Showing papers on "Pain assessment published in 2002"

The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment.

Abstract: Pain assessment remains difficult in children with cognitive impairment (CI). In this study, we evaluated the validity and reliability of the Face, Legs, Activity, Cry, Consolability (FLACC) tool for assessing pain in children with CI. Each child’s developmental level and ability to self-report pain were evaluated. The child’s nurse observed and scored pain with the FLACC tool before and after analgesic administration. Simultaneously, parents scored pain with a visual analog scale, and scores were obtained from children who were able to self-report pain. Observations were videotaped and later viewed by nurses blinded to analgesics and pain scores. One-hundred-forty observations were recorded from 79 children. FLACC scores correlated with parent scores (P 0.001) and decreased after analgesics (P 0.001), suggesting good validity. Correlations of total scores (r 0.5– 0.8; P 0.001) and of each category (r 0.3– 0.8; P 0.001), as well as measures of exact agreement ( 0.2– 0.65), suggest good reliability. Test-retest reliability was supported by excellent correlations (r 0.8 – 0.883; P 0.001) and categorical agreement (r 0.617– 0.935; 0.400 – 0.881; P 0.001). These data suggest that the FLACC tool may be useful as an objective measure of postoperative pain in children with CI.

Development and evaluation of the multidimensional German pain questionnaire

Abstract: The German pain questionnaire (DSF) has been developed and validated by the Task force on "Standardization and Economy in Pain Management" of the German Chapter of the International Association for the Study of Pain (DGSS). The concept of the DSF is based on a bio (medical) - psycho - social pain model. The modular approach to pain assessment consists of:demographic data,pain variables (e. g. pain sites, temporal characteristics, duration, intensity),pain associated symptoms,affective and sensory qualities of pain (adjective list by Geissner, SESCopyright ),pain relieving and intensifying factors,previous pain treatment procedures,pain-related disability (Pain Disability Index by Tait et al.),depression test CES-D (Center for Epidemiological Studies Depression Test),comorbid conditions,social factors (educational level, occupation, retirement status, compensation and/or litigation status, disability for work),health related quality of life (SF-36Copyright ). Practicability and content validity were tested in some 3000 patients. Comparison with external criteria (e. g. medical and psychiatric-psychological diagnoses, physician-determined chronicity of pain) proved good content validity and excellent reliability of patients statements in the questionnaire. The great majority of patients stated that the DSF covered their pain history completely and in an orderly fashion. Difficulty to answer the questions was considered low. The German pain questionnaire is a reliable and valid instrument for recording the multidimensional experience of pain. Data from such questionnaires are indispensable for follow-up studies and internal and external quality assessments. The DSF can be ordered from the German Society for the Study of Pain (www.dgss.org) and is a core instrument of the computer program "quality assurance in pain management" (QUAST) of this society.

Reproducibility of pain measurement and pain perception.

Abstract: The reproducibility of both the conscious experience of pain and the reproducibility of psychophysical assessments of pain remain critical, yet poorly characterized factors in pain research and treatment. To assess the reproducibility of both the pain experience and two methods of pain assessment, 15 subjects evaluated experimental heat pain during four weekly sessions. In each session, both brief (5 s) and prolonged (90 s) heat stimuli were utilized to determine effects of stimulus duration on reproducibility. Multiple presentations of the brief heat stimuli in each session were used to evaluate effects of response averaging. Both visual analog scales (VAS) and randomized verbal descriptor scales (VDS) were employed to better distinguish variations in the pain experience from variations in pain scale usage. Subjects also rated the intensity of visual stimuli in order to provide an independent assessment of the session-to-session variation in the use of both types of scales. Within-subjects analyses revealed that ratings of visual stimuli exhibited significantly less session-to-session variation than ratings of heat pain. Thus, pain perceptions were more variable than perceptions of visual stimuli after controlling for session-to-session variations in scale usage. Comparisons between scales indicated that intensity ratings acquired with the VAS had significantly smaller session-to-session variation than those acquired with the VDS, although VDS ratings were spread across a larger range of the scale. For both scales, analyses of the effects of stimulus averaging and stimulus duration revealed that averaging multiple assessments of the same stimulus substantially reduces session-to-session variation and that multiple assessments of brief stimuli produce responses which are more reproducible than a single presentation of a prolonged stimulus. However, the VAS was significantly more sensitive to small differences in perceived pain intensity and pain unpleasantness, and did not exhibit some of the order effects present with the VDS. Taken together, these results indicate that the reproducibility of psychophysical ratings of pain can be maximized: (1) by averaging responses to multiple, brief stimuli; (2) by providing subjects with a training period distinct from the study period; and (3) by ensuring that interpretation of scale parameters remains constant over time. Thus, although the experiences of both experimental and clinical pain are highly variable, pain assessment procedures can be structured to minimize session-to-session variability.

Buprenorphine: a reappraisal of its antinociceptive effects and therapeutic use in alleviating post-operative pain in animals

Abstract: Buprenorphine has been widely used for post-operative analgesia in laboratory animals. Clinical efficacy has been demonstrated in both subjective and objective pain assessment schemes, however doubts have been expressed as to its value as an analgesic. Initial dosage recommendations were based on analgesiometric studies. It is unlikely, however, that the pain elicited in analgesiometric tests is comparable to post-operative pain. This has resulted in recommendations of excessive dose rates and inappropriate clinical indications. Studies involving tests of the efficacy of buprenorphine for alleviating behavioural or other signs of tonic (post-surgical) pain provide a more appropriate estimation of the analgesic capabilities of the drug. However, buprenorphine also has major effects upon the behaviour of normal (unoperated) animals, and this makes assessments of efficacy difficult with some of the systems used for scoring clinical pain. Nevertheless, our most recent studies of the effects of buprenorphine upon pain-related behaviours in rats support the view that it is an effective post-operative analgesic. This short review critically reappraises the role of buprenorphine in this capacity and discusses a rational approach to the relief of pain in laboratory animals. We conclude that buprenorphine remains a valuable agent for pain relief in a wide range of animal species when used in an appropriate manner.

Observation of pain assessment and management − the complexities of clinical practice

Abstract: Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. This observational study sought to investigate nurse-patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings. Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions. Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients. These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.

Recognizing and assessing pain, suffering and distress in laboratory animals: a survey of current practice in the UK with recommendations.

Abstract: A survey was undertaken to evaluate how animal pain, suffering and distress are recognized and assessed in UK scientific procedure establishments designated under the Animals (Scientific Procedures) Act 1986. A total of 28 institutions were visited between June 1999 and April 2001, within which 137 people were interviewed including scientists, veterinarians and animal technicians. All 28 establishments use clinical observation sheets to assist the recognition of adverse effects, nine use score sheets and seven use computerized data management systems. Clinical signs used as indicators of potential pain, suffering or distress are largely subjective. The survey also addressed protocols and methods for avoiding and alleviating adverse effects, record keeping, review of policies and protocols and issues relating to team work and training. Respondents use a range of techniques for reducing suffering including analgesia, humane endpoints, ensuring competence and refining husbandry. All establishments review projects regularly but few have the time or resources formally to review adverse effects noted in practice and to compare observations with predictions made in licence applications. Training is very consistent between different establishments and most aim to achieve a 'team approach' for monitoring and assessing animals. Results are summarized in the present, abridged paper and set out in full in a report that can be downloaded at http://www.lal.org.uk/pain/(Hawkins 2002). The present paper and the full report, including its recommendations, are intended to provide a source of information, discussion topics and ideas for all establishments that need to monitor animal well-being.

Postsurgical pain outcome assessment

Abstract: Reliable and valid measures of pain are essential for conducting clinical trials of pain treatments. Perhaps the most important aspect of a pain measure's validity is its sensitivity, or ability to detect changes in pain over time and due to treatment. Several factors may affect a measure's sensitivity, including the complexity of the rating task for the measure, the number of pain intensity levels assessed by the measure, the dimension of pain assessed (e.g. pain intensity vs. pain relief), and the number of individual ratings (e.g. single rating vs. composite score) used to create the measure. The purpose of this study was to compare the relative sensitivity of three measures of outcome and a composite made up of all three measures for detecting analgesic effects in two samples of persons participating in a randomized controlled trial. One hundred and twenty-three patients who had undergone knee surgery and 124 women who had undergone a laparotomy were given one of three medications in the day after their surgery: morphine, ketorolac, or placebo. Two measures of pain intensity (a visual analog scale (VAS) and a 4-point verbal rating scale (VRS)) were administered at baseline, and these measures plus a 5-point VRS of pain relief were administered at 16 additional time points up to 24 h following surgery. As predicted, we found variability in the sensitivity of the outcome measures used in these studies, with the 4-point VRS showing less sensitivity than the VAS or relief ratings. However, contrary to our prediction, a composite measure of outcome made up of all three measures was not consistently superior to the individual measures for detecting treatment effects. Finally, we found that pain relief ratings were related to, but also distinct from, change in pain intensity as measured by changes in pain intensity ratings from baseline to each postmedication assessment point. These findings have important implications for the assessment of pain in clinical trials.

Multimodal assessment of pain in the esophagus: a new experimental model.

Abstract: A new multimodal pain assessment model was developed integrating electrical, mechanical, cold, and warmth stimuli into the same device. The device, with a bag and electrodes for electrical stimulat...

Treatment of Pain in Acutely Burned Children

Abstract: The child with burns suffers severe pain at the time of the burn and during subsequent treatment and rehabilitation. Pain has adverse physiological and emotional effects, and research suggests that pain management is an important factor in better outcomes. There is increasing understanding of the private experience of pain, and how children benefit from honest preparation for procedures. Developmentally appropriate and culturally sensitive pain assessment, pain relief, and reevaluation have improved, becoming essential in treatment. Pharmacological treatment is primary, strengthened by new concepts from neurobiology, clinical science, and the introduction of more effective drugs with fewer adverse side effects and less toxicity. Empirical evaluation of various hypnotic, cognitive, behavioral, and sensory treatment methods is advancing. Multidisciplinary assessment helps to integrate psychological and pharmacological pain-relieving interventions to reduce emotional and mental stress, and family stress as well. Optimal care encourages burn teams to integrate pain guidelines into protocols and critical pathways for improved care.

Pain Assessment and Management in Cognitively Impaired Nursing Home Residents: Association of Certified Nursing Assistant Pain Report, Minimum Data Set Pain Report, and Analgesic Medication Use

Abstract: OBJECTIVES: The primary purpose of this preliminary study was to investigate the associations between certified nursing assistant (CNA) report of pain, Minimum Data Set (MDS) report of pain, and analgesic medication use in cognitively impaired nursing home residents. DESIGN: Correlational study. SETTING: Three nursing homes in the greater Birmingham, Alabama area. PARTICIPANTS: Fifty-seven cognitively impaired nursing home residents with a mean Mini-Mental State Examination (MMSE) score of 11.1. MEASUREMENTS: Pain was assessed using a three-item proxy pain questionnaire (PPQ), developed by the researchers and administered to the residents' primary CNA. MDS and analgesic medication data corresponding with the time of PPQ data collection were gathered from medical records. Cognitive status was measured with the MMSE. RESULTS: The PPQ elicited substantially higher estimates of pain prevalence than the MDS (48% versus 20%), and the PPQ and the MDS were not well correlated (pain frequency: r = .19, P = .18; pain intensity: r = .22, P = .11). The PPQ was also more strongly associated with analgesic medication use than the MDS. Cognitive status was significantly associated with pain report on the PPQ but not on the MDS. Test-retest reliability coefficients for the three items of the PPQ were excellent, ranging from .84 to .87 (P≤ .01). CONCLUSIONS: The CNA-generated PPQ was a more sensitive measure of pain than the MDS for this sample. Although the MDS represents an important step toward systematic and standardized assessment of pain, more emphasis should be placed on multimodal assessment, including CNAs' perceptions and observations about pain experienced by cognitively impaired nursing home residents.

Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream.

Abstract: Our knowledge of pain in neonates has increased significantly during the last fifteen years.We now have an improved understanding of the pain system and of the negative effects of untreated pain. Advances in neonatal care have increased the nwnber of preterm and severely ill infants who are treated in neonatal intensive care units (NICU). These infants are subjected to a variety of painful procedures as part of their management. Sufficient pain relief is needed and for this, valid pain assessment is one prerequisite.The aim of this research was to improve the management of procedural pain and to examine the assessment of neonatal pain in clinical practice.In an earlier study, oral glucose was found to reduce pain during blood sampling. To further evaluate the pain-reducing effect of oral glucose and to compare this effect with different blood sampling techniques, a trial was performed. The pain score was lower and crying time shorter in the venipuncture group than in the heel stick group when no glucose was given. When glucose was administered, the pain score was lower in both glucose groups than in the groups not receiving glucose (paper I).In a randomized, controlled study, the effect of oral glucose was compared with that of a topical local anaesthetic, EMLA, during venipuncture. The pain scores were found to be lower in the glucose group and fewer infants were scored as having pain. Crying time was also shorter in the glucose group (paper II).To compare the pain-reducing effect of oral glucose with that of breast-feeding shortly before venipuncture, a new trial was performed. The pain score was significantly lower in the infants receiving glucose than in those not given glucose. There was no significant difference in pain score between the infants who were fed and the fasting infants (paper III).In a previous study we found an increase in heart rate in newboms when they received glucose as pain relief. We therefore investigated whether oral glucose in itself could cause an increase in heart rate in healthy infants. In a trial, infants were randomized to receive oral glucose or placebo without undergoing any painful procedure. The heart rate was significantly higher in the glucose than in the placebo group (paper IV).Activation of endogenous opioids is suggested as one possible mechanism underlying the pain-reducing effect of oral glucose. We therefore investigated whether administration of an opioid antagonist would reduce the effect of oral glucose at heel stick in full-term newboms. There were no significant differences in pain score or crying between the group receiving an opioid antagonist before oral glucose and the group receiving placebo before oral glucose during heel stick (paper V).To document whether pain is assessed in Swedish neonatal units and by what methods, a questionnaire was distributed to all neonatal wards in Sweden in 1993, and again in 1998. Only a small proportion of neonatal units in Sweden attempted to assess pain. There was a minor increase in the nwnber of wards that used a structured method for pain scoring. Docwnentation of pain is still inadequate and needs to be improved (paper VI). We compared parental assessment during blood sampling with measurement of the pain score with a multidimensional tool and crying. There was low agreement between these variables during the procedure (paper III).In conclusion, we found that oral glucose reduces signs of pain from both heel stick and venipuncture blood sampling. Oral glucose reduces pain better than does EMLA cream and better than if the infant is breast-fed shortly before the procedure. Oral glucose increases the heart rate in infants and the pain-reducing effect of oral glucose in newboms was not diminished by injection of an opioid antagonist. Parental assessment of an infant's pain cannot replace measurement by pain scores. The pain assessment at neonatal units in Sweden needs to be improved.

Long-term pain conditions after a stroke.

Abstract: The aim of this study was to classify and describe the characteristics of different long-term pain conditions after a stroke by clinical examination and pain assessment using the Pain-O-Meter and a Pain questionnaire. Pain was classified as central post-stroke pain (n = 15), nociceptive pain (n = 18), and tension-type headache (n = 10). In 65%, pain onset was within 1-6 months and the pain intensity revealed individual differences. Many pain descriptors was common, some were discriminating as burning in central and cramping in nociceptive pain, and pressing and worrying in headache. More than half with central or nociceptive pain had continuous or almost continuous pain. Cold was the factor mostly increasing the pain in central, physical movements in nociceptive pain, and stress and anxiety in headache. More than one-third had no pain treatment and two-thirds of those with central pain had no or inadequate prescribed pain treatment. The clinical findings support the classification of pain and describe discriminating and common pain characteristics in pain conditions after a stroke.

Validation of the Pain Assessment in Neonates (PAIN) scale with the Neonatal Infant Pain Scale (NIPS).

Abstract: Purpose To establish the validity and clinical usefulness of a modified pain assessment scale, the Pain Assessment in Neonates (PAIN) scale. Design Correlational design to compare scores obtained on the PAIN with scores obtained on the Neonatal Infant Pain Scale (NIPS). Sample A convenience sample of 196 neonates from an NICU and a step-down unit with gestational ages of 26 to 47 weeks. Method Bedside nurses observed the neonates for two minutes and then scored their responses on both scales. The scales were scored sequentially and in a randomized order. Main outcome variable Correlation of individual item scores and total scores on the PAIN and the NIPS. Results The scores for individual items on the PAIN were significantly associated with scores obtained on the NIPS. Overall correlation between the scales was 0.93. These associations suggest that the PAIN is a valid scale for assessment of neonatal pain.

Nursing documentation of postoperative pain management.

Abstract: Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware.

Attitudinal barriers to effective treatment of persistent pain in nursing home residents.

Abstract: OBJECTIVES: To systematically explore nursing home (NH) resident and staff attitudes that serve as barriers to detection and management of persistent pain. DESIGN: Survey. SETTING: Six community-based and one Veterans Affairs long-term care facility PARTICIPANTS: Seventy-five NH nurses, 75 certified nursing assistants (CNAs), and 75 communicative NH residents who reported some pain or discomfort “every day or almost every day.” MEASUREMENTS: Three structured pain attitudes questionnaires (one each for NH residents, CNAs, and nurses) that incorporated constructs gleaned from a comprehensive literature review were designed. One-week test-retest reliability was calculated on a subsample of 25 residents, 19 CNAs, and 26 nurses. Attitudinal differences between the three groups were evaluated using multivariate analysis of variance (MANOVA). RESULTS: Of 12 constructs evaluated, 10 had fair to excellent reliability indices (residents 0.46–0.80; CNAs 0.57–0.76; nurses 0.62–0.94). Of these 10 reliable constructs, MANOVA indicated significant overall attitude differences between the three groups. Follow-up analyses indicated that attitudes endorsed most strongly by residents were that chronic pain does not change, belief in external pathology over pain reports, fear of addiction, and fear of dependence. CNAs attitudes endorsed most strongly were lack of time and complaints unheard. The nurse attitude endorsed most strongly was complaints unheard. CONCLUSIONS: These findings suggest that, if residents' fears regarding addiction, worsening dependence, and the immutable nature of persistent pain were quelled, and if CNAs could feel that adequate time is available for pain assessment, perhaps improved pain management in the NH would result.

Using quality improvement strategies to enhance pediatric pain assessment

Abstract: Objective. To evaluate the impact of a quality improvement approach to implementing developmentally appropriate pain assessment guidelines for pediatric inpatients. Patient and staff satisfaction with pain assessment and management, and staff documentation were evaluated one year following the implementation of the revised pain assessment guidelines. Design. Quasi-experimental design. Setting. The pediatric hematology/oncology unit of a regional children’s hospital. Study participants. A convenience sample of 36 children and 68 staff at time 1 (T1) and 49 children and 82 staff at time 2 (T2). Interventions. Staff were educated on the use of pediatric pain assessment tools and a standardized pain assessment protocol was put into practice. Children or their primary caregivers were interviewed, using a questionnaire modified from the American Pain Society quality assurance guidelines, regarding their experiences with pain assessment and management on the unit at T1, just prior to the staff education, and one year later at T2. Multidisciplinary unit staff completed a parallel questionnaire at T1 and T2. Main outcome measures. Patient and staff satisfaction with pain assessment and management, and chart audit of compliance with pain assessment documentation. Results. Patients, family members, and staff reported increased pain assessment, improved staff responsiveness to patients’ pain and greater satisfaction with assessment tools between T1 and T2. Increased compliance with the assessment guidelines was confirmed by chart audit. Conclusions. Improved pain assessment and management practices with resultant increase in patient and staff satisfaction can be achieved and sustained over time using quality improvement strategies.

Pain in cognitively impaired nursing home residents: how well are physicians diagnosing it?

Abstract: OBJECTIVES: This study examined the reliability and validity of geriatricians' assessments of pain in cognitively impaired nursing home residents. DESIGN: Cross-sectional analysis. SETTING: A large suburban nursing home. PARTICIPANTS: Seventy-nine nursing home residents participated in the study. Of these, 31 had mild/moderate cognitive impairment (average Mini-Mental State Examination (MMSE) = 16.04) and 48 were severely cognitively impaired (average MMSE = 1.91). More than 80% of the participants were female, and the average age was 87. MEASUREMENTS: Two geriatricians from outside the nursing home examined laboratory results, performed a physical examination, and completed a detailed assessment of pain. The personal geriatricians of 42 of the participants also completed the same assessment. RESULTS: Intergeriatrician agreement rates were statistically significant and moderate in magnitude. When examined by subgroup, the correlations were significant only for those with mild/moderate impairment. Some of the geriatricians' ratings of pain correlated significantly with residents' self-reports. All relationships were weaker in the severely cognitively impaired group. Ratings of greater pain were significantly correlated with higher cognitive functioning. CONCLUSIONS: The results validate geriatricians' evaluations of pain during a medical examination for moderately impaired persons and question their ability to evaluate pain in the severely cognitively impaired. There is a need for increased awareness of pain in this population and a need for improved methodologies to identify it.

Management of pain in older people within the nursing home: a preliminary study.

Abstract: The provision of continuing care for older people has largely shifted from the hospital setting to the community, and nursing homes increasingly provide support for older people, many of whom exhibit multiple pathology and complex health and social care needs. However, the quality of pain management within this setting has been identified as an issue of concern. It has been estimated that approximately two-thirds of people aged 65 years and over experience chronic pain, and that the prevalence of chronic pain in nursing home residents is between 45% and 80%. However, there exist a number of barriers to the identification and management of chronic pain among older people resident in nursing homes, including sensory impairments in older people themselves and educational deficits among professionals. Such barriers need to be overcome if pain management is to be improved. The present study involved administering a pre-piloted postal questionnaire to the managers of 121 nursing homes within a geographically defined area. Sixty-eight (56%) were completed and returned. The questionnaire broadly covered the following: prevalence of chronic pain and use of interventions; assessment and management strategies; education and training; and communication barriers. Overall, 37% of nursing home residents were identified as experiencing chronic non-malignant pain (pain lasting longer than 3 months not caused by cancer) and 2% were reported as experiencing chronic malignant pain (pain lasting for more than 3 months caused by cancer). Paracetamol was identified as the most 'often' used analgesia for both pain modalities. Sixty-nine per cent of nursing homes did not have a written policy regarding pain management and 75% did not use a standardised pain assessment tool. Forty-four per cent of nursing homes provided education or training sessions for qualified staff and 34% provided this for care assistants. Forty per cent of qualified staff and 85% of care assistants had no specialist knowledge regarding the management of pain in older people. The present study confirms the need for the development of effective pain management strategies underpinned by appropriate training and education in order to meet the particular needs of older people.

Assessment of clinically significant changes in acute Pain in children

Abstract: Objective: To quantify, using two pain assessment scales, the amount of change in pain severity required to achieve a clinically significant improvement in pain in children presenting to a pediatric emergency department (ED) with pain. Methods: Prospective, descriptive study involving all children presenting to a pediatric ED between 5 and 16 years of age inclusive with acute pain. Children were excluded if they 1) were intoxicated or had altered sensorium, 2) were clinically unstable, 3) were non-English-speaking, or 4) were developmentally delayed. Written informed consent was obtained. Children were asked to mark their current pain severity on the standardized Color Analogue Scale (CAS) and Faces Pain Scale (FPS). After each pain control intervention the child was asked to repeat these measurements and to describe whether his or her pain was “much less,”“a little less,”“about the same,”“a little worse,” or “much worse” compared with before. This process was repeated until the child was discharged from the ED or had a score of zero. The main outcome measure was the smallest change on the CAS or FPS necessary to cause the child to describe his or her pain as a “little less.” This was defined as the clinically significant change in pain. The “ideal” change in pain was defined as the amount of change necessary for the child to describe the pain as “much less” or at which point the child thought he or she no longer required any medicine to help the pain go away. Results: One hundred twenty-one children were enrolled with a mean age of 9.8 years (SD ± 3.15). Males accounted for 56%. Pain was traumatic in 65% and nontraumatic in 35%. A total of 153 pain comparisons were made using the CAS and 154 using the FPS. Only three children complained that their pain got worse (two a little worse and one much worse). Pain was described as “the same” in 20. Of the 60 pain comparisons judged to be a “little less,” the CAS score changed by a median of 2.0 cm [interquartile ratio (IQR) 1-3], and the FPS by 1.0 face (IQR 1-2). In the 71 children who judged their pain to be “much less,” the CAS decreased by a median of 4.0 cm (IQR 2-5) and the FPS by 2.0 faces (IQR 2-3). Conclusions: The assessment and treatment of pain in children are an important component of pediatric practice, especially in the ED. This study provides health care professionals and clinical investigators the information necessary to assess whether their method of pain control in children is clinically relevant.

A prospective evaluation of patients undergoing surgery for the palliation of an advanced malignancy.

Abstract: Decisions regarding the use of surgical procedures for the palliation of symptoms caused by advanced malignancies require the highest level of surgical judgment. Prospective analysis of palliative surgical care may facilitate a more effective and representative evaluation of these patients. Patients requiring surgery planned solely for the palliation of an advanced malignancy were offered entry onto this study. Outcome measurements were made before surgery and monthly thereafter until the patient’s death. Accepted techniques of pain assessment, quality of life, and functional status were used. Between May 1997 and December 1999, 26 patients were enrolled. Although 46% (12 of 26) of patients demonstrated improvement in pain control or quality of life after palliative surgery, these benefits lasted a median of only 3.4 months. Palliative surgery was associated with significant postoperative complications in 35% (9 of 26) patients. Although many patients had no apparent demonstrable benefit from surgery, surgeons were able to identify a group of patients who experienced significant benefits after a palliative procedure. The relationships between the patient and family members and the surgeon play an important role in decision-making throughout the palliative phase of cancer treatment.

Severity of HIV-associated neuropathy is associated with plasma HIV-1 RNA levels

Abstract: Objective: To determine if there is an association between plasma HIV-1 RNA levels and severity of HIV-associated distal symmetrical polyneuropathy (DSP). Design: Substudy of AIDS Clinical Trials Group Protocol 291, a double-blind, placebo-controlled study of recombinant human nerve growth factor for the treatment of painful DSP. Methods: Two-hundred and thirty-six subjects had plasma HIV-1 RNA load assayed at baseline. Mean and maximum neuropathic pain was assessed once daily by the Gracely Pain Scale. Other measures included subjects' global pain assessment and quantitative sensory tests (QST). These values were correlated with baseline HIV-1 RNA levels. Results: Among 168 subjects with detectable plasma HIV-1 RNA, there was a significant correlation between plasma HIV-1 RNA and the severity of maximum and global pain, and toe cooling thresholds. Maximum and global pain assessment correlated with plasma HIV-1 RNA in individuals with detectable viral load (r, 0.162 and 0.194; P= 0.04 and 0.01, respectively). Conclusions: There is an association between plasma HIV-1 RNA levels and the severity of pain and QST results in HIV-associated DSP. Further studies are needed to determine if aggressive use of antiretroviral drugs, including the use of dideoxynucleosides, may be of benefit to prevent or improve peripheral neuropathy.