Interference In Daily Activities Research Articles

Assessment of the emetogenic potential of intrathecal chemotherapy and response to prophylactic treatment with ondansetron.

The purpose of this study was to document the emetogenic potential of intrathecal chemotherapy (IC) in children and to evaluate the efficacy of ondansetron in reducing nausea and vomiting with this chemotherapy treatment. Patients less than 18 years of age with acute lymphoblastic leukemia were eligible to participate in a survey project measuring the emetogenic potential of various chemotherapy treatments. Patients surveyed for 1 or more IC treatments were included in this report. The IC consisted of methotrexate, hydrocortisone and cytarabine, dosed according to patient age. A nausea/vomiting survey instrument was completed by each patient and/or parent following IC treatment. The instrument rated nausea, vomiting and daily activity interference (DAI) on a 4-point scale of 0 = none, 1 = mild, 2 = moderate and 3 = severe, and collected data on the number of vomiting and/or retching episodes in addition to the child's appetite following the chemotherapy treatment. When ondansetron was employed, it was administered in an i.v. infusion at a dose of 0.15 mg/kg before and after chemotherapy or as an oral dose of 4 mg or 8 mg before chemotherapy. Courses of IC without antiemetics were analyzed to determine the emetogenic potential of IC. For patients receiving IC both with and without ondansetron, courses were compared with each patient used as their own control to determine the influence of ondansetron upon survey responses. Statistical analysis consisted of nonparametric Friedman 2-way ANOVA for ordinal variables and a paired t-test for continuous variables. The binomial test was employed to analyze for differences between ondansetron and no antiemetic in the number of patients with complete control of both nausea and vomiting or vomiting alone. A total of 63 children with a mean age of 7.6 +/- 4.2 years were each studied on one or more occasions. Thirty-seven children were surveyed for 87 IC treatments without antiemetics (group I), and 17 children from this group were surveyed for 48 IC courses with i.v. ondansetron (group IA). An additional 18 children were subsequently surveyed for 39 IC courses with i.v. ondansetron (group II). Fifteen patients (7 of whom were members of group I) were surveyed following 33 IC courses with oral ondansetron (group III). The survey scores for group I patients were: nausea severity 1.3 +/- 1.1, vomiting severity 1.2 +/- 1.1, DAI 1.2 +/- 1.0 and mean number of emetic episodes 4.7 +/- 8.4. The mean appetite score was 1.5 +/- 1.1. For patients in group IA, nausea severity (0.8 +/- 0.9), vomiting severity (0.5 +/- 0.8), DAI (0.7 +/- 0.8), and the number of emetic episodes (1.4 +/- 2.8) were all significantly lower than with prior IC treatments without ondansetron. For complete protection, children receiving i.v. ondansetron had greater complete protection rates from both nausea and vomiting or vomiting alone than did patients receiving no antiemetic. Survey responses were also lower for patients receiving oral ondansetron, but insufficient control data did not allow for statistical analysis. IC results in mild to moderate nausea and vomiting in children. The emetogenic potential of IC is significantly reduced by i.v. ondansetron.

In reply

In reply: Dr. Reyes-Ortiz provides an informative review of recent literature on the psychosocial factors that affect outcomes in coronary disease. This is an interesting and burgeoning area that has seen interesting results from well designed studies in recent years. Prospective data linking depression with cardiovascular mortality has been derived from clinical1 and population-based studies.2 Social isolation has also been shown to be an independent risk factor for mortality in those with coronary disease.3 There are fewer studies of the effect of psychosocial factors on non-mortality outcomes in coronary disease. We have another report on the same sample in press,4 which prospectively demonstrates a significant effect of anxiety and depression on physical function, daily activity interference, and role function after controlling for coronary disease severity, medical comorbidity, medical versus surgical coronary disease management during follow-up, age, gender, education, and social class. Dr. Reyes-Ortiz centers his attention on the question of hope, which he places rightfully at the intersection of the psychological and spiritual domains. There have been some interesting studies that addressed the issue of hopelessness specifically. Anda et al. reported data on 2832 adults, aged 45 to 77 years followed for a mean of 12 years in the National Health Examination Follow-up Study (NHANES II).5 After controlling for demographic and known risk factors, they noted a relative risk for fatal ischemic heart disease of 1.5 for depressed affect and 1.6 for those endorsing a single item about moderate to severe hopelessness. These findings are consistent with a large series of studies conducted over the last 30 years that demonstrate the importance of “negative affectivity” in coronary disease.6 Research to identify the pathophysiological mechanisms by which these psychosocial factors exert their effects on the heart remains largely to be done. However, there have been intriguing hypotheses concerning the role of platelet reactivity7 and autonomic tone8 raised in the literature. The next few years will, we hope, provide information leading to interventions to improve quality of life for patients with one of our most common and disabling chronic diseases.

Treatment-seeking behaviour and stated preferences for prostatectomy in Spanish men with lower urinary tract symptoms.

To determine whether men in the community with lower urinary tract symptoms sought treatment, would choose to have a prostatectomy, and the factors that might influence their decision. The study was a cross-sectional population survey using interviewers in the autonomous community of Madrid and comprised 2002 men aged > or = 50 years. The main outcome measures were self-reported International Prostate Symptom Scores (IPSS), treatment-seeking behaviour and the patients' stated preference for prostatectomy. The response rate among eligible subjects was 68.1%; overall, 38.2% of men sought medical advice for their lower urinary tract symptoms. Whether a man sought medical advice was related to symptom severity, 'bothersomeness', interference in daily activities and his perception of the future; of these, bothersomeness and interference in activities were more likely to determine whether or not a man consulted his doctor. Most men in the sample (84.9%) reported that they would choose a prostatectomy, although this value depended on whether they had had a previous prostatectomy, were younger, and on the content of the information presented. Men were more likely to report that they would accept surgery if their doctor recommended it and less likely when presented with information on the outcomes of treatment. Many Spanish men with lower urinary tract symptoms do not seek medical advice for their symptoms, although most stated that they would accept a prostatectomy on the recommendation of their doctor. Further research should examine whether reported patient preferences correspond to actual behaviour and what is the most appropriate type of information to give to potential patients.

Assessment of Chemotherapy-Induced Emesis and Evaluation of a Reduced-Dose Intravenous Ondansetron Regimen in Pediatric Outpatients with Leukemia

To measure the severity of nausea and vomiting in pediatric patients receiving intravenous or intrathecal chemotherapy for acute lymphoblastic leukemia and to evaluate the effectiveness of 2 intravenous doses of ondansetron for this condition. Patients were surveyed during repeated treatments of maintenance chemotherapy, given with or without ondansetron, using a repeated measures pretest/posttest design. Outpatient pediatric oncology clinic. Sixteen pediatric patients (aged 2-15 years, mean 6.2) with acute lymphoblastic leukemia. Surveys to assess nausea and vomiting and the extent of interference with daily activities were administered following emetogenic chemotherapy with or without ondansetron. A total of 255 surveys following emetogenic chemotherapy with daunorubicin, cyclophosphamide, carmustine, and etoposide and cytarabine combined, as well as intrathecal therapy with methotrexate, hydrocortisone, and cytarabine, were analyzed. Analysis was performed on surveys of 149 courses without antiemetic therapy and 106 courses after 2 doses of ondansetron 0.15 mg/kg iv. The most emetogenic chemotherapy treatment was the etoposide/cytarabine combination (p < 0.05). Ondansetron completely protected patients (defined as no nausea or no vomiting) during most (> 50%) of the chemotherapy treatments, except for those in which cyclophosphamide was used. Ondansetron provided greater control of nausea and vomiting, a higher percentage of complete protection, and decreased the daily activity interference rating for carmustine and etoposide/cytarabine compared with courses of chemotherapy without antiemetics (p < 0.05). Two intravenous doses of ondansetron also provided durable antiemetic efficacy over time for the most emetogenic chemotherapy treatment (etoposide/cytarabine). Etoposide/cytarabine proved to be the most emetogenic of the chemotherapy treatments studied. A reduced-dose regimen of intravenous ondansetron was shown to be an effective antiemetic for the outpatient treatments with etoposide/cytarabine and carmustine, but not with cyclophosphamide.

A cross‐cultural comparison of adaptation to chronic pain among Anglo‐Americans and native Puerto Ricans

Using quantitative and qualitative data from studies in New England and Puerto Rico, we compare the chronic pain experiences of Anglo-Americans and native Puerto Ricans. We also compare adaptation to chronic pain between and within these two groups. Positive adaptation is defined as the process of adjustment in behavior and attitudes which facilitates resumption and continuation of a life defined by the subject as meaningful and worthwhile. Our case studies and quantitative analyses demonstrate that successful adaptation is associated with a reduction in depression, tension, and worry; and the realistic continuation of family, social, and work roles. Our analyses also demonstrate that the factors most often associated with adaptation are cultural (meanings and standards), psychosocial (social support, age, socioeconomic status, psychological coping style), the cultural context of care (providers' world views), and the political and economic circumstances under which compensation and rehabilitation are sought. Our quantitative analyses show significant inter- and intra-cultural group differences in pain intensity and emotional responses to the pain. However, despite higher pain intensity and more emotional responses among Puerto Ricans, there was no significant difference between the two groups regarding interference in daily activities. The two groups simply appear to experience chronic pain differently. We propose that the difference is not positive or negative in itself--it is simply a different reality which should be evaluated from an emic perspective and not through the cultural lens of the outside provider or researcher. Intra-group analyses are essential because they provide insight into the standards, norms, and variations within specific cultural groups.

Brief group cognitive-behavioral intervention for temporomandibular disorders

Temporomandibular disorders (TMD) are currently viewed as an interrelated set of clinical conditions presenting with signs and symptoms in masticatory and related muscles of the head and neck, and the soft tissue and bony components of the temporomandibular joint. Epidemiologie and clinical studies of TMD confirm its status as a chronic pain problem. In this report we present results from a randomized clinical trial which compared, at 3- and 12-month follow-ups, the effects of usual TMD treatment on TMD pain and related physical and psychological variables with the effects of a cognitive-behavioral (CB) intervention delivered to small groups of patients before usual TMD treatment began. The purpose of this study was to determine whether a minimal CB intervention followed by dental TMD treatment enhanced the effects of usual clinical dental treatment. A second purpose of the study was to determine whether patients classified as high in somatization and psychosocial dysfunction would respond less favorably to this minimal intervention than would those low in somatization and dysfunction. Patients who participated in the CB intervention followed by usual treatment showed greater long-term decreases in reported pain level and pain interference in daily activities than did patients who received only usual treatment. The benefits of CB intervention were not seen when the CB and UT groups were compared at 3-month follow-up. During the 3–12-month follow-up interval, however, the UT group maintained essentially the same level of improvement in characteristic pain while the CB group continued to improve, as hypothesized. During this same follow-up interval, the CB group also showed a strong trend toward continued improvement in pain interference. Such effects were not observed for depression, somatization, or clinical measures of jaw range of motion. Additionally, as hypothesized, dysfunctional chronic pain patients did not appear to benefit from the brief CB intervention. Intent to treat analyses were also performed to assess generalizability of the results.

Community Leg Ulcer Clinics: Effect on Quality of Life

Objective: To investigate changes in the quality of life of patients with leg ulcers being treated in community leg ulcer clinics. Design: Patients were interviewed using a standard questionnaire, and then reinterviewed after 12 weeks of compression bandaging to observe changes. Setting: Community ulcer clinics held in health centres within Riverside Health District. Patients: All new patients presenting to community leg ulcer clinics up to 6 months from the start of a clinic and treated with four-layer compression bandaging. Main outcome measures: Changes in quality of life, interference in daily activities caused by leg ulceration and general health after 12 weeks of treatment. Results: Treatment over 12 weeks resulted in a mean reduction in anxiety (2.79 v 1.73, p &lt; 0.001), depression (2.61 v 1.89, p &lt; 0.001), hostility (1.59 v 1.00, p &lt; 0.001) and cognition (1.29 v 0.87, p = 0.015). Pain significantly improved following treatment (χ2 trend = 103.7, 1d.f., p &lt; 0.001). Changes in depression and hostility were related to complete ulcer healing. Conclusions: There were clear changes in quality of life following 12 weeks in a community leg ulcer clinic, which were related to the healing of the ulcer. Systems of care that offer rapid healing and improve patients' well-being must be considered when planning an effective leg ulcer service.

Relief of spasticity in SCI men and women using rectal probe electrostimulation

Although there are numerous approaches to the treatment of spasticity, many patients are still unable to find a satisfactory method of managing their spasms with acceptable side effects. In the course of our fertility studies using rectal probe electrostimulation (RPES) in SCI men to produce ejaculation, we observed that a majority of the men experienced significant relief of their spasticity for many hours. This report describes a prospective, single-blinded study of this phenomenon in six SCI men and three SCI women who underwent RPES a total of 71 times. The mean age of the subjects was 28.2 years (21-41), the mean time from injury was 6.0 years (0.5-15); there were three paraplegic and six quadriplegic persons: four were Frankel class A and five were class B. Although all subjects had moderate to severe spasticity, only four took antispasm medications; one had undergone surgery for implantation of an epidural stimulator. The effectiveness of RPES on spasticity was evaluated by each subject for frequency of spasms and interference of daily activities and by independent, blinded assessors for tone, frequency of spasms and DTRs; four patients underwent quantitative videotape analysis of the pendulum test and two underwent somatosensory evoked potentials (SSEPs) to evaluate electrical activity in the central nervous system. Treatment variables included varying probe sizes and number of stimulations. All subjects experienced good to excellent decrease in tone, frequency of spasms and interference with ADL from 3 to 24 hours depending on treatment variables used. Mean duration of relief was 8.2 hours.(ABSTRACT TRUNCATED AT 250 WORDS)