Unpleasant Treatment Research Articles

The indicator of sedation need (IOSN)

Conscious sedation in dentistry is usually indicated because a patient's anxiety can prohibit the necessary dental treatment being undertaken. It may also be indicated because of unpleasant or lengthy treatment or to prevent exacerbation of a patient's medical or behavioural condition by anxiety. The indicator of sedation need (IOSN) tool has been developed to help support dentists in their clinical decision-making and uses information about a patient's anxiety, medical and behavioural status and treatment complexity. The IOSN has been used to measure sedation need and has shown that 5.1% of patients attending general dental practices have a high need of conscious sedation. IOSN has also been used to investigate the need for conscious sedation in the general population among dental practice attenders and those who don't attend. The proportion was found to be 6.7%. Some patients require conscious sedation in order to access dental care. The indicator of sedation need (IOSN) tool helps in the decision-making process.

The Acceptability of Acupuncture for Low Back Pain: A Qualitative Study of Patient’s Experiences Nested within a Randomised Controlled Trial

IntroductionThe National Institute for Health and Clinical Excellence guidelines recommend acupuncture as a clinically effective treatment for chronic back pain. However, there is insufficient knowledge of what factors contribute to patients’ positive and negative experiences of acupuncture, and how those factors interact in terms of the acceptability of treatment. This study used patient interviews following acupuncture treatment for back pain to identify, understand and describe the elements that contribute or detract from acceptability of treatment.MethodsThe study used semi-structured interviews. Twelve patients were interviewed using an interview schedule as a sub-study nested within a randomised controlled trial of acupuncture for chronic back pain. The interviews were analysed using thematic analysis.Results and DiscussionThree over-arching themes emerged from the analysis. The first entitled facilitators of acceptability contained five subthemes; experience of pain relief, improvements in physical activity, relaxation, psychological benefit, reduced reliance on medication. The second over-arching theme identified barriers to acceptability, which included needle-related discomfort and temporary worsening of symptoms, pressure to continue treatment and financial cost. The third over-arching theme comprised mediators of acceptability, which included pre-treatment mediators such as expectation and previous experience, and treatment-related mediators of time, therapeutic alliance, lifestyle advice and the patient’s active involvement in recovery. These themes inform our understanding of the acceptability of acupuncture to patients with low back pain.ConclusionThe acceptability of acupuncture treatment for low back pain is complex and multifaceted. The therapeutic relationship between the practitioner and patient emerged as a strong driver for acceptability, and as a useful vehicle to develop the patients’ self-efficacy in pain management in the longer term. Unpleasant treatment related effects do not necessarily detract from patients’ overall perception of acceptability.

CAM for cancer: preying on desperate people?

Cancer patients are uniquely vulnerable, desperate people, willing to grasp at any straw. Complementary and alternative medicine (CAM) offers to relieve symptoms and even to cure cancer with methods that may appear more ‘natural’ or more palatable than surgery, radiation, and chemotherapy. It may be reasonable for cancer patients to try CAM to relieve pain, nausea, and fatigue; relieve stress; ease worries; and give them a sense of empowerment, of being able to do something to help themselves. But it is unfortunate when they use CAM with unwarranted expectations or in lieu of effective treatment. Some CAM methods might eventually prove to be helpful in cancer, but a scientifically rigorous review shows that, at present, the evidence just is not there. CAM has much to offer cancer patients. But then, quackery has much to offer them too: hope (albeit false hope), comforting beliefs, symptom relief (through the placebo phenomenon), the promise of ‘cures’, and a more palatable (but unfortunately ineffective) substitute for effective but unpleasant conventional treatments. No ethical physician would knowingly promote quack medical treatments for cancer patients. Uniform standards of good science must be applied to every treatment to allow ethical doctors to offer patients proven treatments whenever possible. When no proven treatment is available, they may offer unproven treatments and clearly identify them as experimental; and they may offer simple comfort measures without any unrealistic claims. They must not mislead patients by claiming that a treatment has been proven effective when it has not.

About the treatment of gonorrhea in the former Soviet Union

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Crohn Disease

Crohn disease (CD) presents a range of physical, social, and psychological challenges, and can adversely affect the quality of life of those affected by it. The present study aimed to investigate the health-related quality of life of paediatric patients with CD in the Wellington region. Measuring health-related quality of life assists with resource allocation decisions and assesses various forms of interventions. Patients ages 9 to 18 years with CD in the Wellington region were assessed using the IMPACT-III inflammatory bowel disease-specific questionnaire (n = 16). Eight participants filled it out and returned it by post; the remaining 8 filled it out in a meeting with the researcher and then underwent cognitive debriefing as part of a cross-cultural adaptation of the questionnaire. Of a maximum possible value of 175, the total health-related quality of life score had a mean value of 119.2 (standard deviation 30.7). Using Spearman rank correlation analysis, significant findings included a positive correlation between disease duration and quality of life (ρ = 0.534, sig. <0.05) and a negative correlation between disease activity and quality of life (ρ = -0.596, sig. <0.05). Qualitative information included difficulties in coping with long-term and unpleasant treatments and feelings of isolation. Children with Crohn disease in the Wellington region may benefit from age-specific social and psychological support. Because there is limited information on quality of life in young patients with CD in New Zealand, the results of the present study may be used as baseline data for future studies.

Ultrasound Circular Cyclo-Coagulation – Innovation in Glaucoma with High Intensity Focused Ultrasound

Existing treatment modalities for glaucoma, including pharmacological therapy, lasers, surgery and shunts, are all associated with shortcomings. Ultrasonic coagulation of the ciliary body with pinpoint precision using high intensity focused ultrasound (HIFU) enables significant reduction of aqueous inflow and intraocular pressure (IOP). Energy is focused through non-optically transparent media with controlled energy absorption, reducing effects on adjacent tissues. Energy deposition and tissue heating at the focus site do not depend on tissue pigmentation, thus improving predictability. Currently, high-frequency miniaturised transducers create small focal zones for improved treatment area targeting, and ultrasound focusing provides enhanced control. The high operating frequency allows a sharp transition between the focal zone and the untreated area, reducing risks of heating adjacent healthy tissue. Such transducers are used extensively in malignant tumour treatments. Novel Ultrasound Circular Cyclo-Coagulation (UC3) with a miniaturised annular transducer uses HIFU technology. The circular geometry of the device allows precise, constant and reproducible positioning. Results from animal studies and from a clinical pilot study of patients with refractory glaucoma indicate that ultrasonic coagulation of the ciliary body using HIFU delivered by a circular miniaturised transducer is an effective and well-tolerated method of reducing IOP. The single-step procedure is short, easy to perform and accurate. Glaucoma impacts patients’ quality of life, including unpleasant treatment side effects and social and physical aspects. Gold-standard trabeculectomy shortcomings highlight the need for precise, focused surgical modalities. HIFU is a non-invasive, cost-effective innovation that, should the multicentre clinical trial demonstrate similar results to the preclinical and pilot studies, will be a useful addition to current glaucoma management techniques.

Women, poverty and adverse maternal outcomes in Nairobi, Kenya

BackgroundThe link between poverty and adverse maternal outcomes has been studied largely by means of quantitative data. We explore poor urban Kenyan women's views and lived experiences of the relationship between economic disadvantage and unpleasant maternal outcomes.MethodSecondary analysis of focus group discussions and in-depth individual interviews data with women in two slums in Nairobi, Kenya.ResultsUrban poor women in Nairobi associate poverty with adverse maternal outcomes. However, their accounts and lived experiences of the impact of poverty on maternal outcomes underscore dynamics other than those typically stressed in the extant literature. To them, poverty primarily generates adverse maternal outcomes by exposing women to exceedingly hard and heavy workloads during pregnancy and the period surrounding it; to intimate partner violence; as well as to inhospitable and unpleasant treatment by service providers.ConclusionsPoverty has wider and more intricate implications for maternal outcomes than are acknowledged in extant research. To deliver their expected impact, current efforts to promote better maternal outcomes must be guided by a more thorough perspective of the link between women's livelihoods and their health and wellbeing.

Gastrointestinal tract morphological alteration by unpleasant physical treatment and modulating role of Lactobacillus in broilers

1. An experiment was conducted to determine the effects of supposedly unpleasant physical treatment on broiler performance, small intestinal development and ameliorating role of probiotics. 2. The following treatments were applied from day one: (1) chicks exposed to normal human contact fed basal diet (control); (2) chicks were exposed to unpleasant physical treatment and fed basal diet (UPT-BD); and (3) chicks were exposed to unpleasant physical treatment and fed basal diet supplemented with Lactobacillus (UPT-BDL). Chicks were exposed to UPT from days 1 to 21. Different segments of gastrointestinal tract were sampled at 14, 28, 35 and 42 d of age. 3. Broilers of UPT-BD had lower feed consumption compared with control group at 7 d of age. Overall, UPT-BDL birds showed higher body weight gain (BWG) and better feed conversion ratio (FCR) over the course of the experiment. 4. Birds of UPT-BD had lower concentrations of lactic, propionic and butyric acids in the caecum as compared with other groups at 14 d of age. Acetic acid concentration was profoundly decreased in both UPT groups compared to the control. 5. Duodenal villus height of UPT-BD broilers showed a slight reduction compared to the control and UPT-BDL birds at 14 d of age. Afterwards until day 42, UPT-BDL birds showed the highest villus height among treatments in different parts of the small intestine. 6. The results suggested that, even though UPT did not have significant inhibitory effects on the development of the small intestine and broiler performance, it negatively affected bacterial metabolic end products in the caecum, which could be ameliorated by the addition of Lactobacillus.

Optimizing topical therapy for psoriasis

There are a wide variety of topical treatment options for psoriasis. Despite their effectiveness in clinical trials, control of psoriasis in clinical practice remains a challenge. A multitude of factors limits patients’ use of medication, including frustration with poor efficacy, inconvenience, fear of side effects, financial restraints, vague application instructions, complicated regimens and unpleasant treatment characteristics. The first step to optimize topical therapy is to develop a physician–patient relationship that contributes to realistic expectations and proper use of medication. Patients should be involved in the choice of medications and vehicles. Topical corticosteroids form the foundation of treatment and topical vitamin D analogs and other noncorticosteroid agents can be used as complements to optimize long-term results.

Reply

Sir: We thank Dr. Azizzadeh for the comments on the article “Late-Onset Infections and Granuloma Formation after Facial Polylactic Acid (New-Fill) Injections in Women Who Are Heavy Smokers.”1 We would like to address the issues presented by Dr. Azizzadeh. First, New-Fill has been in use for a variety of indications, including correction of human immunodeficiency virus lipodystrophy and lip atrophy, in addition to the common cosmetic indications for treatment of rhytides. We described granuloma formation with palpable nodules at the nasolabial folds after correction of rhytides (one of the principal indications for cosmetic use of New-Fill). In addition, we described a similar phenomenon at the lip vermilion when the New-Fill filler was injected to correct lip atrophy. In our view, the place of injection is not the main issue and was not part of our considerations. Second, we would like to mention that all of the patients were injected in different outpatient clinics and all of the patients were referred to our treatment after frustration with their physician’s failure to provide a satisfactory solution. Third, there are prior descriptions of adverse events after injections of New-Fill2,3; our experience was not unique. We must not forget that those women underwent a series of unpleasant treatments before their referral. Fourth, the late onset of the adverse effects described in our article suggests that granuloma formation and especially infection are not technique related. Although nodule formation is a well-known consequence of soft-tissue augmentation, not all dermal fillers cause this undesired effect and therefore may be preferred. Finally, our article is a case presentation depicting adverse events after filler injection. We may only suggest causality with smoking, but further research is necessary to establish it. Nevertheless, our center is a tertiary referral center, and we have seen more smokers with New-Fill late complications compared with other fillers. Oren Goldan, M.D. Gil Grabov-Nardini, M.D. Department of Plastic and Reconstructive Surgery Sheba Medical Center Ramat Gan, Israel

An appreciation of Dr Steven Pfeiffer, 1940–2007

Soon after this special edition of the Journal of Neurochemistry went to press, we were informed of the sad news that Steve Pfeiffer had succumbed to cancer after a 2-year struggle. Steve was a loyal friend, a wonderful colleague, and his interactions with many scientists in the fields of glial cells and glycosphingolipids were always positive and stimulating. He will be greatly missed by his family and friends. A detailed obituary of Steve can be found on the ASN website, and also in the Hartford Courant on Monday, August 27. What follows are thoughts from two friends, who got to know Steve well over the past few years. One of us (AF) was a co-chair of the symposium to which this special issue is dedicated, and spent the year or so before the symposium working on a day-to-day basis with Steve, so much so that over 1300 e-mails were exchanged! It seems more than a little strange not to be consulting with Steve now about the contents of this short note. Steve had a productive research career, mainly in the field of myelin biology. He published his first paper, on selecting synchronous populations of mammalian cells, in Nature in 1967, and after that, moved to the study of Schwann cells, glial cells, and oligodendrocytes. This led him to the study of galactolipids and other glycolipids, and in the 1990s, he became an active member of the sphingolipid community and was a regular participant at many conferences in this field. He was particularly interested in the possible roles of lipid rafts in myelin function, and lectured on this issue at recent meetings. Apart from his scientific contributions, Steve was simply a great person to know and spend time with. By way of example, at a recent Gordon Conference, Steve was asked to chair a ‘poster session’, in which mainly young scientists were asked to give short 5-min talks. Steve was asked to chair this session, as we felt his easy-going manner, and excellent interactions with students and postdocs, would be perfectly suited for this task. At the ISN Neurochemistry Conference in Antigua, Steve was his usual bubbly self and maintained his sense of humor, despite the fact that at the time he was undergoing a number of unpleasant treatments for cancer. Steve was in particularly good form when he met the Prime Minister of Antigua, and when he chaired the closing session of the meeting! That was the last time that we saw him, though emails continued to flow back and forth till as recently as August 3, when Steve wanted to discuss the role of myelin proteins in a mutant mouse. Steve is sadly no longer with us. We will cherish the memories of all of our wonderful interactions with him.

Fatigue, emotional exhaustion and perceived health complaints associated with work-related characteristics in employees with and without chronic diseases

Ageing of the Dutch working force and increasingly more stringent restrictions regarding early retirement and disability benefits are leading to higher numbers of workers with ill health. Until now, only a few studies have explored how employees with ill health perceive their work. This study investigated possible differences in scores on fatigue, emotional exhaustion, perceived health complaints and various work-related characteristics between chronically ill (CIWs) and non-chronically ill workers (NCIWs), as well as differences in associations between work- and health-related characteristics. A questionnaire was sent to all employees of a Dutch university to collect data on perceived work-related and health-related characteristics (response 49.1%). Differences in various scores were analysed using chi (2)-tests and the general linear model. Associations between the work- and the health-related characteristics were determined by multiple linear regression analyses in the CIWs (n = 444) and NCIWs (n = 1,347) separately. Interaction terms were included to detect differences between the two groups. The results indicated that the CIWs had less favourable scores on the three health-related characteristics. Also, the CIWs scored less favourably than the NCIWs on almost all the work-related characteristics. In the two groups, negative work-related aspects, such as higher work pressure, contributed most to explaining the variance in the health-related characteristics. However, in the CIWs, fatigue was not explained by the work-related aspects as much as in the NCIWs. In the CIWs, the association between unpleasant treatment and the health-related characteristics was stronger than in the NCIWs, but there were indications that autonomy, possibilities for learning and social support from superiors also played an important role. CIWs perceived more fatigue, emotional exhaustion and health complaints than NCIWs. There were different patterns of associations between work- and health-related characteristics in the NCIWs and CIWs. Future studies on associations between work-related characteristics and health should take the presence of chronic disease into account.

Review Essay: Avoiding conventional understandings: the enduring legacy of Eliot Freidson

Review Essay: Avoiding conventional understandings: the enduring legacy of Eliot Freidson

Social support, locus of control, and depressive symptoms in hemodialysis patients

This study aimed to reveal how social support and psychological well-being association might differ with locus of control orientation for chronically ill patients receiving a restrictive and unpleasant medical treatment (i.e., hemodialysis). Data were collected from 104 hemodialysis patients. After controlling for the variance accounted for by gender and duration of dialysis, for patients with internal locus of control, lack of "perceived social support" was found to be associated with depressive symptoms. On the other hand, for patients with external locus of control, the same analysis revealed that lack of "satisfaction from the received social support" was associated with depressive symptoms. Thus, for hemodialysis patients the variables associated with depressive symptoms varied with their locus of control orientations. Furthermore, the present study underlined the importance of considering different aspects of social support while studying with chronically ill patients.

THE CLASSIC: Penicillin: Its Practical Application in Orthopaedic Surgery and Fractures

THE CLASSIC: Penicillin: Its Practical Application in Orthopaedic Surgery and Fractures

Editor's Choice

Editor's Choice

Withholding information from cancer patients as a physician's decision under risk.

When cancer is diagnosed, the physician may face a dilemma regarding disclosure of information to the patient. While he or she may feel a responsibility to maintain the patient's hope, even through the withholding of information, there is a risk involved: if treatment fails, the patient will eventually know the truth. Patients who would rather live their final days in peace rather than undergo unpleasant treatment of an uncertain nature may be furious and frustrated that they have been deprived of this liberty, ending their lives feeling worse than they would have had they been told the truth at the outset. The author applies three theories of decision making under uncertainty (expected utility theory, prospect theory, and regret theory) to the physician's problem of whether and to what extent to withhold information from a cancer patient, deriving comparative predictions with regard to the relationships between the physician's behavior and illness, patient, and physician characteristics. The results help explain why physicians whose norm of behavior is full disclosure sometimes opt to withhold information and why junior physicians are more likely to disclose the truth than their senior colleagues, as well as the empirical findings that physicians tend to disclose more truthful information to patients the greater the severity of illness and the more inquisitive the patient.

Interferon in chronic hepatitis C

Hepatitis C virus (HCV) was discovered in 1989. Shortly thereafter, it became clear that HCV had a high prevalence and unusual ability to cause very long-lasting infection. This year, two studies have proposed modifications in the use of interferon in chronic hepatitis C (Poynard) and in patients with HCV cirrhosis (Nishiguchi). Administration of a-interferon to patients with chronic hepatitis C may inhibit virus replication, leading to longterm remission and eradication of infection in sustained responders (Ann Intern Med 1994; 121: 276). Unfortunately, interferon causes serious side-effects (BMJ 1993; 306: 107), and is very expensive. However, the main drawback is the low rate of sustained reponse achieved with standard regimens. Larger doses of interferon; the use of titrated doses; increases in the length of the treatment; and the administration of interferon in association with corticosteroids, ursodesoxycholic acid, non-steroidal anti-inflammatory agents, and antivirals (such as ribavarin) have all been enthusiastically explored. Chemello reports that administration of interferon for 12 months rather than 6 reduces the risk of relapse after interferon withdrawal in responding patients. Most of the patients who develop a sustained response have a return to normal of aspartate aminotransferase and a negative HCV-RNA test within 4-8 weeks of therapy (.7 Med Virol 1995; 46: 109). Accordingly, prolonging an expensive and often unpleasant treatment in patients who are not responding does not seem reasonable. Association with ribavirin (Gastroenterology 1994; 107: 812) seems a promising improvement. Attempts to differentiate bad from good responders to interferon show that HCV genotype lb and a high level of viraemia are associated with a poor response (Ann Intern Med 1995; 122: 161; Lancet 1995; 345: 562; Lancet 1995; 346: 425). Other factors such as older age, very longlasting infection, excess body weight, high gammaglutamyltransferase serum concentrations, high serum ferritin or liver iron content, and severe hepatic fibrosis or cirrhosis are also associated with a poor response. Therapy should be maintained for at least 1 year in responders or withdrawn after 3-4 months in nonresponders. After several months of treatment, disappearance of HCV-RNA from the liver in responders would be the most reliable predictor of no relapse upon discontinuation of therapy (Shindo). Two reports argue against such a restrictive use of a-interferon in chronic HCV infection. Poynard reported

A comparison of anxiety levels associated with root canal therapy and oral surgery treatment

Questionnaires regarding experience, hearsay, and perceptions of anxiety toward eight dental treatments were distributed to a general patient population. Data revealed that among 349 respondents 35% heard that root canal therapy was the most unpleasant dental treatment, whereas 29% listed oral surgery treatment as having the worst reputation. However, 53% of those experiencing oral surgery treatment stated that an oral surgery treatment was the most unpleasant treatment whereas only 17% experiencing root canal therapy stated the same for root canal therapy. On the basis of anxiety scores, root canal therapy and oral surgery treatment were categorized in the high-anxiety category, crowns, dentures, and fillings in the moderate-anxiety category, and cleaning, sick call, and examination in the low-anxiety category. The anxiety levels of root canal therapy and oral surgery treatment were then analyzed as they related to different experience groups (combinations of root canal therapy and oral surgery and experience), hearsay experience, and most unpleasant experience with root canal therapy and oral surgery. Patients having experience with root canal therapy or oral surgery treatment had lower anxiety levels toward these respective treatments than did those who had no such experience. Patients who have heard negative stories (hearsay) of root canal therapy and oral surgery showed higher levels of anxiety toward these respective treatments than did those who have not heard such stories. But former endodontic patients who had heard negative stories about root canal therapy actually recorded lower anxiety levels toward root canal therapy than those patients with no negative hearsay experience.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of aversively handling pigs, either individually or in groups, on their behaviour, growth and corticosteroids

The influence of three handling treatments, imposed for 10 weeks from 15 kg liveweight, on the behaviour, growth, subsequent reproductive performance and free corticosteroid concentrations were studied in 60 female pigs. The pleasant treatment involved individually handling the pig in a pleasant manner (e.g. gentle stroking). There were two unpleasant handling treatments; one involved individually handling the pig in an unpleasant manner (e.g. brief shocking or brief slapping) whenever the pig failed to withdraw from the experimenter and the other involved handling the pig within a group in an unpleasant manner whenever the pig failed to withdraw from the experimenter. The individual handling treatments were imposed for 30 s day −1 for 5 days week −1 and the group handling treatment was imposed for 2.5 min day −1 for 5 days week −1. There were no differences between treatments in growth rates over the 10-week period; however, the pigs in the pleasant handling treatment had a higher ( P<0.01) growth rate in the first 5 weeks of the handling period than pigs in the two unpleasant handling treatments. The feed conversion efficiency of pigs in the pleasant handling treatment was also superior ( P<0.05) in the first 5 weeks. The pigs in the unpleasant handling treatments were more ( P<0.01) fearful of humans, as indicated by their approach behaviour to a stationary experimenter at 20 weeks of age, and those that were individually handled experienced a greater ( P<0.05) increase in their free corticosteroid response to humans at 24 weeks of age than did pigs in the pleasant handling treatment. There was no physiological evidence at 24 weeks of age that the pigs in the unpleasant handling treatments were chronically stressed. These results indicate that aversive handling of pigs, either as individuals or as members of a group, will adversely affect the growth performance of the young pig. The fact that there was no evidence that the unpleasantly handled pigs were chronically stressed and that some recent results in this area are contradictory are considered in the discussion.