Patients' perceptions and responses to procedural pain: results from Thunder Project II.

BACKGROUND: Little is known about the painfulness of procedures commonly performed in acute and critical care settings. OBJECTIVE: To describe pain associated with turning, wound drain removal, tracheal suctioning, femoral catheter removal, placement of a central venous catheter, and nonburn wound dressing change and frequency of use of analgesics during procedures. METHODS: A comparative, descriptive design was used. Numeric rating scales were used to measure pain intensity and procedural distress; word lists, to measure pain quality. RESULTS: Data were obtained from 6201 patients: 176 younger than 18 years and 5957 adults. Mean pain intensity scores for turning and tracheal suctioning were 2.80 and 3.00, respectively (scale, 0-5), for 4- to 7-year-olds and 52.0 and 28.1 (scale, 0-100) for 8- to 12-year-olds. For adolescents, mean pain intensity scores for wound dressing change, turning, tracheal suctioning, and wound drain removal were 5 to 7 (scale, 0-10); mean procedural distress scores were 4.83 to 6.00 (scale, 0-10). In adults, mean pain intensity scores for all procedures were 2.65 to 4.93 (scale, 0-10); mean procedural distress scores were 1.89 to 3.47 (scale, 0-10). The most painful and distressing procedures were turning for adults and wound care for adolescents. Procedural pain was often described as sharp, stinging, stabbing, shooting, and awful. Less than 20% of patients received opiates before procedures. CONCLUSIONS: Procedural pain varies considerably and is procedure specific. Because procedures are performed so often, more individualized attention to preparation for and control of procedural pain is warranted.

Sexual abuse and sexual risk behaviors of minority women with sexually transmitted diseases.

The relationship between sexual abuse and sexually transmitted disease (STD) represents an important and underinvestigated context of domestic violence. This study examined the association between sexual abuse, sexual risk behaviors, and risk for reinfection and HIV among minority women with STD. Mexican American and African American women (n = 617) with active STD entered a randomized study of behavioral intervention to reduce STD recurrence. Each underwent questioning at entry regarding sexual abuse and sexual risk behaviors. Comparisons of these behaviors using chi-square, t tests, and logistic regression were made by history of sexual abuse. Sexually abused women were more likely to have lower incomes, earlier coitus, STD history, currently abusive partners, new sex partners, anal sex, and bleeding with sex, placing them at increased risk for STD reinfection and HIV. Due to this association with sexual risk behavior, assessment for sexual abuse is essential in programs focusing on STD/HIV prevention.

Predictors of the vaginal microflora.

OBJECTIVE: Our purpose was to define influences on the patterns of the vaginal microflora. STUDY DESIGN: We enrolled 617 African American and Mexican American women in a 1-year longitudinal study of sexual behaviors and the vaginal microflora on the basis of the presence of gonorrhea, chlamydial infection, trichomoniasis, or syphilis at the initial visit. The patients were assigned randomly to a behavioral intervention or standard counseling regarding sexually transmitted disease. We reevaluated 508 (82%) and 549 (89%) women at 6 and 12 months, respectively. A comprehensive survey of lower genital tract organisms was conducted at baseline and at 6 and 12 months. Behavioral and microbiologic associations were screened by bivariate analysis. All variables associated with an organism at P < or = .15 were included in a multivariate analysis. Associations between behavior and the genital tract microflora were identified by logistic regression coefficients with P <.05. RESULTS: African American race had a consistent association with vaginal microflora, specifically, Mycoplasma hominis, Trichomonas vaginalis, bacterial vaginosis, group B streptococci, Neisseria gonorrhoeae, and Chlamydia trachomatis. Various behaviors had a less consistent effect, including multiple partners, douching, frequency of coitus >3 times a week, and cunnilingus, fellatio, and anal intercourse at the last sexual encounter. M hominis (but not Ureaplasma urealyticum ), Gardnerella vaginalis, and Lactobacillus species were associated with bacterial vaginosis. Lactobacillus species appeared to protect against bacterial vaginosis and infection with G vaginalis. Sexually transmitted diseases (caused by M hominis, N gonorrhoeae, C trachomatis, and T vaginalis ) were associated with each other. In contrast, hormonal status, vaginal blood, and foreign bodies had little effect. CONCLUSION: The presence of other microorganisms and race have a more consistent association with the presence or absence of a cervical-vaginal organism than sexual behavior, hormonal status, vaginal devices, or the presence of abnormal vaginal bleeding.

Minority women with sexually transmitted diseases: sexual abuse and risk for pelvic inflammatory disease.

Mexican American and African American women (N = 617) with a sexually transmitted disease (STD) underwent a targeted physical exam and questioning regarding sexual abuse, current genitourinary symptomatology, and pelvic inflammatory disease (PID) risk behaviors to determine the relationship between sexual abuse and risk for PID. Sexually abused women (n = 194) reported higher PID risk behaviors, including earlier coitus, more sex partners, higher STD recurrence, and a tendency toward delayed health-seeking behavior. They also reported more severe genitourinary symptomatology, confirmed by physical exam, and presumptive diagnoses of PID. These characteristics identify sexually abused women at high risk for PID. Because of its considerable impact on risk for PID, assessment for sexual abuse is essential in clinical management of women with STD and for diagnosis of PID.

Translating research into practice. Implications of the Thunder Project II.

The Thunder Project II study described procedural pain in a variety of acute and critical care settings. The procedures studied were turning, tracheal suctioning, wound drain removal, nonburn wound dressing change, femoral sheath removal, and central venous catheter insertion. Turning had the highest mean pain intensity, whereas femoral sheath removal and central venous catheter insertion had the least pain intensity in adults. Nonwound dressing change had the highest pain intensity for teenagers. Pain occurred in procedures that are often repeated several times a day as well as in those that may be single events. There is a wide range of pain responses to any of these procedures; as a result, standardized and thoughtful pain, and distress assessments are warranted. Planning of care, including the use of preemptive analgesic interventions, needs to be individualized. Future studies are needed to describe patient responses to other commonly performed nursing procedures and to identify effective interventions for reducing procedural pain and distress.

A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women.

BACKGROUND: African-American and Hispanic women are disproportionately affected by sexually transmitted diseases, including the acquired immunodeficiency syndrome (AIDS). In the effort to reduce infection rates, it is important to create and evaluate behavioral interventions that are specific to the target populations. METHODS: We enrolled women with nonviral sexually transmitted diseases in a randomized trial of a sex- and culture-specific behavioral intervention. The intervention consisted of three small-group sessions of three to four hours each designed to help women recognize personal susceptibility, commit to changing their behavior, and acquire necessary skills. The control group received standard counseling about sexually transmitted diseases. The design of the intervention was based on the AIDS Risk Reduction Model and ethnographic data on the study populations. Participants in both groups underwent screening, counseling, and an interview before randomization and at the 6- and 12-month follow-up visits. The principal outcome variable was subsequent chlamydial or gonorrheal infection, which was evaluated on an intention-to-treat basis by logistic-regression analysis. RESULTS: A total of 424 Mexican-Americans and 193 African-American women were enrolled; 313 were assigned to the intervention group and 304 to the control group. The rate of participation in the intervention was 90 percent. The rates of retention in the sample were 82 and 89 percent at the 6- and 12-month visits, respectively. Rates of subsequent infection were significantly lower in the intervention group than in the control group during the first 6 months (11.3 vs. 17.2 percent, P=0.05), during the second 6 months (9.1 vs. 17.7 percent, P=0.008), and over the entire 12-month study period (16.8 vs. 26.9 percent, P=0.004). CONCLUSIONS: A risk-reduction intervention consisting of three small-group sessions significantly decreased the rates of chlamydial and gonorrheal infection among Mexican-American and African-American women at high risk for sexually transmitted disease.

Positioning of chest tubes: effects on pressure and drainage.

BACKGROUND: Maintaining a chest drainage tube in a position that is free of dependent loops, as is commonly recommended, can be very difficult. Is there a beneficial effect on the patient's outcome when the drainage tubing is free of dependent loops? OBJECTIVE: The purpose of this study was to determine, under controlled laboratory conditions, (1) what are the differences in drainage with tubing in straight, coiled, or dependent-loop (with and without periodic lifting) positions and (2) what are the differences in pressure with each of the four tubing conditions? METHODS: In laboratory simulations, pressure and drainage were observed in a chest tube drainage system that was connected to a glass bottle simulating the lung. Pressure and drainage were measured for 1 hour with the drainage tubing placed in straight, coiled, and dependent-loop positions. For the periodic lifting condition, the dependent loop was lifted and drained every 15 minutes. RESULTS: We found no differences in pressure or drainage between straight and coiled positions of the drainage tubing. However, with the dependent-loop position, pressure at the "lung" side increased from about -18 cm H2O to as high as +8 cm H2O. Drainage dropped to zero without tube lifting. When the tube was lifted and drained every 15 minutes, there was no difference in drainage with the tubing in the straight or coiled positions. CONCLUSION: Findings support recommendations to maintain tubing free of dependent loops by placing tubing in straight or coiled positions. Frequently lifting and draining a dependent loop will provide the same total drainage amount as maintaining the tubing in a straight or coiled position, but pressures may be altered sufficiently within the tube to exceed recommended levels.

Medicare-certified home health services: national and regional supply in the 1980s.

The number of Medicare-certified home health agencies nearly doubled from 1980 to 1990. Using Health Care Financing Administration data, this study documented national and regional patterns of entry and exist by Medicare home health providers from 1980 to 1990. Nationally, agency origination rates accelerated during the early 1980s and then dropped abruptly in the second half of the decade. The proprietary sector, accounting for approximately 42% of agencies in existence during the period of the study, exhibited the greatest volatility. Regional differences are also evident. Both expansion and contraction in Medicare home health services appear to be a response to the incentives of legislation implemented during this period.

Growth and decline in the supply of providers of Medicare-covered home health services in the 80's: national and regional experience.

Using Health Care Financing Administration (HCFA) data, this study documents national and regional patterns of market entry and exit in the home health industry from 1980 to 1990. Nationally, agency origination rates accelerated during the early 1980's, then dropped abruptly in the second half of the decade. The for-profit sector exhibited the greatest volatility. Of the 3,620 proprietary agencies in existence during the decade, 3,284 (90.7%) were new entrants, and 1,551 exited the market by 1990. Regional differences in growth rates and the timing of market entry are also evident. Both growth and decline in the home health industry appear to be a response to the incentives of legislation implemented during this period.

The use of recombinant human erythropoietin in the correction of anemia in predialysis patients and its effect on renal function: a double-blind, placebo-controlled trial.

Fourteen nondialyzed patients with chronic renal insufficiency (serum creatinine 265 to 972 mumol/L [3.0 to 11.0 mg/dL]) and severe anemia (hematocrit less than 30%) were randomized to receive either recombinant human erythropoietin (r-HuEPO) or a placebo subcutaneously thrice weekly for 12 weeks or until reaching a hematocrit of 38% to 40%. Anemia was significantly ameliorated in the treated patients. No acceleration in the progression of renal failure (1/serum creatinine v time) or change in serum potassium was noted for either the placebo or treated group over the 12-week period. Six of seven treated patients had a significant decrease in serum ferritin and percent transferrin saturation (plasma iron/total iron-binding capacity). This resulted in functional iron deficiency and the requirement for iron supplementation. The average systolic and diastolic blood pressure did not differ significantly between the two groups of patients during the study. Quality of life was improved in all r-HuEPO-treated patients but not in those in the placebo group. This study demonstrates the safety and efficacy of r-HuEPO in the correction of anemia in predialysis patients without adverse effects on renal function over a 12-week period. Improved patient well-being as a result of the correction of anemia resulted in one patient refusing appropriate initiation of dialysis therapy.

Alpha-fetoprotein levels in amniotic fluid between 11 and 15 weeks.

We have shown that alpha-fetoprotein levels in amniotic fluid peak at 13 weeks and then fall by about 10% a week until 20 weeks. Use of cutoff levels obtained by extrapolation backward from medians at later dates gives results that are too high and could cause diagnostic errors. The ability to monitor alpha-fetoprotein levels accurately provides an advantage to this method of early prenatal diagnosis.

Correcting for variable age of onset in the estimation of familial relative risk when there is a secular trend in incidence of disease.

We discuss the effects that a secular trend in incidence would have on estimation of familial relative risk (ratio of observed to expected cumulative incidence among relatives of index cases). For example, when age-specific incidence rates of a condition have increased during the lifetimes of relatives among whom relative risk is to be estimated, familial relative risk will be biased downward if cross-sectional, age-specific incidence data are used to estimate expected cumulative incidence among relatives. The stronger the trend and the older the ages of unaffected relatives, the greater the bias will be. Incorporating different age-specific incidence curves for different birth cohorts into the analysis is an approach we suggest for correcting the bias.

Kidney transplantation trends from UCLA registry Data, 1975-1982.

A total of 23,607 cases transplanted in 1975-1982 were analyzed for proportion and survival trends within eleven classification variables. Increases of up to 2% of total cases per year in proportions of registered transplants over the eight years are found in the following subcategories (with corresponding decreases in complementary subcategories): first grafts, cadaver donors, recipients with diabetes mellitus, and kidneys shipped more than 50 miles. Larger proportional increases of 3-7% per year are found for HLA-DR matching, cold ischemia times greater than 24 hr, cold storage, and pretransplant transfusions. Recipient population cross-sections are unchanged for age, race, HLA-A,B matching, and cytotoxic antibodies at transplant. Only the pretransplant transfusion classification has no increased graft survival in any subcategory; all other variables have one or more categories with increasing graft survival. It appears likely that the marked shift in transfusion policy nationwide has been the primary factor in increasing graft survival rates overall.

Improving success rates of kidney transplantation.

One-year patient survival rates have improved remarkably, from 84% in 1968 to 97% in 1980 for parental donor grafts, and from 65% to 90% for cadaver donor grafts. In contrast, graft survival rates showed a steady decline from 1968 to 1975 but subsequently improved at a rate of 2.4% per year for parent donor transplants and 2.7% per year for cadaver donor transplants. During this period of improving survival rates, the pretransplant transfusion exposure rate increased from 52% in 1977 to 91% by 1981. We conclude that transplantation has now reached a new level of acceptability as a clinical treatment modality and that blood transfusion has produced its effect on graft survival when results are disseminated over a large number of transplant centers.

Analysis of interracial variation in kidney transplant and patient survival.

Negro recipients appear to have essentially the same graft and patient survival rates as Caucasian recipients after accounting for the center effect. Cadaver kidneys from Negro donors yielded very slightly lower survival rates than kidneys from Caucasian donors after correction for the center effect. It appears that centers with poor results may have influenced the conclusions from earlier data regarding Negro donors. Transplants into Oriental recipients either from related donors or from Caucasian cadaver donors result in transplant outcomes that are comparable to the outcomes in Caucasian recipients. Most interesting is the comparable survival rate from Caucasian donors into either Caucasian recipients or Oriental recipients, despite a considerable difference in histocompatibility antigen frequencies between these races. Both Caucasian and Negro patients with nephrosclerosis have graft and patient survival rates that are comparable to patients of the same race without nephrosclerosis. The transfusion effect is noted in both Caucasian and Negro recipients. Comparable proportions receive similar numbers of transfusions in each race.

HLA frequencies in cancer: a third study.

Frequencies of 25 HLA antigens in 526 Caucasian patients were compared to those in 629 healthy controls who were HLA-typed between September 1975 and February 1977. Haplotypes were compared for 711 patients and 549 controls typed between September 1974 and December 1976. Frequency deviations were found in those with ALL, AML, breast cancer, lymphoma and ovarian cancer, but only the increase in A29 in AML patients was statistically significant when corrected for the number of specificities. Interesting associations, when compared with earlier studies, include elevation of AW24 in both ALL and AML patients and increased B27 in ALL patients. Significant haplotype differences were increased A3-B8 and absence of A1-BW17 in ALL patients and increased A11-B5 and A2-BW40 as well as absence of A2-B5 in AML patients.