A preliminary study of the utility of the brief hospice inventory.

The increasing number of palliative care patients necessitates a simple, reliable instrument to routinely measure outcomes among hospice patients. We tested the utility of the Brief Hospice Inventory (BHI) to assess outcomes of hospice patients and estimations of patients' outcomes by nurse caregivers. In a prospective study, 145 home-based hospice patients were enrolled in the study from VistaCare Hospice. During the first week of admission, patients and nurse caregivers completed the BHI, which assessed patients' symptoms, satisfaction with care, and quality of life. Factor analysis supported a two-factor structure for the BHI for patients and caregivers, including a symptom subscale and quality of life subscale. Patients with severe symptoms showed improvement on the symptom subscale, but not the quality of life subscale, during the first 2 weeks after admission. The BHI shows utility in measuring hospice patients' symptom severity and quality of life over time.

Opioid analgesic drugs in older people.

Many studies have corroborated the finding that older patients in all clinical settings are at risk for insufficient assessment and inadequate management of pain. Opioid analgesics can greatly improve the quality of life and functional capacities of older patients with moderate to severe pain that is not responsive to other therapies; however, these agents are underused in this population. To improve the care of older patients, clinicians must develop expertise in appropriate indications, pharmacologic properties, drug-disease and drug-drug interactions, and ongoing monitoring of opioid analgesic therapy.

A novel mechanism for benign essential blepharospasm.

PURPOSE: The purpose of this study is to test the hypothesis that the photophobia of benign essential blepharospasm (BEB) is caused by sympathetically maintained pain. METHODS: Nineteen patients with photophobia and BEB were enrolled in an unblinded prospective treatment trial. The intervention was blockade of the superior sympathetic ganglion with local anesthetic. Outcome measures included the patient's subjective report of ocular surface dryness, foreign body sensation, and eyelid spasm. We also obtained video recordings of eyelid movements. RESULTS: Of the 19 patients, 13 reported subjective improvement in BEB symptoms after cervical sympathetic blockade (CSB). Thirteen of 19 patients also had objective evidence of decreased light-induced eyelid spasm after CSB. Ocular surface disease was present in 18 of 19 patients. CONCLUSION: These data support the hypothesis that in many patients with BEB there is a sympathetically maintained pain syndrome associated with external ocular disease. We speculate on a neurologic circuit that may explain these findings.

Low-dose ketamine in the management of opioid nonresponsive terminal cancer pain.

Two patients with far-advanced cancer, near death, who were experiencing excruciating and intractable pain that was poorly responsive to rapidly escalating doses of morphine and hydromorphone were treated with low-dose intravenous ketamine (0.1-0.2 mg/kg). This intervention eliminated the need for any further opioid use, providing profound analgesia and a sense of calm during the last hours and days of these patients' lives. These case reports add to the small but growing body of clinical literature suggesting that ketamine may have a significant place in the care of patients with pain that is poorly responsive to opioids, or who experience dose-limiting adverse effects, near the end of life. This is an important matter to disseminate in order to reassure the public that we do have the tools necessary to keep the promise that no one need die with uncontrolled pain. This therapeutic approach may also serve to reassure concerned physicians that their efforts to assure pain relief may not be misconstrued as hastening death.

Characterization of breakthrough pain by hospice patients and their caregivers.

This study sought to characterize the nature of breakthrough pain experienced by 22 hospice patients and to assess the perceptions of their respective caregivers. Questionnaires were administered by trained hospice nurses to determine key elements of episodic pains in this home-based terminally ill population. Eighty-six percent of the patients surveyed experienced breakthrough pain, with an average of 2.9 episodes per 24-hr period and a mean pain intensity of 7 on a ten-point scale, compared with average baseline pain scores of 3.6 (daytime) and 2.6 (nighttime). Breakthrough pain episodes lasted 52 min on average, with a range of 1-240 min. The range of time to relief of breakthrough pains was 5-60 min, with a mean of 30 min. Caregivers' perceptions of the pain intensities, duration, amount of relief, and time to relief were much more likely to be inaccurate, and were usually underestimates. This study suggests that breakthrough pain is common in the hospice setting and that there is poor concordance between patients' self-reports and their caregivers' perceptions of these pains. It is concluded that the pharmacodynamics of currently available oral analgesics are not well-suited for breakthrough pain and that better communication between patients and caregivers may lead to more optimal pain management.

A review of oral transmucosal fentanyl citrate: potent, rapid and noninvasive opioid analgesia.

The physiochemical characteristics of the potent synthetic opioid agonist fentanyl make it ideal for noninvasive transmucosal delivery. Studies of oral transmucosal fentanyl citrate (OTFC), a candied matrix formulation administered orally as a palatable lozenge on a stick, have investigated and determined this analgesic's pharmacokinetics and pharmacodynamics in a number of clinical settings, including premedication before surgery, acute analgesia for painful medical procedures, and, most recently, for the control of breakthrough cancer pain. The onset to meaningful pain relief in patients with acute pain from surgery or breakthrough pain from cancer is between 5 and 10 minutes after initiating OTFC use, equivalent to intravenous morphine. Analgesic dose equivalency studies suggest that OTFC is, on average, about 10 times more potent than morphine, although, in randomized, controlled, and blinded studies, many patients who were using relatively high doses of opioid anlagesics on an around the- clock schedule for control of cancer pain reported that even a low dose of OTFC (i.e., 200 microg) provided adequate relief from breakthrough pain. Side effects from OTFC are similar in character and frequency to other opioids, including sedation, nausea, and pruritus. These effects appear to wane rapidly with repeated use of this medication. To date there have been no reported serious adverse events in any of the population groups studied or treated with OTFC.

A preliminary laboratory investigation of air embolus detection and grading using an artificial neural network.

SUMMARY STATEMENT: Processed digitized Doppler signals abstracted from recordings during continuous air infusion in dogs were used to train a neural network to estimate air embolism infusion rates. BACKGROUND: Precordial Doppler is a sensitive technique for detecting venous air embolism during anesthesia, but it requires constant attentive listening. Since neural networks are particularly well suited to the task of pattern recognition, we sought to investigate this technology for detection and grading of air embolism. METHODS: Air was infused into peripheral veins of four anesthetized dogs at rates of 0.025, 0.05, 0.10, 0.25, 0.50 and 1.0 ml-1.kg-1.min-1 while digital recordings of the precordial Doppler ultrasound signal were collected. The frequency content of the recordings was determined by Fourier analysis. The output of the Fourier transform was the input to a neural network. The network was then trained to estimate the air infusion rate. RESULTS: The correlation coefficient between the size of the air embolism and the air infusion rate was greater than r2 = 0.93 for each of the four animals in the study when the network was trained using the data for all four dogs. When the data from a dog was withheld from the training set and used only for testing the correlation coefficients ranged from r2 = 0.75 to r2 = 0.27. For frequencies below 250 Hz, the acoustic energy tended to fall as the air infusion rate increased. The opposite occurred at frequencies above 325 Hz. CONCLUSIONS: Neural network processing of the precordial Doppler signal provides a quantitative estimate of the size of an air embolism.

A controlled trial of regional sympatholysis in the treatment of photo-oculodynia syndrome.

INTRODUCTION: The mechanism(s) underlying the eye pain syndrome characterized by photo-oculodynia and decreased tears (herein referred to as PODS) is unknown. Postulating a sympathetically maintained pain mechanism, cervical sympathetic ganglion blocks (CSB) were performed in an open-label trial in two patients as a pilot test of our hypothesis. Because these patients experienced clinically dramatic reductions in signs and symptoms, a double-masked controlled trial was initiated. METHODS: With Institutional Review Board approval and written informed consent, four other subjects with PODS who had experienced temporary reduction (> 50%) of symptoms with a single lidocaine CSB were enrolled. A randomized, double-masked series of three CSBs (saline, bupivacaine, lidocaine) was scheduled for each subject 2-7 days apart. RESULTS: CSB with lidocaine and bupivicaine, but not saline, reduced spontaneous pain and light sensitivity and increased production of tears. Symptom reduction lasted for hours to days, extending beyond clinical signs of local anesthetic-induced sympatholysis. It was also observed that sympatholysis extinguished associated blepharospasm in those subjects with this dystonic condition (one subject in the open-label pilot trial and two of three in the controlled trial). CONCLUSIONS: Results of these preliminary data suggest that the sympathetic nervous system is involved in mediating symptoms associated with PODS in certain individuals.

Real-time B-scan ultrasound in middle ear assessment. A preliminary report.

Middle ear visualization is difficult otoscopically due to the usual opacity of the eardrum. Though various procedures have been developed, difficulties exist in determining effusion and other middle ear anomalies. Past studies have demonstrated the effectiveness of A-scan ultrasound for such purposes. The present study reports initial results of real-time B-scan sonography on patients with normal and effusion-filled middle ears. Consistent landmarks are seen in the normals. Fluid appears in the abnormals as a band or elliptical area of nonreflectance medial to the eardrum. Though further study is necessary to determine reliability, initial results are promising for this application.