortin/biosynthesis; T-Lymphocytes/drug effects/immunology/metabolism; Transcription
Localized inflammation of a rat's hindpaw elicits an accumulation of beta-endorphin-(END) containing immune cells. We investigated the production, release, and antinociceptive effects of lymphocyte-derived END in relation to cell trafficking. In normal animals, END and proopiomelanocortin mRNA were less abundant in circulating lymphocytes than in those residing in lymph nodes (LN), suggesting that a finite cell population produces END and homes to LN. Inflammation increased proopiomelanocortin mRNA in cells from noninflamed and inflamed LN. However, END content was increased only in inflamed paw tissue and noninflamed LN-immune cells. Accordingly, corticotropin-releasing factor and IL-1beta released significantly more END from noninflamed than from inflamed LN-immune cells. This secretion was receptor specific, calcium dependent, and mimicked by potassium, consistent with vesicular release. Finally, both agents, injected into the inflamed paw, induced analgesia which was blocked by the co-administration of antiserum against END. Together, these findings suggest that END-producing lymphocytes home to inflamed tissue where they secrete END to reduce pain. Afterwards they migrate to the regional LN, depleted of the peptide. Consistent with this notion, immunofluorescence studies of cell suspensions revealed that END is contained predominantly within memory-type T cells. Thus, the immune system is important for the control of inflammatory pain. This has implications for the understanding of pain in immunosuppressed conditions like cancer or AIDS.
1997
Cabot PJ; Carter L; Gaiddon C; Zhang Q; Schafer M; Loeffler JP; Stein C
The Journal Of Clinical Investigation
1997
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Journal Article
<a href="http://doi.org/10.1172/jci119506" target="_blank" rel="noreferrer">10.1172/jci119506</a>
Seizures in children with congenital hydrocephalus: long-term outcome
Child; Humans; Prognosis; Follow-Up Studies; Analysis of Variance; Regression Analysis; Preschool; infant; Q3 Literature Search; Recurrence; Epilepsy/etiology/physiopathology; Hydrocephalus/complications/physiopathology
We documented seizures in 33 of 68 (48.5%) children with congenital hydrocephalus not associated with myelomeningocele. Mental retardation (MR) and CNS malformations correlated with seizure occurrence; age at shunt insertion and number of shunt revisions and infections were not significant variables in predicting seizures. Of 11 patients seizure free for 2 or more years on medication, six had therapy discontinued without seizure recurrence. Among those 33 children with seizures, 14 (42.4%), including five who had failed withdrawal of medication, have adequately controlled seizures on anticonvulsants. Frequent convulsions despite treatment occur in 13 (39.4%) of the 33 children with seizures. Absence of MR, older age and nonparoxysmal EEG at seizure onset, and absence of CNS malformation correlated with seizure remission. Longer time without seizures while on medication did not predict successful discontinuation of therapy. In contrast, MR correlated significantly with seizure recurrence following cessation of treatment. Our study indicates that medication can be safely discontinued in children with congenital hydrocephalus who are of normal intelligence and have been seizure free on anticonvulsants for 3 years.
1992
Noetzel MJ; Blake JN
Neurology
1992
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Journal Article
<a href="http://doi.org/10.1212/wnl.42.7.1277" target="_blank" rel="noreferrer">10.1212/wnl.42.7.1277</a>