Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Australian intensive care unit

This descriptive correlation study evaluated the pain intensity, pain distress and morphine consumption in patients recovering from coronary artery bypass grafting (CABG) surgery in an Australian intensive care unit (ICU) and compared patients' pain intensity ratings with ratings of the nursing staff. Forty-three patients and their attending nurses rated patients' pain intensity and pain distress levels at 8-hourly intervals throughout their stay in ICU. A maximum of five assessments was obtained in the first 48 post-operative hours from patients and their nurses. Pain intensity and pain distress were measured using separate 10-point numerical rating scales (NRS). Patients' worst pain intensity scores increased over time in ICU; the amount of opioids they received was small and decreased over time. Significant differences occurred between patients' and nurses' average pain intensity scores at each time point and, except for worst pain intensity measures at the first assessment, nurses consistently underestimated patients' pain. These results indicate that patients in ICU following CABG can experience considerable pain, which is not always relieved. The application of regular systematic pain assessment and improved communication, together with the administration of adequate pain relief are necessary if nurses are to manage patients' pain effectively.

Phototoxicity in quinolones: comparison of ciprofloxacin and grepafloxacin

Skin photosensitizing reactions have been reported during treatment with fluoroquinolone antibiotics. The incidence and severity of such reactions, however, appear to differ between agents. The photosensitizing effect of grepafloxacin 400 and 600 mg once daily was compared with that of ciprofloxacin 500 mg bd and placebo in a double-blind trial involving 32 healthy subjects. Skin photosensitivity, expressed as the minimal erythemal dose (MED), was measured before treatment and towards the end of the 7 day treatment period. Grepafloxacin showed a mild photosensitizing effect comparable to that of ciprofloxacin, with significant reductions in MED at 335+/-30 and 365+/-30 nm. However, few subjects showed MEDs outside the normal range, and MEDs consistently returned to baseline values within 1 week of stopping treatment. No significant differences between the effects of grepafloxacin and ciprofloxacin could be observed. It is concluded that grepafloxacin has a weak, UVA-dependent and rapidly reversible photosensitizing effect.

Is patch testing necessary in vulval vestibulitis?

Allergic contact dermatitis has been suggested as a possible cause of vulval vestibulitis, a condition of unknown aetiology characterized by burning, stinging and dyspareunia, with symptoms localised to the vestibule. To examine this relationship, 30 women with vulval vestibulitis were patch tested using a standard series of contact allergens and a special series relevant to perianal and vulval disorders. Other potential allergens identified by the patients as causing aggravation were also included. There were 5 positive reactions, 4 to nickel and 1 to fragrance mix, though none of these reactions were considered relevant. Our results suggest that allergic contact dermatitis is unlikely to be a primary factor in the development or persistence of vulval vestibulitis. Patch testing patients with vulval vestibulitis cannot routinely be recommended.

Prolonged benefit following ultraviolet A phototherapy for solar urticaria

Two patients with severe idiopathic solar urticaria, previously resistant to a variety of therapies including plasma exchange, benefited from springtime courses of ultraviolet A (UVA) monotherapy. Sites which are normally exposed to sunlight were treated, in a cabinet fitted with Philips R-UVA lamps (emitting UVA and visible wavelengths, with peak at 350 nm), twice daily for 2-3 weeks. One patient has been treated in this way for 3, and the other for 2, consecutive years. Repeat monochromator phototesting 3 months after their latest courses of UVA showed a persistent reduction in severity of abnormal photosensitivity. Both patients describe a sustained improvement in their condition lasting over 6 months after treatment.

Risk stratification after myocardial infarction using signal-averaged electrocardiographic criteria adjusted for sex, age, and myocardial infarction location

BACKGROUND

The objectives were to investigate the factors influencing signal-averaged ECGs (SAECGs) recorded in patients after myocardial infarction (MI) and to develop criteria for predicting arrhythmic events (AEs) that account for these factors.

METHODS AND RESULTS

SAECGs were recorded 5 to 15 days after MI in 2461 patients without bundle-branch block. The duration (QRSd), terminal potential (VRMS), and terminal duration (LAS) of the filtered QRS were measured. During follow-up (17 +/- 8 months), AEs (arrhythmic death; ventricular tachycardia, VT; ventricular fibrillation, VF) occurred in 80 patients (3.3%). Receiver operating characteristic curves showed that QRSd discriminated patients with all types of AEs, but VRMS and LAS discriminated only VT patients; QRSd minus LAS also discriminated AE patients. Sex, age, and MI location significantly affected the SAECG; survivors without VT or VF were divided into subgroups (2 sex x 4 age x 2 MI), and QRSd values exceeding the 70th percentile in each subgroup predicted AEs with a sensitivity of 65.4%. An unadjusted QRSd criterion showed the same overall sensitivity and specificity but with less uniform values for each subgroup. A Cox model was constructed by use of multiple prognostic indicators, and in rank order, QRSd, previous MI, and Killip class were predictive of AEs.

CONCLUSIONS

SAECG adjustments for sex, age, and MI location did not improve sensitivity and specificity but produced a more uniform predictive performance. The proposed criteria are based only on QRSd, because late potentials (VRMS and LAS) did not discriminate patients with sudden death. Duration of high-level activity during QRS (QRSd-LAS) can predict AEs, suggesting that the arrhythmogenic substate involves a large mass of myocardium.

Bath PUVA--an investigation of the distribution of trioxsalen (TMP) and 8-methoxypsoralen (8-MOP) in bathwater

Trioxsalen (TMP) bath PUVA avoids the side effects of nausea and headache associated with oral 8-methoxypsoralen (8-MOP) treatment and allows shorter irradiation times that can be advantageous in some patients. However we noted that a number of patients developed unusual patterns of phototoxic burning. We thought that this was related to an uneven distribution of the TMP in the bathwater and for this reason, a study of bath water TMP concentrations achieved using different TMP preparations was undertaken. The distribution of 8-MOP in an 8-MOP bath was also measured for comparison. Our results confirm that an uneven distribution of TMP is achieved using TMP capsules or suspension and would explain our observed patterns of burning. With an ethanolic solution of TMP, or the commercial equivalent Tripsor, or with Puvasoralen-8 (an 8-MOP preparation), a homogeneous psoralen distribution is achieved, and they are therefore preferable for use in bath PUVA.

Pharmacological and neurochemical differences between acute and tardive vacuous chewing movements induced by haloperidol

Late onset vacuous chewing movements (VCMs) from chronic neuroleptic treatment have been used as a rat model of tardive dyskinesia (TD). Early onset VCMs have also been observed, raising questions about the validity of this model. To assess the relationship between these two types of VCMs, pharmacological and neurochemical properties of early and late onset VCMs were compared. "Acute" VCMs were induced by daily intraperitoneal injections for 1-21 days. "Tardive" VCMs were induced by intramuscular injections of haloperidol decanoate every 3 weeks for 30 weeks followed by a 24-week withdrawal period. Suppression was attempted for both types of VCMs using several doses of intraperitoneal haloperidol. Striatonigral activation was assessed by measuring mRNA expression levels of the neuropeptides dynorphin and substance P using in situ hybridization histochemistry. Enkephalin mRNA was also measured as an index of striatopallidal activation. The results indicate that acute VCMs cannot be suppressed with increased doses of haloperidol and are associated with reduced dynorphin and substance P. This profile is similar to that seen with an animal model of parkinsonism. Tardive VCMs, in contrast, were markedly suppressed by haloperidol. They have previously been shown to be associated with increased striatonigral activation as indicated by increased dynorphin mRNA. Enkephalin mRNA was elevated following both short and long term treatment. Although superficially similar, acute and tardive VCMs appear to have different pharmacological and neurochemical profiles, suggesting they are related to acute extrapyramidal side effects and tardive dyskinesia, respectively.

8-MOP PUVA for psoriasis: a comparison of a minimal phototoxic dose-based regimen with a skin-type approach

Two ultraviolet A (UVA) regimens for oral 8-methoxypsoralen (8-MOP) photochemotherapy (PUVA) for moderate/severe chronic plaque psoriasis using a half body study technique were compared. Each patient received both regimens. A higher-dose regimen based on minimal phototoxic dose (MPD) with percentage incremental increases was given to one-half of the body. The other half received a lower dose regimen based on skin type with fixed incremental UVA increases. Patients were treated twice weekly. Symmetrical plaques were scored to determine the rate of resolution with each regimen. In addition, the number of treatments, cumulative UVA dose and number of days in treatment to achieve overall clearance were recorded. Patients were reviewed monthly for 1 year to record remission data. Thirty-three patients completed the study. Both regimens were effective and well tolerated. With the MPD-based approach, the number of exposures was significantly less for patients with skin types I and II but not III. Although the cumulative UVA dose was higher with the MPD regimen for all skin types studied, the reduced number of exposures required for clearance for skin types I and II but not III, combined with the security of individualized MPD testing, has practical attractions. MPD testing also identified five patients who required an increased psoralen dose and six patients who required a reduction of the initial UVA dose with the skin type regimen. Forty-two percent were still clear 1 year after treatment and there was no significant difference in the number of days in remission between the regimens for those whose psoriasis had recurred. The reduction in the number of exposures required for clearance with the MPD-based regimen may be safer and more cost effective in the long term.