Improving pain management in an acute care setting. The Crawford Long Hospital of Emory University experience.

PURPOSE: To identify which of three pain intensity measurement scales is most appropriate for use with patients admitted to the inpatient units of the study hospital. The following questions were addressed: Is one of the scales easier for most patients? Is the choice of scales influenced by nursing unit, age, education, race, SES, diagnosis, or type of pain experienced? Do patients perceive that a rating scale helps them describe their pain more effectively? SAMPLE: 267 patients admitted over a 3-week period completed a four-page questionnaire and demographic form distributed on admission. The primary admitting diagnosis for 39.5% of the sample reflected acute pain, 40.3% chronic pain, and 20.2 no pain. METHODS: Three pain rating scales were presented: two visual analogues (one contained a 100 mm line; the other contained six faces depicting graduated levels of distress); and a cognitive number rating scale. Each scale used a 0 (no pain) to 10 (worst pain possible) rating format. Patients completed the questionnaire by rating the intensity of pain experienced using each of the three scales once over the next 24 hours. The last page contained questions related to which of the scales was easiest to use, whether the scale was helpful or needed further explanation, and work and education information. The demographic form was completed from information contained in the patient record. FINDINGS: The scale selected most frequently was the visual analogue containing faces (48.6%), followed by the number (35.3%) and line scales (16.1%). None of the demographic information was found to significantly influence choice of preferred scale. A majority (85.8%) indicated a rating scale as helpful; only 13.6% indicated a need for further explanation. The means for pain intensity ranged from 5.09 to 5.75. The interval between pain ratings for the majority (> 71%) was less than 2 hours. Patients tended to tell the nurse about their pain when the intensity exceeded the midpoint on the scales. A reliability coefficient for the three scales was computed at alpha = 0.88. CONCLUSION: The use of rating scales for pain assessment in adult inpatient units was viewed positively by patients. Recommendations for incorporating self-ratings of pain intensity are set forth. Involving both patients and providers in the process is essential to improving both our processes and the outcomes achieved.

There are two mechanisms of achiasmate segregation in Drosophila females, one of which requires heterochromatic homology.

There are numerous examples of the regular segregation of achiasmate chromosomes at meiosis I in Drosophila melanogaster females. Classically, the choice of achiasmate segregational partners has been thought to be independent of homology, but rather made on the basis of availability or similarities in size and shape. To the contrary, we show here that heterochromatic homology plays a primary role in ensuring the proper segregation of achiasmate homologs. We observe that the heterochromatin of chromosome 4 functions as, or contains, a meiotic pairing site. We show that free duplications carrying the 4th chromosome pericentric heterochromatin induce high frequencies of 4th chromosome nondisjunction regardless of their size. Moreover, a duplication from which some of the 4th chromosome heterochromatin has been removed is unable to induce 4th chromosome nondisjunction. Similarly, in the absence of either euchromatic homology or a size similarity, duplications bearing the X chromosome heterochromatin also disrupt the segregation of two achiasmate X chromosome centromeres. Although heterochromatic regions are sufficient to conjoin nonexchange homologues, we confirm that the segregation of heterologous chromosomes is determined by size, shape, and availability. The meiotic mutation Axs differentiates between these two processes of achiasmate centromere coorientation by disrupting only the homology-dependent mechanism. Thus there are two different mechanisms by which achiasmate segregational partners are chosen. We propose that the absence of diplotene-diakinesis during female meiosis allows heterochromatic pairings to persist until prometaphase and thus to co-orient homologous centromeres. We also propose that heterologous disjunctions result from a separate and homology-independent process that likely occurs during prometaphase. The latter process, which may not require the physical association of segregational partners, is similar to those observed in many insects, in Saccharomyces cerevisiae and in C. elegans males. We also suggest that the physical basis of this process may reflect known properties of the Drosophila meiotic spindle.