Improving preoperative medication instructions and patient adherence: a collaborative, hospital-based quality improvement project.

The goal of this project was to improve preoperative medication instructions. After baseline data were collected prospectively through standardised patient surveys, preoperative care providers were educated to convey clear, appropriate preoperative medication instructions. After the education period, patient surveys were again completed to assess improvement. Hospital-wide education effectively increased the percentage of medications with written, colour-coded, and medically appropriate instructions. Patients found the instructions clearer and easier to follow.

A cross-sectional study correlating lumbar spine degeneration with disability and pain.

STUDY DESIGN: Cross-sectional design. OBJECTIVES: To investigate the correlation between degeneration in the lumbar spine and self-reported disability and pain levels in patients with and without a history of trauma. SUMMARY OF BACKGROUND DATA: The link between lumbar spine degeneration and low back pain remains controversial, as does the correlation between trauma and spinal degeneration. METHODS: Radiographic and questionnaire data were collected from 172 consecutive patients with low back pain. Back pain severity was measured using two scales: one for pain over the entire episode and one for pain during the previous week. All patients also completed the Revised Oswestry Disability Questionnaire before radiography was performed. Further questions concerning the chronicity of symptoms and trauma were included. RESULTS: Controlling for age, patients with low back pain with a history of trauma had a statistically significant increase in the severity of facet degeneration (P < 0.02) compared with nontrauma patients with low back pain. However, there was no difference in disability and pain scores between the trauma and nontrauma patients or between the genders. A weak correlation between pain severity ratings and the number of levels of degeneration and the severity of the degeneration at the disc and facets was noted. CONCLUSIONS: Patients with low back pain with a history of trauma had more severe facet arthrosis than do nontrauma patients with low back pain, but there were no differences in pain and disability. There was a weak correlation between the quantity and severity of lumbar degeneration with pain levels, but not with disability scores. These findings are discussed in the light of recent reports regarding the cervical spine.

The Bournemouth Questionnaire: a short-form comprehensive outcome measure. I. Psychometric properties in back pain patients.

OBJECTIVE: Develop and test a short-form comprehensive outcome measure for back pain. DESIGN: Prospective longitudinal study of 3 consecutive cohorts of back pain patients. SETTING: Anglo-European College of Chiropractic outpatient clinic and several field chiropractic practices. METHOD: Domains judged important in the back pain model and responsive to clinical change were identified from the literature. Items were scored on an 11-point numerical rating scale. The instrument was psychometrically tested by use of those tests relevant to an evaluative measure. RESULTS: Seven dimensions of the back pain model were included in the questionnaire. Having established face validity, the instrument was shown to demonstrate high internal consistency (Cronbach's alpha = 0.9) and good test-retest reliability (ICC = 0.95). All items were retained on the basis that they contributed to the overall score (item-corrected total score correlations) and to the instrument's responsiveness to clinical change (item change-corrected total change score correlations). The instrument demonstrated acceptable construct and longitudinal construct validity with established external measures. The effect size of the instrument was high (1.29) and comparable with established measures. CONCLUSION: A reliable, valid, and responsive instrument has been developed for use in back pain patients. It is practical for use in investigations of both the efficacy and effectiveness of back pain treatments.

Responsiveness of pain scales: a comparison of three pain intensity measures in chiropractic patients.

OBJECTIVE: To compare the responsiveness of three pain scales. DESIGN: Longitudinal prospective single cohort. SETTING: Chiropractic college outpatient clinic. SUBJECTS: Seventy-nine new patients. INTERVENTION: Treatment of painful complaint by senior student interns under supervision of clinical tutors. OUTCOME MEASURES: Pain intensity using the visual analogue scale (VAS), the verbal rating scale (VRS) and the 11-point numerical rating scale (NRS). RESULTS: Mean usual levels of pain were consistently higher than those of current pain. Asking patients to report their current pain levels showed the NRS to be the most responsive of the measures (effect size = 0.86) compared with the VAS (effect size = 0.77) and the VRS (effect size = 0.76). When asking patients to report on their usual level of pain, the responsiveness of all the pain scales was enhanced (effect size = 1.34, 1.34 and 1.12 for the NRS, VAS and VRS, respectively). CONCLUSION: Given the relative ease of use and scoring of the 11-point NRS, and the obvious advantages of using responsive evaluative measures, this scale is recommended for pain intensity measurement in most types of outcome studies. Furthermore, asking patients to report their usual pain levels, rather than current levels, enhances the responsiveness of the measures and is a more representative perspective of their pain experience. The findings of this study have important implications for investigators who wish to select the most appropriate pain scale for use an outcome measure in treatment evaluative trials.

Reliability and concurrent validity of two instruments for measuring cervical range of motion: effects of age and gender.

This study set out to determine the reliability and concurrent validity of two instruments for measuring cervical range of motion and, using these instruments, to establish age and gender effects on cervical mobility. 84 asymptomatic subjects were investigated for age and gender effects on cervical range of motion using the CROM and single inclinometer. Thirty of these subjects also took part in the reliability study. Intraclass correlation coefficients (ICC) for inter- and intra-examiner reliability of the CROM were 0.88 and 0.96 (flexion/extension), 0.84 and 0.96 (lateral flexion) and 0.92 and 0.92 (rotation) respectively. Corresponding values for the inclinometer were 0.84 and 0.94; 0.82 and 0.92; and 0.81 and 0.89. Reliability of the CROM and single inclinometer was thus supported. Concurrent validity of the two instruments was supported for flexion/extension (0.80) and lateral flexion (0.79) but not for rotation (-0.18). Using both measuring devices, cervical mobility decreased with age in all planes of motion (p < 0.0001) but was not significantly affected by gender. Based on our findings, reassessment of normative values of cervical range of motion is indicated taking age, but not gender, into account.

Reliability and concurrent validity of the BROM II for measuring lumbar mobility.

OBJECTIVE: To establish the reliability of the BROM II device for measuring lumbar mobility in the sagittal, coronal and transverse planes and its validity against the double inclinometer method. DESIGN: Blind intra- and interexaminer reliability and concurrent validity. Interexaminer reliability was determined between two examiners. SETTING: Chiropractice teaching college. SUBJECTS: Forty-seven asymptomatic chiropractic students (27 men and 20 women, age range 18 to 38 yr). MAIN OUTCOME MEASURE: Lumbar mobility measurement in degrees using the BROM II and double inclinometer techniques. RESULTS: Intraclass correlation coefficients (ICC) showed good intra- and interexaminer reliability of the BROM II for flexion (0.91 and 0.77, respectively) and lateral flexion (0.91 and 0.85 respectively). Less support was given to the reliability of the instrument in extension (0.63 and 0.35, respectively) and rotation (0.57 and 0.36 respectively). Concurrent validity of the BROM II and double inclinometer methods was partially supported (ICC in all planes range from 0.27 to 0.75). CONCLUSION: The BROM II was found to be a reliable instrument in the measurement of lumbar mobility in the sagittal (flexion) and coronal planes. However, before this device can be recommended as an assessment tool in clinical practice or clinical trials, further investigation into its reliability in a symptomatic group of patients is required. (J Manipulative Physiol Ther 1995; 18:497-502).

Psychological distress and disability in back pain patients: evidence of sex differences.

Using a psychological screening questionnaire, the incidence of psychological distress in back pain patients attending a chiropractic out-patient clinic was sought. In contrast to other back pain populations, only a small proportion of the sample (7.2%) showed overt signs of psychological distress. However, a relatively large proportion of these patients (45%) were classified as at risk of developing significant psychological distress. Sex, age and clinical history appeared to have very little effect on the psychological classification of patients, although women scored significantly higher overall on the psychological questionnaires. The relationship between distress and patients' self-reported disability was also investigated and shown to be particularly sensitive to sex effects. Hence, psychological distress accounted for 1 and 32% of the total variance in disability scores in male and female patients, respectively.

Back pain distribution patterns: relationship to subjective measures of pain severity and disability.

OBJECTIVE: To investigate the relationship between subjective pain measures and clinical subgroupings as determined by pain distribution patterns in back pain patients. DESIGN: A prospective study using a computer-interview system. SETTING: The Anglo-European College of Chiropractic outpatient clinic. PATIENTS: Two hundred fourteen new patients with low back pain completed the computer back pain interview on their first or second visit to the clinic. No other inclusion criteria were applied. MAIN OUTCOME MEASURES: Computer versions of the VAS, Oswestry and St. Thomas' disability questionnaires and the pain drawing. RESULTS: Back pain patients with pain radiating below the knee (Group 3 patients) reported significantly higher levels of disability than patients with back pain alone (Group 1 patients) (p < .001) and back pain with pain referred to the buttock/thigh region (Group 2 patients) (p < .01). Similarly, Group 3 patients reported significantly higher levels of pain severity than both Group 1 (p < .01) and Group 2 (p < .05) patients. The increased level of disability reported by Group 3 patients almost exactly matched the increase in self-assessed pain severity. No differences were observed in the report of either pain severity or disability between Group 1 and Group 2 patients. CONCLUSION: Subjective pain measure scores were shown to be related to recognizable clinical subgroupings of back pain based on the distribution, but not the extent, of the patient's pain. Back pain patients with radicular pain below the knee were found to be a high disability/pain severity group compared with other groups of back pain patients. More work is needed to investigate the potential of subjective pain measures in the differential diagnosis of back pain syndromes.

Effects of an enkephalin analogue (DAMME) on pituitary and pancreatic function in sheep.

The hormonal secretory effects of intravenously and intracerebroventricularly administered DAMME have been studied in the sheep. Serum prolactin and growth hormone levels were significantly elevated after i.v. injection of DAMME (14 micrograms kg-1) while a significant and considerably more prolonged increase occurred following i.c.v. administration of 20 micrograms of the analogue. The responses to i.c.v. but not to i.v. injected DAMME were attenuated by prior i.v. injection of naloxone. Administration of DAMME i.c.v. resulted in a detectable concentration in the peripheral circulation within two minutes and maximal levels at 120-150 minutes. No significant changes occurred in circulating concentrations of the pancreatic hormones investigated although there was a trend to somatostatin and pancreatic polypeptide levels being elevated after systemic injection of the analogue.

Hormonal effects and metabolic clearance rate of the enkephalin analogue DAMME in man.

The enkephalin analogue DAMME (0.25 mg) and normal saline were administered by slow intravenous injection to six normal male subjects in a double-blind crossover study. Plasma DAMME concentrations were measured by a specific radioimmunoassay. A significant rise in plasma growth hormone and prolactin and a significant fall in plasma corticotrophin and cortisol concentrations were observed. The fall in pancreatic polypeptide concentration just failed to reach significance. No significant changes were observed in insulin, glucagon, glucose, adrenaline and noradrenaline. Serum concentrations of DAMME were initially high (greater than 6.7 nmol/1) corresponding with the observed maximum plasma growth hormone and prolactin responses. The serum DAMME concentration was readily detectable when plasma growth hormone and prolactin had returned to control levels, but corticotrophin and cortisol were still significantly depressed.

Metabolic clearance rate in sheep of a met-enkephalin analogue estimated by radioimmunoassay.

A sensitive and specific radioimmunoassay developed for measuring the met-enkephalin analogue d-ala2-met(0)5-ol-enkephalin (DAMME) was used to study the pharmacokinetics of DAMME in the circulation of sheep. Plasma concentrations of DAMME were measured at varying time-intervals after an intravenous bolus injection or following a constant intravenous infusion of the analogue. The mean metabolic clearance rate of DAMME was 2.8 ml/min per kg, the mean circulating half-life was 52 min and the mean volume of distribution was 190 ml/kg. The longer circulating time of the analogue when compared with that of naturally occurring met-enkephalin would appear to explain its prolonged analgesic effect.

Ion transport across the isolated intestinal mucosa of the winter flounder, Pseudopleuronectes americans: II. effects of cyclic AMP.

Addition of cyclic AMP and theophylline to the intestinal mucosa of the winter flounder, Pseudopleuronectes americanus decreased short-circuit current and net Na and Cl absorption and increased total conductance and the serosa-to-mucosa unidirectional Cl flux (JsmCl). The last two changes were independent of the original rate of NaCl absorption and persisted even when net absorption of Na and Cl had been abolished by ouabain. Voltage clamp experiments revealed that the increment in JsmCl produced by cyclic AMP is PD-insensitive and therefore not due to an increase in the Cl conductance of the paracellular shunt. Cyclic AMP appears, therefore, both to inhibit net NaCl absorption and to increase the Cl permeability and total conductance of the intestinal epithelial cells; its failure to stimulate secretion (in contrast to its action on mammalian intestine) may be related to the absence of crypts in flounder intestinal epithelium.

Ion transport across the isolated intestinal mucosa of the winter flounder, Pseudopleuronectes americanus. I. Functional and structural properties of cellular and paracellular pathways for Na and Cl.

The isolated intestinal mucosa of the flounder, Pseudopleuronectes americanus, when bathed in a 20 mM HCO3-Ringer's solution bubbled with 1% CO2 in O2, generated a serosa-negative PD and, when short-circuited, absorbed Cl at almost 3 times the rate of Na. Reducing HCO3 to 5 mM decreased the net Cl flux by more than 60%. The following results suggest that, despite the PD, Na and Cl transport processes are nonelectrically coupled: replacing all Na with choline abolished both the PD and net Cl flux; replacing all Cl with SO4 and mannitol abolished the PD and the net Na flux; and adding ouabain (to 0.5 mM) abolished the PD and the net Cl flux. Nearly all of the unidirectional serosa-to-mucosa Cl flux (JClsm) seemed to be paracellular since it varied with PD and Cl concentration in a manner consistent with simple diffusion. JClsm was only about one-fourth of JNasm, suggesting that the paracellular pathway is highly cation-selective. The data can be explained by the following model: (i) Na and Cl uptake across the brush border are coupled 1 : 1; Na is pumped into the lateral space and Cl follows passively, elevating the salt concentration there; (ii) the tight junction is permeable to Na but relatively impermeable to Cl; and (iii) resistance to Na diffusion is greater in the lateral space (considered in its entirety) than in the tight junction. If these assumptions are correct, the serosa-negative transmural PD is due mainly to a salt diffusion potential across the tight junction and, under short-circuit condition, most of the Na pumped into the lateral space diffuses back into the luminal solution, whereas most of the Cl enters the serosal solution. Morphological features of the epithelium support this interpretation: the cells are unusually long (60 micrometer); there is little distension of the apical 12 micrometer of the lateral space during active fluid absorption; and distension distal to this region is intermittently constricted by desmosomes.

Effects of protein synthesis inhibitors on angiotensin-stimulated and angiotensin-inhibited fluid transport by rat jejunum in vivo.

A study has been made of the effects of protein synthesis inhibitors on the responses of rat jejunum in vivo to intravenous infusions of angiotensin. Actinomycin D, an inhibitor of the transcription stage of protein synthesis, was without effect on the stimulation of fluid transport which follows the infusion of low doses of angiotensin. Cycloheximide, an inhibitor of the translation stage of protein synthesis, blocked the stimulatory response to angiotensin, but was without effect on the inhibitory response to high doses of the hormone. It is concluded that low (physiological) doses of angiotensin stimulate fluid transport by a mechanism involving protein synthesis at a stage later than transcription whereas high doses of the hormone inhibit fluid transport by a process which does not require protein synthesis.