Changing Patterns in the Acute Pain Service: Epidural versus Patient-controlled Analgesia

This study involved an audit and a survey of the Acute Pain Service at Princess Alexandra Hospital. It was found in the audit that the relative choice of epidural analgesia had declined by 50% over the five-year time period of 1998–2003. The survey of consultants showed that 82% of them had changed their practice and that they were performing fewer epidural anaesthetics. Two of the most common reasons given for this change in practice related to fear of litigation (34%) and lack of evidence (21%). These results show that within this department approaches to postoperative pain control had changed and that this appears to have resulted from factors such as the medicolegal environment and the possible influence of evidence based medicine.

The feasibility and acceptability of a physical activity intervention for older people with chronic musculoskeletal pain: The iPOPP pilot trial protocol

INTRODUCTION

This pilot trial will inform the design and methods of a future full-scale randomized controlled trial (RCT) and examine the feasibility, acceptability and fidelity of the Increasing Physical activity in Older People with chronic Pain (iPOPP) intervention, a healthcare assistant (HCA)-supported intervention to promote walking in older adults with chronic musculoskeletal pain in a primary care setting.

METHODS AND ANALYSIS

The iPOPP study is an individually randomized, multicentre, three-parallel-arm pilot RCT. A total of 150 participants aged ≥65 years with chronic pain in one or more index sites will be recruited and randomized using random permuted blocks, stratified by general practice, to: (i) usual care plus written information; (ii) pedometer plus usual care and written information; or (iii) the iPOPP intervention. A theoretically informed mixed-methods approach will be employed using semi-structured interviews, audio recordings of the HCA consultations, self-reported questionnaires, case report forms and objective physical activity data collection (accelerometry). Follow-up will be conducted 12 weeks post-randomization. Collection of the quantitative data and statistical analysis will be performed blinded to treatment allocation, and analysis will be exploratory to inform the design and methods of a future RCT. Analysis of the HCA consultation recordings will focus on the use of a checklist to determine the fidelity of the iPOPP intervention delivery, and the interview data will be analysed using a constant comparison approach in order to generate conceptual themes focused around the acceptability and feasibility of the trial, and then mapped to the Theoretical Domains Framework to understand barriers and facilitators to behaviour change. A triangulation protocol will be used to integrate quantitative and qualitative data and findings.

Molybdenum doped titanium dioxide photocatalytic coatings for use as hygienic surfaces: the effect of soiling on antimicrobial activity

Titanium dioxide (TiO2) surfaces doped with molybdenum (Mo) were investigated to determine if their photocatalytic ability could enhance process hygiene in the brewery industry. Doping TiO2 with Mo showed a 5-log reduction in bacterial counts within 4 to 24 h and a 1-log reduction in yeast numbers within 72 h. The presence of a dilute brewery soil on the surface did not interfere with antimicrobial activity. The TiO2-Mo surface was also active in the dark, showing a 5-log reduction in bacteria within 4 to 24 h and a 1-log reduction in yeast numbers within 72 h, suggesting it could have a novel dual function, being antimicrobial and photocatalytic. The study suggests the TiO2-Mo coating could act as a secondary barrier in helping prevent the build-up of microbial contamination on surfaces within the brewery industry, in particular in between cleaning/disinfection regimes during long production runs.

The effect of vascular risk factors on the efficacy of rivastigmine patch and capsule treatment in Alzheimer's disease

Background

Vascular risk factors (VRF) may influence response to rivastigmine in Alzheimer's disease (AD).

Methods

AD patients who participated in a randomized, double-blind, placebo-controlled trial of rivastigmine patch and capsule treatment were stratified by baseline VRF status. Treatment response was evaluated using the AD Assessment Scale-cognitive subscale (ADAS-cog), AD Cooperative Study-Clinical Global Impression of Change (ADCS-CGIC) and the AD Cooperative Study-Activities of Daily Living (ADCS-ADL) scale.

Results

ADAS-cog scores significantly improved in all rivastigmine-treated patients (p < 0.05 vs. placebo), except 9.5 mg/24 h patch-treated patients with VRF, and were significantly affected by VRF status in the study population as a whole. Significant benefits were seen on the ADCS-ADL in 9.5 mg/24 h patch- and capsule-treated patients with, but not without, VRF. The ADCS-CGIC significantly improved in capsule-treated patients with, and patch-treated patients without VRF. Although non-significant, patients without VRF showed an apparent faster rate of placebo decline.

Conclusion

VRF may influence AD progression and response to rivastigmine.

AFQ056 treatment of levodopa-induced dyskinesias: results of 2 randomized controlled trials

Study objectives were to assess the efficacy, safety, and tolerability of AFQ056 in Parkinson's disease patients with levodopa-induced dyskinesia. Two randomized, double-blind, placebo-controlled, parallel-group, in-patient studies for Parkinson's disease patients with moderate to severe levodopa-induced dyskinesia (study 1) and severe levodopa-induced dyskinesia (study 2) on stable dopaminergic therapy were performed. Patients received 25-150 mg AFQ056 or placebo twice daily for 16 days (both studies). Study 2 included a 4-day down-titration. Primary outcomes were the Lang-Fahn Activities of Daily Living Dyskinesia Scale (study 1), the modified Abnormal Involuntary Movement Scale (study 2), and the Unified Parkinson's Disease Rating Scale-part III (both studies). Secondary outcomes included the Unified Parkinson's Disease Rating Scale-part IV items 32-33. The primary analysis was change from baseline to day 16 on all outcomes. Treatment differences were assessed. Fifteen patients were randomized to AFQ056 and 16 to placebo in study 1; 14 patients were randomized to each group in study 2. AFQ056-treated patients showed significant improvements in dyskinesias on day 16 versus placebo (eg, Lang-Fahn Activities of Daily Living Dyskinesia Scale, P = .021 [study 1]; modified Abnormal Involuntary Movement Scale, P = .032 [study 2]). No significant changes were seen from baseline on day 16 on the Unified Parkinson's Disease Rating Scale-part III in either study. Adverse events were reported in both studies, including dizziness. Serious adverse events (most commonly worsening of dyskinesias, apparently associated with stopping treatment) were reported by 4 AFQ056-treated patients in study 1, and 3 patients (2 AFQ056-treated patient and 1 in the placebo group) in study 2. AFQ056 showed a clinically relevant and significant antidyskinetic effect without changing the antiparkinsonian effects of dopaminergic therapy. © 2011 Movement Disorder Society.

Early experience of tomotherapy-based intensity-modulated radiotherapy for breast cancer treatment

AIMS

New technology - specifically intensity-modulated radiotherapy (IMRT) - is now being applied to breast radiotherapy and a recent dosimetric analysis confirmed the advantages of IMRT over 'wedge-only' plans. Such application to everyday practice raises new issues and here we present the early experience of IMRT-based breast irradiation in a single centre.

MATERIALS AND METHODS

We present cases of breast cancer treated by Tomotherapy-based IMRT, where the perceived advantages of IMRT are considerable. Cases presented are bilateral disease, left breast irradiation, pectus excavatum, prominent contralateral prosthesis and internal mammary chain disease. We discuss the practicalities of such treatment and the advantages over standard breast irradiation techniques.

RESULTS

Advantages include better conformity of treatment with lowering of dosages to underlying organs at risk, for example ipsilateral lung and heart. There is improved coverage of the planning target volume, including regional nodes, without field junction problems. Planning, quality assurance and treatment delivery are more time consuming than for standard breast irradiation and the low dose 'bath' is increased.

CONCLUSIONS

The standard radiotherapy tangential technique for breast/chest wall treatments has not significantly changed over many decades, whereas across many other tumour sites there have been great advances in radiotherapy technology. The dosimetric advantages of IMRT are readily apparent from our early experience. The wider spread of the lower dose zone (the low dose 'bath' of radiation) is a potential concern regarding late oncogenesis and methods to minimise such risks should be considered.

A dosimetric comparison between two intensity-modulated radiotherapy techniques: tomotherapy vs dynamic linear accelerator

This manuscript describes a direct comparison between radiation treatment plans in terms of dosimetric outcomes created by two different IMRT systems: TomoTherapy HiArt and dynamic linac intensity-modulated radiotherapy (dIMRT). Three patient cases were selected (with disease in different anatomical areas): vertebral metastasis re-treatment, radical prostate therapy and an ethmoid sarcoma re-treatment. Each case presents significant and varying dosimetric difficulties with respect to avoidance of adjacent organs. The patients were each planned and treated at the Cromwell Hospital (London, UK) using the TomoTherapy HiArt system, with planning replicated at St Bartholomew's Hospital (London, UK) using Eclipse Treatment Planning System and a 6EX linac with a 120-leaf multileaf collimator (Varian Medical Systems). For both modalities, all treatment plans conformed to the stringent clinical dose constraints set. For the vertebral body re-treatment, both techniques demonstrated adequate and similar planning target volume (PTV) coverage and sparing of the spinal cord. The critical structure sparing and PTV coverage for the prostate treatment was again similar for both modalities. For re-treatment of the paediatric ethmoid sarcoma, tomotherapy was able to produce slightly better organ sparing whilst producing PTV coverage similar to linac dIMRT. The data presented in this manuscript demonstrate subtle dosimetric differences between the two techniques but no marked advantage with either system. Therefore, other factors may need to be considered when making a decision between tomotherapy and linac dIMRT.

Evidence of a possible role for Lys-gamma3-MSH in the regulation of adipocyte function

Lys-gamma3-MSH is a melanocortin peptide derived from the C-terminal of the 16 kDa fragment of POMC. The physiological role of Lys-gamma3-MSH is unclear, although it has previously been shown that, although not directly steroidogenic, it can act to potentiate the steroidogenic response of adrenal cortical cells to ACTH. This synergistic effect appears to be correlated with an ability to increase the activity of hormone sensitive lipase (HSL) and therefore the rate of cholesterol ester hydrolysis. Ligand binding studies have suggested that high-affinity binding sites for Lys-gamma3-MSH exist in the adrenal gland and a number of other rat tissues that express HSL, including adipose, skeletal muscle and testes. To investigate the hypothesis that Lys-gamma3-MSH may play a wider role in cholesterol and lipid metabolism, we tested the effect of Lys-gamma3-MSH on lipolysis, an HSL-mediated process, in 3T3-L1 adipocytes. In comparison with other melanocortin peptides, Lys-gamma3-MSH was found to be a potent stimulator of lipolysis. It was also able to phosphorylate HSL at key serine residues and stimulate the hyperphosphorylation of perilipin A. The receptor through which the lipolytic actions of Lys-gamma3-MSH are being mediated is not clear. Attempts to characterise this receptor suggest that either the pharmacology of the melanocortin receptor 5 in 3T3-L1 adipocytes is different from that described when expressed in heterologous systems or the possibility that a further, as yet uncharacterised, receptor exists.

Predictors of Oxygen Uptake and Performance During Tennis

Tennis ball machine tests permit the concurrent measurement of physiological function and groundstroke performance in a sport specific manner. The purpose of this study was to understand further the demands of groundstroke performance during a test with progressively increasing ball frequency, by determining the running speed between strokes, upper and lower limb acceleration and pulmonary gas exchange throughout. Sixteen tennis players (n = 8, male; n = 8, female; all right handed) completed three 4 min stages of hitting against a ball feed frequency of 15, 20, 25 ball.min(-1) interspersed by 8 min of rest. Stepwise multiple regression analysis identified a predictive model of VO2 containing the variables of left arm acceleration and right ankle acceleration but not running speed (p < 0.0001; adjusted r2 = 0.93; left wrist acceleration Beta = 1.04; right ankle acceleration Beta = - 0.12; S. E. E. = 2.61 ml.kg(-1).min(-1)). Regression analysis found that the strongest predictors of stroke performance (ball speed [m.s(-1)] x stroke accuracy [%]) were right wrist acceleration and stroke economy (p < 0.0001; adjusted r2 = 0.28; right wrist acceleration Beta = - 0.59; movement economy Beta = - 0.28). The findings of this study highlight the contribution of limb acceleration and not running speed to the oxygen cost of tennis groundstroke performance.

The reliability and validity of a field hockey skill test

High test retest reliability is essential in tests used for both scientific research and to monitor athletic performance. Thirty-nine (20 male and 19 female) well-trained university field hockey players volunteered to participate in the study. The reliability of the in house designed test was determined by repeating the test (3 - 14 days later) following full familiarisation. The validity was assessed by comparing coaches ranks of players with ranked performance on the skill test. The mean difference and confidence limits in overall skill test performance was 0.0 +/- 1.0 % and the standard error (confidence limits) was 2.1 % (1.7 to 2.8 %). The mean difference and confidence limits for the "decision making" time was 0.0 +/- 1.0 % and the standard error (confidence limits) was 4.5 % (3.6 to 6.2 %). The validity correlation (Pearson) was r = 0.83 and r = 0.73 for female players and r = 0.61 and r = 0.70 for male players for overall time and "decision making" time respectively. We conclude that the field hockey skill test is a reliable measure of skill performance and that it is valid as a predictor of coach-assessed hockey performance, but the validity is greater for female players.

Novel erythropoiesis stimulating protein (darbepoetin alfa) alleviates anemia associated with chronic inflammatory disease in a rodent model

OBJECTIVE

We developed a rodent model of noninfectious systemic inflammation to examine the pathogenesis of the associated anemia of chronic disorders (ACD), to evaluate the similarity of this ACD model to human ACD, and to evaluate the potential efficacy of novel erythropoiesis stimulating protein (darbepoetin alfa) as an ACD therapy.

METHODS

Lewis rats were immunized with peptidoglycan-polysaccharide polymers (PG-APS), the chronic inflammation and associated ACD were characterized, and the effects of darbepoetin alfa treatment on complete blood counts (CBC), red blood cell (RBC) indices, and iron metabolism were analyzed weekly.

RESULTS

Acutely inflamed rats had reduced peripheral blood (PB) RBC counts and hemoglobin (Hb) concentrations and increased reticulocyte counts. PB RBC numbers normalized during chronic inflammation, but RBC remained hypochromic and microcytic. Consequently, the rats remained chronically anemic. Anemic rats had fluctuating serum erythropoietin (EPO) concentrations, but mean EPO concentrations never varied significantly from baseline control levels. Histology of anemic rat spleen sections revealed reticuloendothelial siderosis. Total serum iron concentrations were chronically low. Peritoneal exudate cells (PEC) isolated from anemic rats and stimulated with PG-APS in vitro produced more interleukin (IL)-1alpha and interferon (IFN)-gamma, and significantly more tumor necrosis factor (TNF)-alpha and IL-10 than control cultures. Darbepoetin alfa restored Hb concentrations to baseline levels within 2 to 7 weeks, depending on dosage. A refined treatment strategy restored Hb to baseline and maintained those levels with reduced dosing.

CONCLUSION

ACD in this rodent model closely replicates human ACD. Darbepoetin alfa treatment reversed ACD in this model by increasing RBC production and RBC hemoglobinization while reducing siderosis and hypoferremia.

Behaviour change and treatment of core groups: its effect on the spread of HIV/AIDS

A general model is considered for treatment and behaviour change of the Human Immunodeficiency Virus (HIV) infected in a highly sexually active core group of female commercial sex workers (CSWs) and a 'bridge population' of young unpartnered males. In this model, the spread of HIV/AIDS in the community is carried out mainly through the sexual interaction between the core group and the bridge population which acts as a bridge for the spread of disease to the general population. We will consider the effect of treatment of the infected and/or the subsequent behaviour change when targeted toward the core group and the bridge population. Analytical results will be given for a strategy which targets treatment and behaviour change at either the core group or the bridge population. Numerical examples are also provided to illustrate the biological significance of the treatment/behaviour change and its effect on the threshold parameter values. The results show that if the contact rates and transmission probabilities of the treated individuals are sufficiently reduced, the treatment/behaviour change can eradicate the disease provided that the level of treatment in the infected population is sufficiently high. However, an ill-planned treatment program which fails to meet the required reductions in contact rate or transmission probability could have a detrimental effect on the spread of the epidemic.

Interaction of maturation delay and nonlinear birth in population and epidemic models

A population with birth rate function B(N) N and linear death rate for the adult stage is assumed to have a maturation delay T>0. Thus the growth equation N'(t)=B(N(t-T)) N(t-T) e(-)d(1)T- dN(t) governs the adult population, with the death rate in previous life stages d(1)>==0. Standard assumptions are made on B(N) so that a unique equilibrium N(e) exists. When B(N) N is not monotone, the delay T can qualitatively change the dynamics. For some fixed values of the parameters with d(1)>0, as T increases the equilibrium N(e) can switch from being stable to unstable (with numerically observed periodic solutions) and then back to stable. When disease that does not cause death is introduced into the population, a threshold parameter R(0) is identified. When R(0)<1, the disease dies out; when R(0)>1, the disease remains endemic, either tending to an equilibrium value or oscillating about this value. Numerical simulations indicate that oscillations can also be induced by disease related death in a model with maturation delay.

Natural killer and lymphokine-activated cytotoxicity following anaesthesia in patients with uveal malignant melanoma

The role of enucleation in the treatment of ocular melanoma has been questioned by those who believe that it may increase circulating melanoma cells, increasing the incidence of metastases. Some aspects of the immune system are depressed by general anaesthesia, therefore this study was initiated to assess the effect of general anaesthesia on natural killer (NK) cell and interleukin-2 (IL-2)-activated cytotoxicity in 19 patients using 51Cr-labelled target cells (K 562 and SW 742). NK cytotoxicity was increased at induction and during the operation which was due to significant increases in female, but not male patients. At 1 week post-surgery, female patients had decreased NK cytotoxicity compared with males at this interval. NK cytotoxicity compared with males at this interval. NK cytotoxicity was increased intra-operatively when alfentanyl was used, and if the mean tumour diameter was > 15.0 mm the NK cytotoxicity was increased intra-operatively compared with that in patients with smaller tumours. IL-2-stimulated cytotoxicity was reduced at 1 day post-surgery in females only. There was an increased IL-2-stimulated cytotoxicity at induction when propofol was used and IL-2-stimulated cytotoxicity was reduced at 1 week post-operatively if the patient's mean tumour diameter was > 15.0 mm. If NK cell and lymphokine-stimulated cell cytotoxicity are involved in limiting metastatic disease, the patient' sex and tumour size and the anaesthetic agent used may influence the survival rates following surgery.

A model for HIV in Asia

A model is proposed in which the spread of HIV/AIDS in the community is mainly due to the sexual interaction between a core group of female prostitutes and young unmarried males. Several threshold parameters are obtained that determine persistence of endemic proportions, persistence of total population, and the persistence of infective population given the extinction of endemic proportions in a population tending to infinity. Conditions are given for the existence of multiple endemic equilibria as well as the existence of multiple stable equilibria with separatrix and their asymptotic behavior and biological significance are discussed. In all cases, global analysis is accompanied by bifurcation diagrams, and numerical examples are provided for some particular cases of interest. This model was proposed with the recent rapid growth of the HIV/AIDS epidemic in Asia in mind.

MR urography: technique and application

PURPOSE

To evaluate a magnetic resonance (MR) technique for depicting the kidneys and urinary tract.

MATERIALS AND METHODS

Fourteen patients with urinary tract obstruction and 20 without obstructions were examined with a modified, heavily T2-weighted fast spin-echo pulse sequence (MR urography). In addition, six healthy volunteers underwent modified MR urography with intravenous administration of furosemide and ureteral compression prior to imaging.

RESULTS

MR urography provided high-resolution images of the kidneys and urinary tract in all patients with obstruction with intact collecting systems. Anatomic anomalies were depicted in two patients. Intraluminal neoplasia was well demonstrated in both obstructed and nonobstructed systems (n = 4). Furosemide-enhanced MR urography provided fine anatomic and functional detail of both the kidneys and urinary tract (n = 6).

CONCLUSION

MR urography may provide an alternative to more conventional urinary tract imaging techniques. It does not require ionizing radiation or iodinated contrast material. When combined with furosemide and ureteral compression, MR urography provides fine detail and reflects function.

General practice consultations involving pigmented naevi presented for assessment of malignancy

AIM

To outline the initial general practice care of pigmented naevi presented for assessment of malignancy.

METHOD

Fifty six general practitioners completed a brief record for each patient presenting a pigmented skin lesion for assessment of malignancy; records were maintained prospectively for periods over October 1988 to April 1989. 2614 records were received.

RESULTS

Numbers of consultations increased sharply with age to peaks at 15-19 for men and 30-44 for women; at ages 20 44 the sex ratio was 1.9 (F/M). Lesions were usually typical (51%) or atypical (24%) moles. 22% of patients were biopsied by the practitioner and 8% were referred, to dermatologists (4%) or surgeons (4%).

CONCLUSIONS

The age pattern of presentations is younger than is optimal. General practitioners' decisions and actions are of crucial importance in the effective functioning of melanoma early detection programmes.

Radioprotection of mice by recombinant rat stem cell factor

Treatment with recombinant rat stem cell factor (rSCF) protects mice from the lethal effects of irradiation. Mice treated with a single dose of rSCF prior to irradiation of up to 1150 rads [given as a split dose (1 rad = 0.01 Gy)] resulted in > 80% long-term survival, whereas a single injection given after the last dose of irradiation was not radioprotective. The combination of pre- and posttreatment (-20 h, -2 h, and +4 h) with rSCF resulted in 100% survival of otherwise lethally irradiated mice. Using this optimum schedule of rSCF administration, a radioprotective factor of 1.3-1.35 was achieved. The major cause of death in the control animals was massive bacteremia consisting of enteric organisms. The rSCF-treated animals had a much lower frequency of septicemia, due primarily to a rapid hematopoietic recovery of bone marrow function not evident in control animals.

Primary malignant melanoma of skin in four regions of New Zealand

AIMS

to describe the incidence and thickness of a representative collection of melanomas occurring in recent years in New Zealand.

METHODS

all pathology reports of primary malignant melanoma of the skin, in defined periods in 1987-9, were collated for four regions of New Zealand.

RESULTS

nonMaori incidence rates were 52 and 58 melanomas per 100,000 person years for men and women, respectively. These rates are much higher than the 24 per 100,000 person years for melanoma registrations in 1983-4. The age standardised invasive melanoma rate of 35 per 100,000 person years was higher than those of most Australian states and close to the rate for Queensland in 1986. Preinvasive melanomas comprised 26% of all melanomas. Of invasive melanomas, 58% in men and 55% in women were less than 0.76 mm in thickness; 7% of invasive melanomas in men and 5% in women were at least 3.5 mm thick.

CONCLUSIONS

increasingly early detection of malignant melanomas in successive years is likely to have contributed to the recent increase in incidence, perhaps to a major degree, but an environmental cause cannot be excluded.

Growth in children after bone marrow transplantation for advanced neuroblastoma compared with growth after transplantation for leukemia or aplastic anemia

The linear growth of 26 children with progressive and advanced neuroblastoma treated with high-dose chemotherapy, total body irradiation, and bone marrow transplantation between 1978 and 1988 at the Children's Hospital of Philadelphia was compared with the growth of 33 children who had transplants for leukemia and of 12 who had transplants for aplastic anemia. The mean growth velocity, expressed as a standard deviation score, for the children who underwent bone marrow transplantation for neuroblastoma was -2.83. This was significantly (p less than 0.005) less than the standard deviation scores for children with transplants for acute lymphoblastic leukemia, acute nonlymphocytic leukemia, and aplastic anemia, which were -0.98, -0.07, and -1.05, respectively. A 6-year follow-up study of 32 long-term survivors of cancer revealed that the 11 patients with neuroblastoma continued to grow poorly, whereas a comparison group of 21 survivors of bone marrow transplantation for leukemia had essentially normal growth 2 years after the procedure. Major therapeutic differences between the two groups included the doses of local radiotherapy and the type and number of cytotoxic agents used. In comparison with the relatively mild growth-inhibiting effects of preparative regimens for leukemia and aplastic anemia, the very intensive preparative regimens used in patients with neuroblastoma have significant negative effects on growth.

Trends in nonmelanoma skin cancer mortality

Nonmelanoma skin cancer mortality rates for recent decades show a biphasic pattern: from 1950-65 rates decreased; from 1966-86 rates increased. Age standardised mortality rates for 35-74 year old males increased from 1.6 (95% CI, 1.3-1.9) deaths per 100,000 person years in 1966-72 to 2.3 (95% CI, 2.0-2.5) deaths per 100,000 person years in 1980-86. Rates in women were lower but showed a similar percentage increase (46%), between these periods, to that observed for men (44%). The increased mortality from 1966 was presumably a result of increased ultraviolet exposure.

The health effects of aluminium--a review

This review covers the occurrence of aluminium in soil, air, water and food. In addition, aluminium levels in body tissues and its movement within the body have been considered. The adverse effects of aluminium that have been reported in recent years include Alzheimer's disease, dementia and hyperactivity and learning disorders in children.

Perceptions of pain relief after surgery

OBJECTIVE

To assess patients' satisfaction with postoperative pain relief.

DESIGN

A descriptive and questionnaire study of patients' experience.

SETTING

Two surgical and two gynaecological wards.

PATIENTS

50 Patients admitted to hospital for cholecystectomy and 51 admitted for hysterectomy.

MAIN OUTCOME MEASURES

Visual analogue scales with no divisions were completed by the patients immediately after each dose of postoperative analgesia was administered throughout their stay in hospital. A questionnaire completed on the fifth postoperative day recorded patients' recollections of their experience. Opinions were also sought from medical and nursing staff.

RESULTS

During the first 24 hours after surgery recorded pain levels were 60% of the maximum and were not influenced by age, sex, or the type of operation performed. The median interval between the return of pain and a further injection of analgesic was 2 hours (interquartile range 1 to 3.5 hours). Expectations of pain relief were low, and for 70% of the patients the pain was at least as bad as they had expected. Only half of the medical and nursing staff questioned thought that postoperative analgesia should relieve pain completely; drugs were prescribed and administered with too little attention to the patient's response and too much concern about adverse effects and opioid dependence.

CONCLUSIONS

The results suggest that the standard of postoperative pain relief is poor because of inadequate education of patients in what to expect (and demand), and of medical and nursing staff in how to prescribe and administer analgesia with reference to individual drug response.

On the role of long incubation periods in the dynamics of acquired immunodeficiency syndrome (AIDS). Part 1: Single population models

In this study, we investigate systematically the role played by the reproductive number (the number of secondary infections generated by an infectious individual in a population of susceptibles) on single group populations models of the spread of HIV/AIDS. Our results for a single group model show that if R less than or equal to 1, the disease will die out, and strongly suggest that if R greater than 1 the disease will persist regardless of initial conditions. Our extensive (but incomplete) mathematical analysis and the numerical simulations of various research groups support the conclusion that the reproductive number R is a global bifurcation parameter. The bifurcation that takes place as R is varied is a transcritical bifurcation; in other words, when R crosses 1 there is a global transfer of stability from the infection-free state to the endemic equilibrium, and vice versa. These results do not depend on the distribution of times spent in the infectious categories (the survivorship functions). Furthermore, by keeping all the key statistics fixed, we can compare two extremes: exponential survivorship versus piecewise constant survivorship (individuals remain infectious for a fixed length of time). By choosing some realistic parameters we can see (at least in these cases) that the reproductive numbers corresponding to these two extreme cases do not differ significantly whenever the two distributions have the same mean. At any rate a formula is provided that allows us to estimate the role played by the survivorship function (and hence the incubation period) in the global dynamics of HIV. These results support the conclusion that single population models of this type are robust and hence are good building blocks for the construction of multiple group models. Our understanding of the dynamics of HIV in the context of mathematical models for multiple groups is critical to our understanding of the dynamics of HIV in a highly heterogeneous population.

Migratory patterns of sockeye salmon (Oncorhynchus nerka) smolts in the Strait of Georgia, British Columbia, as determined by analysis of parasite assemblages

Sockeye salmon smolts from the Fraser River system, migrating northward through the Strait of Georgia towards the Pacific Ocean, follow either an eastern route by immediately travelling northward upon leaving the Fraser River estuary or a western route by first crossing the Strait of Georgia towards Vancouver Island and then moving northward diagonally across the Strait of Georgia to join smolts migrating along the mainland shore. We used variations in parasite assemblages among Fraser River and Lake Washington sockeye smolt stocks and a maximum-likelihood mixture model to estimate the stock composition of the smolts along the two migratory routes. The results showed that most Fraser River sockeye smolts migrate northward via both the eastern and western routes through the Strait of Georgia, indicating that there is no stock specific route selection. Lake Washington smolts were more prevalent along the western route and we suggest that these smolts are transported westward when attempting to cross the Fraser River plume.

Grading severity of childhood disablement: comparing survey measures with a paediatrician's assessment

This study investigates the relationship between a paediatrician's assessment of the overall severity of disablement in a sample of 10-year-old children and the survey data on which this assessment was based. An attempt was made to identify disabilities or combinations of disabilities which were good predictors of the paediatrician's assessment. It was possible to do this with some success with children assessed as severely disabled but it was much more difficult to do so where the degree of disablement was assessed as mild or moderate. The implications of these findings for the assessment of children with disabilities which are less than severe are discussed.

Child disablement, family dissolution and reconstitution

The results of a study of a nationally representative sample of disabled children and controls are presented. The findings suggest that although, at any one time, families containing a disabled child are not no more likely to be one-parent families, disabled children do appear to be more likely to experience a spell in a one-parent family at some time in their lives. Where these spells occur, they are of longer duration than for the general population, which suggests that family reconstitution may be more difficult where a disabled child is present.

Housing circumstances and standards of families with disabled children

Research on the impact of a disabled child on family resources suggests that housing standards are likely to be lower for these families than for other families. This article attempts to assess the extent to which this is actually the case. The article employs data from a nationally representative sample of disabled children and compares their housing standards according to five criteria with those of a control sample. Families with disabled children were found to be significantly more likely than control families to be living in local authority housing, more likely to be living in overcrowded accommodation and less likely to have central heating and certain consumer durables in the household.

Informal support for the carers of disabled children

This article draws on data from a nationally representative sample of disabled children to investigate the support which careers receive from spouses, relatives, friends, neighbours and voluntary organizations. The results confirm the findings of previous studies that, within families, mothers bear the major burden both of child care and housework. However, the results indicate that families with disabled children generally do not receive as much support from relatives, friends and neighbours as some previous studies of children with particular disorders have suggested, and that membership of voluntary organizations is very low.

Take-up of benefits by families with disabled children

The take-up of four cash benefits by families with disabled children is assessed using a national sample drawn from the 1970 birth cohort. The four benefits are invalid care allowance, attendance allowance, mobility allowance and the Family Fund. None of the few families in the sample who were eligible for the invalid care allowance knew about it or had claimed it, but none would have been better off if they had done so. Take-up of the attendance allowance was lower than previous studies have suggested; between a half and two-thirds of those who appeared to be eligible were receiving the attendance allowance. About 80% of those children who were eligible for the mobility allowance were receiving it. About 65% of those families who met the eligibility criteria of the Family Fund had received help.