Pain management at home. Struggle, comfort, and mission.

This article presents findings from an exploratory, descriptive study that investigated the experiences of pain in the home from the perspective of the patient, the primary family caregiver, and the home care nurse. The following research questions are addressed: What are the special problems associated with pain management at home as identified by patients, caregivers, and nurses? What are the similarities and differences among patients, caregivers, and nurses regarding issues of managing pain at home? Qualitative techniques were used to collect and analyze data. The sample included 10 cancer patients with pain and their respective caregivers and nurses. After the in-depth interviews were transcribed, a multidisciplinary research team performed content analysis on the data. Overall, the findings suggest that patients approach pain management with a struggle for control, whereas self-denying caregivers seek to provide comfort, and nurses attempt to fulfill an urgent mission to eradicate pain.

A technical analysis of an intraoperative radiation detection probe.

A technical evaluation was made of a commercial intraoperative radiation probe. This device utilizes a CsI (T1) scintillation detector and light pipe arrangement to count gamma radiation in vivo. After determining the optimal window and threshold setting, additional evaluations included linearity, distance response function, detector dead time, counter reproducibility, detector sensitivity, angular resolution, and energy resolution. Detector dead time (21.2 microseconds) was found to be characteristic of a nonparalysable system. Activity response for each radionuclide was linear (R = 0.99) both with and without collimation. Energy resolution, 25% at 210 keV, was not sufficient to separate the two photons (172 and 247 keV) emitted by 111In. Detector sensitivity was 1136 and 626 counts per s per microcurie of 111In and 99mTc, respectively. The mean effective distance from the face of the uncollimated probe to the crystal was determined to be 2.03 cm in air.

Intraoperative gamma detection probe with presurgical antibody imaging in colon cancer.

In this study, presurgical gamma camera imaging and an intraoperative gamma detection probe were used in 12 consecutive patients 6 to 22 days after infusion with indium 111-labeled anticarcinoembryonic antigen monoclonal antibody (111In-MoAb). In three of 11 patients who underwent laparotomy, clinical management was affected by the probe findings: localization of occult retroperitoneal disease, identification of an occult cecal lesion, and localization of residual disease at a site of local recurrence. Of all intra-abdominal lesions seen using any method, the probe identified 18 (86%) of 21, compared with 14 (67%) of 21 with the 111In-MoAb scan, 10 (48%) of 21 by computed tomographic scan, and 16 (76%) of 21 after surgical exploration. Uptake of 111In-MoAb in the portal (n = 3) and mediastinal (n = 3) lymph nodes was not associated with histologic findings of malignant neoplasms. For all pathologically confirmed extrahepatic and nonportal sites of cancer, the probe localized nine of nine, compared with five of nine by 111In-MoAb scan, two of nine by computed tomographic scan, and six of nine by surgical exploration. Important clinical uses of the intraoperative probe included occult lesion identification, localization of areas with 111In uptake shown with MoAb scanning, and verification of complete resection of areas with 111In-MoAb uptake.

Comparison of immunoscintigraphy and computerized tomography in identifying colorectal cancer: individual lesion analysis.

Monoclonal antibody scintigraphy with 111In-ZCE025 was used in presurgical staging of 45 patients prior to abdominal exploration for primary, recurrent or metastatic colorectal carcinoma. A total of 186 lesions were identified, of which 147 were evaluated by abdominal surgery and pathology. Sensitivity was 40.5% (49 of 121) for immunoscintigraphy (IS), 61.2% (74 of 121) for computerized tomography (CT), and 72.7% (88 of 121) for IS and CT combined. The positive predictive value was 83.1% (49 of 59) for IS and 88.1% (74 of 84) for CT. Sensitivity of IS was 100% (23 of 23) for primary tumors, 17.7% (11 of 62) for hepatic metastases, and 41.7% (15 of 36) for extrahepatic abdominal metastases. Of the 50 hepatic lesions evaluated by single-proton emission computerized tomography, 11 were localized by IS. Only one was visualized by planar scintigraphy. Sensitivity of CT was 87% (20 of 23) for primary tumors, 67.7% (42 of 62) for hepatic metastases, and 33.3% (12 of 36) for extrahepatic abdominal metastases. Sensitivity of IS combined with CT was 72.6% (45 of 62) for hepatic and 55.6% (20 of 36) for extrahepatic abdominal metastases. Of 24 malignant lesions measured by the pathologist to be less than 3.0 cm (maximum dimension), 7 (29.2%) were detected by IS and 3 (12.5%) by CT. Of 28 malignant lesions greater than 3.0 cm, 23 (82.1%) were detected by IS and 24 (85.7%) by CT. Overall, IS and CT complemented each other in presurgical staging of colorectal carcinoma. IS was of greater value for identification of extrahepatic and small metastases. CT was more effective for identification of hepatic metastases.

Replication of the compartment syndrome in a canine model: experimental evaluation of treatment.

The sequence of acute ischemia, reperfusion, and elevated tissue pressure, with subsequent neuromuscular damage, results in the clinical entity known as the compartment syndrome. We have developed a canine hindlimb model that successfully replicates these clinical features. Surgical devascularization of both hindlimbs at the popliteal level isolates perfusion to a single vascular pedicle. Total ischemia is produced in the left limb for 8 h, while the right limb serves as a surgical control. Ischemia is confirmed by measurement of transfascial oxygen tension (TF-PO2) as well as lactate and blood gases in the venous effluent. Pressure in the anterior compartment of the hindlimb is monitored by the slit catheter technique. After reperfusion, muscle damage is assessed by histology, creatine phosphokinase (CPK), and uptake of technetium-99m pyrophosphate (Tc-PyP), expressed as a ratio of the experimental (L) limb to the control (R) limb (L/R ratio). Muscle necrosis was greatest in untreated controls; the L/R ratio was 8.9 +/- 5.0. Significant diminution of muscle necrosis was achieved by fasciotomy prior to reperfusion (2.6 +/- 0.8), mannitol (1.8 +/- 0.6), albumin-conjugated superoxide dismutase (SOD) 2.8 +/- 0.8), native SOD (2.3 +/- 1.0), fasciotomy combined with SOD (1.9 +/- 0.7), and continuous heparin (1.6 +/- 0.4) (p less than .01 vs controls). When fasciotomy was delayed until 2 h after reperfusion, there was no significant decrease in the L/R ratio (5.4 +/- 1.5; p = .15). Early fasciotomy following prolonged severe limb ischemia remains the treatment of choice, although these results suggest an emerging role for nonsurgical therapies as well. A summary of work done with this model as well as a review of other techniques is presented, along with a discussion of the pathophysiology of the compartment syndrome.