Patient empowerment and feedback did not decrease pain in seriously ill hospitalized adults

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources. Patients' pain was determined from hospital interviews with patients and surrogates. Pain 2 and 6 months later or after death and satisfaction with its control at all time periods were also assessed. All analyses were adjusted for baseline risk of being in pain and propensity to be in the intervention group. Overall, 50.9% of patients reported some pain. After adjustment for other variables associated with pain, comparing the intervention to the control group, there was not a statistically significant difference in level of pain (OR for higher levels of pain 1.15; CI 1.00-1.32) or satisfaction with control of pain during the hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2 or 6 months after discharge, or during the last 3 days of life. A multifaceted intervention using information, empowerment, advocacy, counseling and feedback was ineffective in ameliorating pain in seriously ill patients. Control of pain in these patients remains an important problem. More intensive pain treatment strategies addressing the needs of seriously ill hospitalized adults must be evaluated.     

Outcomes of acute exacerbation of severe congestive heart failure: quality of life, resource use, and survival. SUPPORT Investigators. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments

BACKGROUND: Congestive heart failure (CHF) is a common disease with high health care costs and high mortality rates. Knowledge of the health-related quality of life outcomes of CHF may guide decision making and be useful in assessing new therapies for this population. METHODS: A prospective cohort study was conducted involving 1390 adult patients hospitalized with an acute exacerbation of severe CHF (New York Heart Association class III-IV). Demographic data and health-related quality of life were determined by interview; physiologic status and cost and intensity of care were determined from hospital charts. RESULTS: The median (25th, 75th percentiles) age of patients was 68.0 (58.2, 76.9) years; 61.7% were male. Survival was 93.4% at discharge from the index hospitalization, 72.9% at 180 days, and 61.5% at 1 year. Of patients interviewed at 180 days, the median health rating on a scale of 0 to 100 (0 indicates death; 100, excellent health) was 60 (interquartile range, 50-80), and 59.7% were independent in their activities of daily living. Overall quality of life was reported to be good, very good, or excellent in 58.2% at 180 days. Patients with worse functional capacity were more likely to die. Health perceptions among the patients with available interview data improved at 60 and 180 days after acute exacerbation of severe CHF. CONCLUSIONS: Patients hospitalized for acute exacerbation of severe CHF have a generally poor 6-month survival, but survivors retain relatively good functional status and have good health perceptions. Furthermore, health perceptions improve after the acute exacerbation.     

Religious coping and health status in medically ill hospitalized older adults

Associations between specific religious coping (RC) behaviors and health status in medically ill hospitalized older patients were examined and compared with associations between nonreligious coping (NRC) behaviors and health status. The sample consisted of 577 patients age 55 or over consecutively admitted to the general medical inpatient services of Duke University Medical Center (78%) or the Durham VA Medical Center (22%). Information was gathered on 21 types of RC, 11 types of NRC, and 3 global indicators of religious activity (GIRA). Health measures included multiple domains of physical health, depressive symptoms, quality of life, stress-related growth, cooperativeness, and spiritual growth. Demographic factors, education, and admitting hospital were control variables. "Negative" and "positive" types of religious coping were identified. Negative RC behaviors related to poorer physical health, worse quality of life, and greater depression were reappraisals of God as punishing, reappraisals involving demonic forces, pleading for direct intercession, and expression of spiritual discontent. Coping that was self-directed (excluding God's help) or involved expressions reflecting negative attitudes toward God, clergy, or church members were also related to greater depression and poorer quality of life. Positive RC behaviors related to better mental health were reappraisal of God as benevolent, collaboration with God, seeking a connection with God, seeking support from clergy/church members, and giving religious help to others. Of 21 RC behaviors, 16 were positively related to stress-related growth, 15 were related to greater cooperativeness, and 16 were related to greater spiritual growth. These relationships were both more frequent and stronger than those found for NRC behaviors. Certain types of RC are more strongly related to better health status than other RC types. Associations between RC behaviors and mental health status are at least as strong, if not stronger, than those observed with NRC behaviors.     

Psychological differences among groups of critically ill hospitalized patients, noncritically ill hospitalized patients, and well controls.

Examined differences on 9 psychological measures among groups of 25 critically ill hospitalized patients, 25 noncritically ill hospitalized patients, and 25 normal well controls. The instruments used were the Purpose in Life Test, the Fundamental Interpersonal Relations Orientation-Behavior test, and 2 listening measures on which eye-blink rates were recorded. 4 multivariate discriminate function analyses were performed to determine those variables that discriminated groups of Ss. The critically ill group expressed (a) more "purpose in life," (b) an increased need for affection and inclusion, (c) a decreased "wanted control" from others, and (d) an increased rate of eye blinks in response to disease-related material. The critically ill group appeared to be psychologically unique, since there was little difference between the results of the other 2 S groups. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The seriously ill or dying analyst and the limits of neutrality.

Discusses a major dilemma that confronts the analyst who suffers from a prolonged or terminal illness. How much factual information should be revealed to patients concerning the illness and the prognosis? The impact of the illness on communications with the patient (e.g., how appointments are canceled) is explored. Discussion focuses on accounts by 4 analysts who suffered serious illnesses and wrote about their experiences. Transference and countertransference issues are considered, followed by relevant references to neutrality—its uses and abuses—when serious illness strikes. It is argued that the analyst cannot hide behind the concept of neutrality to avoid facing the demands of unusual situations in the analytic experience. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depression and physical disability outcomes in depressed medically ill hospitalized older adults

The authors examined depression/disability outcomes in hospitalized older medical patients during the year after hospital discharge to assess the pattern and rate of changing depression and disability, the causal relationship between these variables, and to identify patients at greatest risk for poor outcomes. A group of 119 medical patients at Duke Hospital were both depressed and disabled; they were followed for a median of 47 weeks after hospital discharge. Time-series analyses showed that depression and disability tended to track together, and most changes occurred within the first 6 months after discharge. Blacks were more likely to remit from depression despite continued disability and less likely to experience continued depression despite decreased disability. Patients with a history of depression were less likely to experience improvement in depression unless disability improved. Number of medical diagnoses and depression severity independently predicted poorer depression outcomes. Certain characteristics of patients during hospitalization predict depression/disability outcomes after discharge.     

Longitudinal assessment of inpatient use and functioning of seriously mentally ill veterans with and without co-occurring substance use disorders

Within a fungal species, a subset of individuals may have more than the minimal complement of chromosomes. If the extra chromosomes are composed primarily of DNA not found in all representatives of the species, they are most appropriately referred to as supernumerary chromosomes. The patterns of repeated DNA sequences on certain supernumerary chromosomes suggest that they have a different evolutionary history from the essential chromosomes in the same genome. Supernumerary chromosomes can carry functional genes and, in at least two fungal species, genes on such chromosomes play important roles in host-pathogen interactions. Supernumerary chromosomes that confer an adaptive advantage in certain habitats, such as the ability to cause disease on a specific host, may be referred to as "conditionally dispensable" chromosomes in order to reflect their importance in some, but not all, growth conditions. In addition to describing the structural and functional characteristics of known supernumerary chromosomes in fungi, this review discusses the relative merits of the terms that have been used to describe them, and establishes experimental criteria for their identification.     

The relationship between victimization and cognitive schemata among episodically homeless, seriously mentally ill women

This study explored the extent to which specific aspects of violent victimization are associated with cognitive schemata in the context of ongoing, often lifelong, trauma and negative life events. Specifically, we examined the relationships between cognitive schemata (safety, self- and other esteem, intimacy, and trust) and three dimensions of physical and sexual assault histories (recentness, frequency, and variety) among 91 predominantly African American, episodically homeless, seriously mentally ill women. Findings indicated that even in the context of pervasive violence, more frequent, recent, and varied abuse was associated with more negative cognitive schemata. We discuss these findings in the context of research and practice with disenfranchised populations at high risk for violent victimization.     

Burden of self-care in seriously ill patients: Impact on adjustment.

Perceived, but not actual, control over treatment has been consistently related to better adjustment in chronic illness. This study examined the relationship between actual control over treatment and severity of illness and their influence on depression in a chronically ill population of end-stage renal disease (ESRD) patients. The authors hypothesized that as severity of illness increases, the burden of control over treatment would increase depression. Severity of illness and depression was assessed for 98 ESRD patients. Control over treatment was represented by whether dialysis patients were self-administering treatment (high control) or were receiving treatment from the medical staff (low control). Results indicated that for the most severely ill patients, high control over treatment resulted in poorer adjustment. Furthermore, this effect was due in part to how illness interferes with social relationships in seriously ill, self-care patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depressive symptom differences in hospitalized, medically ill, depressed psychiatric inpatients and nonmedical controls.

This study compared depressive and anxious symptoms in chronic medically ill individuals and depressed psychiatric inpatients using conceptually based standardized measures of cognitions and symptoms. Seventy-five hospitalized medical patients, 52 depressed psychiatric inpatients, and 25 normal controls were assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987), the Mood and Anxiety Symptom Questionnaire, Hamilton Rating Scales of Anxiety and Depression, Hospital Anxiety and Depression Scales, Beck Depression Inventory, Cognitions Checklist, and Hopelessness Scale. Analysis revealed that depression in medical patients was best distinguished by symptoms of anhedonia, low positive affect, and physiological hyperarousal, whereas syndromal depression in psychiatric inpatients was specifically characterized by negative cognition symptoms. Implications are discussed for assessing depression in medically ill populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Race differences in stress-induced reactivity in young adults.

Studied the cardiovascular response to the stress of mental arithmetic in 121 young Black and White adults. Stress-induced reactivity was studied before and following 14 days of oral sodium loading (10 gm NaCl per day). Marginal hypertensives, both Black and White, had greater systolic blood pressure (SBP) levels and greater diastolic BP levels in response to stress. Whites had a greater SBP level during mental stress than Blacks and greater reactivity. The prevalence of sodium sensitivity was greater in Blacks (37.3%) than in Whites (18.4%). Sodium loading did not augment the BP reactivity to the mental stress in any of the racial or BP groups. Data demonstrate racial variation in the cardiovascular response to centrally medicated adrenergic stimuli. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Race, prostate cancer survival, and membership in a large health maintenance organization

BACKGROUND: Population-based cancer registry data have shown that black men with prostate cancer have poorer stage-specific survival than white men, while studies in equal-access health care systems have not found racial differences in stage-specific survival. This study was designed to test the hypothesis that black men and white men with prostate cancer have equal stage-specific survival in equal-access health care systems. METHODS: We conducted a cohort study using cancer registry data from all incident cases of prostate cancer occurring in a five-county San Francisco Bay Area region. Incident cases occurred among members (5263 cases, from January 1973 through June 1995) and nonmembers (16,019 cases, from January 1973 through December 1992) of the Kaiser Permanente Medical Care Program, a large health maintenance organization. Death rate ratios (DRRs, black men versus white men) for Kaiser members and nonmembers were computed for all stages combined (adjusting for age and stage) and for each stage (adjusting for age). RESULTS: Among Kaiser members, adjusted DRRs comparing black men with white men were as follows: all stages combined, 1.28 (95% confidence interval [CI] = 1.14-1.44); local stage, 1.23 (95% CI = 1.01-1.51); regional stage, 1.30 (95% CI = 0.97-1.75); and distant stage, 1.27 (95% CI = 1.07-1.50). Corresponding DRRs for nonmembers were as follows: all stages combined, 1.22 (95% CI = 1.14-1.30); local stage, 1.24 (95% CI = 1.09-1.41); regional stage, 1.48 (95% CI = 1.29-1.68); and distant stage, 1.01 (95% CI = 0.91-1.12). CONCLUSIONS: These results show poorer prostate cancer survival for black men compared with white men in an equal-access medical care setting. The findings are most consistent with the hypothesis of increased tumor virulence in blacks.     

Race and sex differences in the prediction of drug use.

Efforts to prevent adolescent substance abuse often direct prevention efforts at known correlates of substance use. The applicability to minority populations of risk factors uncovered for the general population has been questioned, and the development of different programs targeting the risk factors most salient for different groups has been recommended. Such differentiated programming requires a more precise understanding of ethnic differences in the predictors of substance use than is now available. This article assesses these differences using data from 981 Black and White male and female adolescents and latent variable structural equations techniques. No group differences were observed in the prediction of past year variety of drug use for 9 of the 12 risk factors examined. The predictive validity was higher for Whites than for Blacks for 3 risk factors. The prediction of frequency of use was weaker for Black women than for other groups. The low predictive validity observed for Black women is most likely due to the extremely low level of use among this group. The study concludes that the measures of risk factors predict substance use for all groups examined but that extremely rare behaviors are not well predicted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between opioid use and laxative use in terminally ill cancer patients

BACKGROUND AND OBJECTIVES: Functional pacemaker interference by mobile telephones has been described with analogical systems and with possible greater influence, digital systems, including inhibition and inadequate pacing. The influence of both system has not been extensively studied in patients with implantable cardioverter defibrillators (ICD). PATIENTS AND METHODS: We studied the influence of mobile phones, both digital and analogic network, on the performance of several models of defibrillators, in a standardised test set up designed to provide high sensitivity. The purpose of our study was to establish whether there are any influences on ICD functions, both in in vivo and in in vitro models. Several mobile phones, with different transmission powers, were moved towards the defibrillator and the electrode, under continuous documentation of defibrillator sensing and interrogation afterwards. The experimental model was performed with the aid of an arrhythmia simulator (Intersim) and demo-defibrillators. The tests were repeated both in and out of a solution of saline water with an impedance within normal human limits. RESULTS: Partial loss of telemetry was found in 14 patients, 8 with analogical phones and 6 with digital phones. Fourteen patients showed alterations only on the surface electrocardiogram channel and five on the intracavitary channel. The same results were reproduced in the in vitro model. However, the in vitro test allowed us to simulate multiple ventricular arrhythmias, and demonstrate the normal sensing and functioning of the defibrillator during a "spontaneous" arrhythmia. After testing, we demonstrate that no real oversensing/undersensing was documented in any device. There was no evidence of ICD reprogramming or pacing inhibition. In particular, no inadequate therapies were delivered. CONCLUSIONS: a) in our series, we have not demonstrated clinically significant electromagnetic interferences with mobile phones of digital or analogical networks: b) the in vitro model allowed us to conclude that even if a spontaneous arrhythmia appears, the function of the defibrillator is not altered; c) the use of mobile phones seems to be safe for defibrillator patients, and d) however, some basic rules, such as to maintain the phone at least 15 cm away from the defibrillator, are advised.     

Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system

BACKGROUND: The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma. METHODS: This retrospective cohort study included all white or black male veterans given a new diagnosis of colorectal carcinoma in 1989 at Veterans Affairs Medical Centers nationwide. After adjusting for patient demographics, comorbidity, distant metastases, and tumor location, the authors determined the likelihood of surgical resection, chemotherapy, radiation therapy, and death in each case. RESULTS: Of the 3176 veterans identified, 569 (17.9%) were black. Bivariate analyses and logistic regression revealed no significant differences in the proportions of patients undergoing surgical resection (70% vs. 73%, odds ratio 0.92, 95% confidence interval 0.74-1.15), chemotherapy (23% vs. 23%, odds ratio 0.99, 95% confidence interval 0.78-1.24), or radiation therapy (17% vs. 16%, odds ratio 1.10, 95% confidence interval 0.85-1.43) for black versus white patients. Five-year relative survival rates were similar for black and white patients (42% vs. 39%, respectively; P=0.16), though the adjusted mortality risk ratio was modestly increased (risk ratio 1.13, 95% confidence interval 1.01-1.28). CONCLUSIONS: Overall, race was not associated with the use of surgery, chemotherapy, or radiation therapy in the treatment of colorectal carcinoma among veterans seeking health care at Veterans Affairs Medical Centers. Although mortality from all causes was higher among black veterans with colorectal carcinoma, this finding may be attributed to underlying racial differences associated with survival. This study suggests that when there is equal access to care, there are no differences with regard to race.     

Intelligence, Race, and Genetics.

In this article, the authors argue that the overwhelming portion of the literature on intelligence, race, and genetics is based on folk taxonomies rather than scientific analysis. They suggest that because theorists of intelligence disagree as to what it is, any consideration of its relationships to other constructs must be tentative at best. They further argue that race is a social construction with no scientific definition. Thus, studies of the relationship between race and other constructs may serve social ends but cannot serve scientific ends. No gene has yet been conclusively linked to intelligence, so attempts to provide a compelling genetic link of race to intelligence are not feasible at this time. The authors also show that heritability, a behaviorgenetic concept, is inadequate in regard to providing such a link. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Spatial cognition and neighborhood use: The relationship in older adults.

Measures of spatial cognition, neighborhood knowledge, and neighborhood use from the research described by D. A. Walsh et al (1981) were examined to determine if laboratory tests of spatial cognition were significant predictors of older adults' use of their neighborhoods. The overall results show that laboratory-based measures of spatial cognition and Ss' knowledge of their neighborhoods are both significant predictors of their use of neighborhood goods and services. The ability to learn and remember the location and orientation of objects, when contextual cues were not provided at test, was more predictive of the participants' neighborhood use than either the participants' number of years in the neighborhood or their mobility. Spatial memory as measured by the Educational Testing Service Building Memory task predicted neighborhood knowledge, which was predictive of neighborhood use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)