Pain assessment in the intensive care unit: development and psychometric testing of the nonverbal pain assessment tool.

BACKGROUND: Few standardized tools measure pain in nonverbal patients in the intensive care unit (ICU). Evidence exists that patient behaviors provide important information about pain in those unable to report their pain. OBJECTIVE: The Nonverbal Pain Assessment Tool (NPAT), a behavioral pain assessment tool, was developed for the nonverbal adult patient in the ICU. Content and criterion validity and internal and interrater reliability were evaluated. METHODS: The validity of NPAT was assessed against the patients' self-reports of pain. Interrater reliability was tested by 5 teams of 2 nurses assessing pain in nonverbal adult patients in 4 different ICUs. RESULTS: The tool underwent 2 revisions and involved 270 patients. During the final evaluation, strong internal reliability (chronbach's α, .82; 95% confidence interval), moderately strong interrater reliability (concordance coefficient, .72; 95% confidence interval; and weighted κ statistic, .35), and moderately strong validity (concordance coefficient, .66; 95% confidence interval) were achieved. CONCLUSION: The NPAT was found to possess moderately strong validity and strong internal and interrater reliability. It is easy to use, and provides a standard approach to assessing pain in the nonverbal adult patient.

Albumin excretion in acute myocardial infarction: a guide for long-term prognosis.

BACKGROUND: Albumin excretion rate has been found to be associated with increased risk of mortality in several clinical settings. We assessed the relationship between urinary albumin and 7-year mortality in a cohort of patients with acute myocardial infarction (AMI). METHODS: In this prospective study, we examined 505 white patients admitted with AMI to the intensive care unit of 3 hospitals. Main end points were nonearly all-cause and cardiovascular (CV) mortality. Albumin-to-creatinine ratio (ACR) was measured by radioimmunoassay on the first, third, and seventh days after admission. Risk estimates were made using Cox proportional-hazard model and relative odds. Forty patients (7.9%) died early inhospital, and 175 (34.7%) died during the rest of the follow-up (nonearly mortality). RESULTS: The ACR measured on the third day predicted the occurrence of 7-year nonearly all-cause and CV mortality. Hazard ratios for ACR > or =0.97 mg/mmol were 3.0 (95% confidence limit 2.2-4.1), P < .0001, for nonearly all-cause mortality and 3.5 (95% confidence limit 2.5-5.0), P < .0001, for CV mortality. Correspondent fully adjusted hazard ratios were 1.9 (95% CI 1.4-2.6), P < .0001, and 2.2 (95% CI 1.5-3.2), P < .0001, respectively. By adding ACR to the 18-variable predictive model, ACR improved significantly both the goodness of fitting of the model for nonearly all-cause (P < .0001) and CV mortality (P < .0001) and the C-statistic value (P < .0001 and P = .002 for nonearly all-cause and CV mortality, respectively). Similar results were obtained for ACR measured on the first day or the seventh day. CONCLUSIONS: An early increase of urinary albumin in AMI is a strong independent predictor of long-term adverse clinical outcome. The ACR improved clinical prediction over and above baseline traditional multivariable risk models.

Association between time from endometriosis surgery and outcome of in vitro fertilization cycles.

OBJECTIVE: To evaluate the effect of time from surgery on the outcome of subsequent in vitro fertilization (IVF) cycles in endometriosis patients. STUDY DESIGN: One hundred five women treated surgically for endometriosis and who underwent 252 IVF cycles were included. Approximately 1/2, 1/4 and 1/5 of the study group underwent 1, 2 and 3 cycles, respectively. We used the cycle as the basic unit of analysis with the time since surgery as the independent variable and the clinical pregnancy as the dependant variable. We used nonparametric approach for estimating the probabilities. To convey the uncertainty of the probability estimates, we produced bootstrap 95% CI. RESULTS: The overall pregnancy rate was 31%. There does not appear to be any relationship between the length of time from surgery and clinical outcome. The point estimates suggest that there may be a slight negative relationship, since the estimated probability decreases steadily from 0.34 to 0.21 as the time since surgery goes from 0.5 to 5 years. CONCLUSION: The data do not provide evidence for a strong relationship between the time since surgery and the probability of a clinical pregnancy with IVF.

Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms.

PURPOSE: To evaluate the predictive factors and outcome of type II endoleaks after endovascular repair of infrarenal abdominal aortic aneurysms with use of a Zenith endograft. MATERIALS AND METHODS: Patients classified at high risk were enrolled in a prospective study and evaluated with serial cross-sectional imaging techniques. The effect of a type II endoleak on sac behavior and associated factors were analyzed. Type II endoleaks were categorized as absent, persistent, or transient, and the morphologic effects were determined. Logistic regression and classification tree were used to predict which patients may be at risk for persistent type II endoleaks. RESULTS: A total of 273 patients were enrolled. Patients were excluded in the absence of a minimum of 6 months digital data or the presence of endoleak not classified as type II. Two hundred four patients met inclusion criteria, with a median follow-up period of 24 months (range, 6-60 months). Early type II endoleak was detected in 35 patients (17%), which resolved spontaneously in 17 cases. There were 18 patients with persistent endoleak, 17 patients with transient type II endoleak, and 169 patients with no endoleak. Aneurysm enlargement was detected in seven patients with persistent endoleak (39%), no patients with transient type II endoleak, and one patient with no endoleak. No variables were predictive of the development of persistent endoleak. The relative risk of aneurysmal growth was 77 with persistent endoleak. Successfully treated persistent endoleaks were not associated with any growth. CONCLUSIONS: Persistent endoleaks are associated with sac growth. Transient type II endoleaks have a benign course and do not require treatment. Successful treatment of persistent endoleak ameliorates the risk of growth.

Effect of off-pump coronary artery bypass graft surgery on postoperative acute kidney injury and mortality.

OBJECTIVE: Risk of mortality after cardiac surgery is associated with severity of acute kidney injury. The aim of this study is to examine the effect of off-pump coronary artery bypass surgery on the risk of postoperative acute kidney injury and its association with mortality. DESIGN: Observational cohort study. SETTING: Tertiary care center. PATIENTS: Some 10,061 patients underwent coronary artery bypass surgery (1998-2002), of which 1,365 patients underwent off-pump surgery. INTERVENTIONS: Acute kidney injury was defined as either requirement of dialysis or >/=50% decline in postoperative glomerular filtration rate but not requiring dialysis. We compared on- and off-pump surgeries and used propensity score matching to examine the effect of off-pump surgery on acute kidney injury and mortality. MEASUREMENTS AND MAIN RESULTS: We found that 2.6% on-pump and 1.2% off-pump patients developed acute kidney injury requiring dialysis among the 2,370 matched subjects (relative risk, 2.06; 95% confidence interval [CI], 1.36-3.36); 5.0% of on-pump patients suffered a >/=50% decline in glomerular filtration rate compared with 2.5% in off-pump group (relative risk, 2.00; 95% CI, 1.48-2.82). The mortality rate in the matched cohort was 2.3% for on-pump group vs. 0.6% in off-pump group (relative risk, 3.88; 95% CI, 2.29-9.50). Among matched patients with acute kidney injury, the risk of mortality was 13.14 (95% CI, 8.43-30.50) in patients requiring dialysis and 9.33 (95% CI, 4.83-19.00) in those with >/=50% decline in glomerular filtration rate but not requiring dialysis. CONCLUSIONS: Off-pump surgery is associated with a lower risk of developing acute kidney injury (regardless of its definition). The risk of mortality is incremental with worsening degrees of acute kidney injury. Lower risk of acute kidney injury may be one of the factors that offer a survival advantage after off-pump surgery.