Routine screening for pain combined with a pain treatment protocol in head and neck cancer: a randomised controlled trial

BACKGROUND

We compared the effectiveness and cost of a pain screening and treatment program, with usual care in head and neck cancer patients with significant pain.

METHODS

Patients were screened for the presence of pain and then randomly assigned to either an intervention group, consisting of a pain treatment protocol and an education program, or to usual care. Primary outcome was change in the Pain Severity Index (PSI) over three months.

RESULTS

We screened 1074 patients of whom 156 were randomized to either intervention or usual care. Mean PSI was reduced over three months in both groups, with no significant difference between the two groups. The Pain Management Index (PMI) at three months, was significantly improved in the intervention group compared with usual care (P<0.001), as was Patient Satisfaction (mean difference in scores was statistically significant: -0.30 [-0.60 to -0.15]). All subjects reported clinically significant levels of anxiety and depression throughout the study. Treatment costs were significantly higher for intervention (mean=£400) compared with usual care (£200), with a low likelihood of being cost-effective.

CONCLUSIONS

There was no difference in the Pain Severity Index between the two groups. However there were significant improvements in the intervention group in patient satisfaction and PMI. The pain screening process itself was effective. Sufficient benefit was demonstrated as a result of the intervention to allow continued development of pain treatment pathways, rather than allowing pain treatment to be left to nonformalised ad hoc arrangements.

Long-term decline of the Amazon carbon sink

Atmospheric carbon dioxide records indicate that the land surface has acted as a strong global carbon sink over recent decades, with a substantial fraction of this sink probably located in the tropics, particularly in the Amazon. Nevertheless, it is unclear how the terrestrial carbon sink will evolve as climate and atmospheric composition continue to change. Here we analyse the historical evolution of the biomass dynamics of the Amazon rainforest over three decades using a distributed network of 321 plots. While this analysis confirms that Amazon forests have acted as a long-term net biomass sink, we find a long-term decreasing trend of carbon accumulation. Rates of net increase in above-ground biomass declined by one-third during the past decade compared to the 1990s. This is a consequence of growth rate increases levelling off recently, while biomass mortality persistently increased throughout, leading to a shortening of carbon residence times. Potential drivers for the mortality increase include greater climate variability, and feedbacks of faster growth on mortality, resulting in shortened tree longevity. The observed decline of the Amazon sink diverges markedly from the recent increase in terrestrial carbon uptake at the global scale, and is contrary to expectations based on models.

Magnetically driven middle ear ossicles for optical measurement of vibrations in an ear with opened tympanic membrane

Vibrations of the middle ear ossicles are easily measured by means of laser vibrometry. However, laser vibrometry requires free visual access to the object under investigation, and acquiring free visual access to the ossicles through the ear canal requires the removal of the tympanic membrane (TM), with the result that the ossicles can no longer be stimulated acoustically. To overcome this, we devised a new setup in which the ossicles can be driven magnetically. After measuring the response of the TM to an acoustic signal, we then remove it and attach a small magnet to the exposed manubrium (a part of the most lateral auditory ossicle, the malleus, which is normally attached to the TM). An electromagnetic excitation coil is then used to drive the magnet, and the output to the coil adjusted until the vibration of the manubrium, as measured by the vibrometer, matches that measured in response to the acoustic signal. Such a setup may have uses in research on middle ear mechanics, such as the measurement of nonlinearities in their response, as well as applications in the diagnosis of middle ear conditions such as the fixation of the ossicles by otosclerosis or in chronic otitis media. We describe our setup and discuss the viability of our method and its future clinical potential by presenting some measurements on an artificially fixated ear.

Use of a gentamicin-impregnated collagen sheet (Collatamp(®) ) following implantation of a sacral nerve stimulator for faecal incontinence

AIM

Gentamicin-impregnated collagen (Collatamp(®) ) is well described for the prevention of infection in surgery. This technical note describes its intraoperative use as a prophylactic measure to prevent infection following implantation of a sacral nerve stimulator for faecal incontinence.

METHOD

Following implantation of the Interstim II Neurostimulator (Medtronic Neuromodulation, 710 Medtronic Parkway, Minneapolis, USA) in a subcutaneous pocket overlying the gluteal muscle, a single sheet of 10cm × 10cm gentamicin-impregnated collagen is placed within the wound covering the implant. The subcutaneous tissue and skin are then closed in separate layers.

RESULTS

To date eight patients [median age 46.5 (30-59) years] have received prophylactic cover with gentamicin-impregnated collagen following permanent sacral nerve stimulator implantation. At a median interval of 89.5 (51-128) days, none of these patients developed a wound infection at the site of the neurostimulator implant.

CONCLUSION

Gentamicin-impregnated collagen (Collatamp(®) ) used in the implantation of a sacral nerve stimulator may be a useful addition to the technique.

Relation of exhaled nitric oxide levels to development of bronchopulmonary dysplasia

OBJECTIVE

To test the hypothesis that exhaled nitric oxide levels on day 28 and changes in exhaled nitric oxide levels in the neonatal period would differ according to whether infants developed bronchopulmonary dysplasia (BPD) and its severity.

DESIGN

Prospective observational study.

SETTING

Tertiary neonatal intensive care unit.

PATIENTS

80 infants (median gestational age 28, range 24-32 weeks), 46 of whom developed BPD.

INTERVENTIONS

Exhaled nitric oxide measurements were attempted on days 3, 5, 7, 14, 21 and 28.

MAIN OUTCOME MEASURES

BPD (oxygen dependency at 28 days), mild BPD (oxygen dependent at 28 days, but not 36 weeks postmenstrual age (PMA)); moderate BPD (oxygen dependent at 36 weeks PMA) and severe BPD (respiratory support dependent at 36 weeks PMA).

RESULTS

On day 28, exhaled nitric oxide levels were higher in infants with BPD compared to those without BPD (p<0.001) and there was a linear trend in exhaled nitric oxide results as BPD severity increased (p = 0.006). No significances in the change in exhaled nitric oxide levels over the neonatal period were found between the four groups.

CONCLUSION

Exhaled nitric oxide levels are raised in infants with established BPD, particularly in those developing moderate or severe BPD, and may reflect ongoing inflammation.

The effect of a c.-8G>T polymorphism on the expression of cytochrome b5A and boar taint in pigs

The level of cytochrome b5A (CYB5A) in pig testis is correlated with boar taint from androstenone and an AF016388:c.-8G>T polymorphism in CYB5A has been linked with low androstenone levels in the fat of pigs. In this study, we developed a polymerase chain reaction-based assay to genotype 1242 boars from eight lines for the c.-8G>T SNP. The c.-8T allele was found in all eight lines at a frequency ranging from 1.8% to 20.3% with an overall frequency of 8.6%. Significant deviations from Hardy-Weinberg equilibrium were found in the Hampshire, Landrace and Yorkshire breeds. The homozygous mutant c.-8TT occurred infrequently and was not found in some lines, but was consistently associated with low androstenone levels in fat. Both CYB5A mRNA and CYB5A protein levels were decreased in the c.-8TT genotype in a subset of Yorkshire boars, suggesting that low levels of CYB5A protein in the c.-8TT mutant were not due to inefficient translation of CYB5A mRNA. There were significant but modest marker effects on fat androstenone levels in Landrace, Yorkshire and a Large White/Duroc cross and fat skatole in Duroc and Sire Line breeds. There was no effect of CYB5A genotype on bulbourethral gland length, suggesting that this SNP will not affect reproductive traits. We conclude that the c.-8G>T SNP in the CYB5A gene has a significant but modest effect on boar taint in male pigs and could be useful in some breeds as part of a panel of SNP markers in a marker-assisted selection programme to produce low boar taint pigs.

Risk factors for respiratory morbidity in infancy after very premature birth

OBJECTIVES

To determine the occurrence of respiratory morbidity during infancy after very premature birth and to identify risk factors.

DESIGN

Prospective follow up study.

SETTING

The United Kingdom oscillation study.

PATIENTS

492 infants, all born before 29 weeks gestation.

INTERVENTIONS

Structured questionnaires were completed by local paediatricians when the infants were seen in outpatients at 6 and 12 months of age corrected for prematurity.

MAIN OUTCOME MEASURES

Cough, wheeze, and treatment requirements and the composite measure of respiratory morbidity (cough, frequent cough, cough without infection, wheeze, frequent wheeze, wheeze without infection, and use of chest medicine) and their relation to 13 possible explanatory variables.

RESULTS

At 6 and 12 months of corrected age, 27% of the infants coughed and 6% had frequent (more than once a week) cough, and 20% and 3% respectively had wheeze or frequent wheeze. At 6 and 12 months, 14% of infants had taken bronchodilators and 8% inhaled steroids. After adjustment for multiple outcome testing, four factors were associated with increased respiratory morbidity: male sex, oxygen dependency at 36 weeks postmenstrual age, having older siblings aged less than 5 years, and living in rented accommodation.

CONCLUSIONS

Male infants are particularly vulnerable to respiratory morbidity in infancy after very premature birth. It is important to identify a safe and effective strategy to prevent chronic oxygen dependency.