Sunday, June 16, 2013

Uncle Ed and Aunt Marian

Best photo of the day! My Aunt Marian has been in the hospital since April. My Uncle Ed went back to the hospital this week. They haven't seen each other Since April. For Father' Day my cousin took his mom to surprise him in the Hospital. Look at the joy on his face.

Music in Managing Pain

Laurie Scudder, DNP, NP

Jun 13, 2013

Music Therapy Reduces Pain in Palliative Care Patients: A Randomized Controlled Trial

Gutgsell KJ, Schluchter M, Margevicius S, et al

J Pain Symptom Manage. 2013;45:822-831

Music Therapy

Management of pain is an important element of palliative care. However, patients also express a desire to be lucid and experience good quality of life during this time, goals that may be negatively affected by the sedation, nausea, and other adverse effects that accompany treatment with opioids and other pain medications.

Music therapy offers a low-risk, nonpharmacologic, low-cost adjunct to pharmacotherapy. Previous research, much of it qualitative, examining the efficacy of this intervention in patients with a range of diagnoses has yielded variable results. The purpose of the study by Gutgsell and colleagues was to examine the efficacy of a single music therapy intervention in reducing pain in a sample of palliative care patients.

Study Summary

The study was conducted at a single university-affiliated hospital. Patients with advanced, life-limiting conditions were referred for the study by members of the palliative care team. Patients invited to participate in the study were older than 18 years, had a pain score of 3 or greater on a numeric rating scale (NRS), were able to understand English, and were alert and oriented. Patients on scheduled pain medications were not excluded, although interventions were scheduled around administration of breakthrough pain medications and immediately before scheduled doses.

The intervention was a single 20-minute music therapy session using harp music played at a low volume and slow tempo. Patients were also given the option for the session to include an ocean drum component. The music intervention accompanied a relaxation exercise that began with placing a "do not disturb" sign on the patient's door, lowering light levels, offering a blanket, turning off cell phones, and guiding the patient through an autogenic relaxation exercise that included visualization of a safe place. Control patients received the relaxation exercises without the accompanying music.

A clinical nurse specialist evaluated all patients before the intervention using 3 different scales:

NRS -- a widely used self-report scale that asks patients to rate their pain on a scale of 0 (no pain) to 10 (worst possible pain).
The Face, Legs, Activity, Cry, Consolability (FLACC) Scale -- a behavioral pain assessment tool in which pain is rated on 5 criteria by a trained observer. Each of these criteria is assigned a score of 0 (no pain) to 2, and total scores range from 0 to 10.
Functional Pain Scale (FPS) -- a scale that allows assessment of a patient's subjective experience of pain by asking patients whether pain is tolerable or intolerable and about its effect on the ability to engage in daily activities. A score of 0 reflects no pain, and a maximum score of 5 indicates intolerable pain with a resultant inability to communicate or perform usual activities.

The clinical nurse specialist, who was blinded to the patient's assignment, left the room following the preintervention evaluation and returned after the intervention to complete a postintervention evaluation using the same 3 scales. Patients assigned to the control group were offered the music intervention following the postintervention evaluation.

Study Findings

Although 400 patients were referred by the palliative care team, only 200 agreed to participate and were randomly assigned to the intervention or control group. NRS scores for both the music therapy and control groups showed significant declines from pre-test to post-test, although the reduction was significantly greater in the intervention group (P < .0001). FLACC scores also declined significantly in both groups and, in contrast to NRS scores, did not differ significantly between the 2 groups. FPS scores declined significantly only in the intervention group.

The researchers conducted further analyses to determine whether baseline patient characteristics, such as age, sex, diagnosis, and severity and duration of pain, were related to the efficacy of the intervention. NRS and FPS scores did not vary in different patients, although the FLACC scores indicated that the effect of the intervention was greater in patients younger than 55 years. The researchers urged caution in interpreting that result because correction for multiple testing was not conducted.

Viewpoint

This study had several limitations. First, although 400 patients were referred for potential inclusion, only one half agreed to participate, suggesting that the final sample may have consisted of individuals inherently predisposed to a musical intervention. In addition, although the researchers did a good job of blinding the clinical nurse specialist who conducted the pre- and postintervention assessments, obviously the patients themselves were not blinded. Because 2 of the 3 assessment scales use patient report, patients' knowledge of their group assignment may have affected their own self-assessment.

This study does add to a growing body of evidence that music can be an effective component of pain management. Unlike many studies of music therapy, which used patient-preferred music, this intervention used the same music in all patients, suggesting that music chosen specifically to be soothing irrespective of patient preference may be effective. Although the music was more effective at relieving pain than the relaxation exercises alone, both groups experienced pain relief.

The investigators suggest that acknowledging a patient's pain and encouraging relaxation -- particularly if accompanied by environmental adjustments, such as dimming lights and diminishing noise -- are important adjuncts to pain management. Although that conclusion is not going to be a surprise to nurses, who have long incorporated therapeutic communication into their care of patients in pain, this study is a valuable reminder of its importance and the need to include these practices in the nursing art of helping patients to manage the unique experience of pain.

Abstract

Cite this article: Laurie Scudder. Music in Managing Pain. Medscape. Jun 13, 2013.

Depression Predicts Early Retirement in Patients With RA

Alice Goodman
Jun 15, 2013
MADRID — Depression is the strongest predictor of work disability leading to early retirement in patients with early rheumatoid arthritis (RA), report researchers. Mental health outpaced disease activity, response to medication, stress at work, and comorbidity.

"Our study shows that whether patients with early RA consider applying for a disability pension is more dependent on depression than disease activity," lead investigator Angela Zink, PhD, from the German Rheumatism Research Center in Berlin, told reporters attending a news conference.

"Identifying patients who are depressed early in the course of RA using a simple question may help patients remain in the workforce," she said. Dr. Zink pointed out that rheumatologists do not often assess patients for depression, and she says she hopes that this study will serve as a wake-up call.

Musculoskeletal diseases account for 50% of all absences from work and 60% of work incapacity in Europe, she said. "Inadequate management of these diseases poses a significant economic burden, estimated to be up to 2% of gross domestic product."

The study, presented here at the European League Against Rheumatism (EULAR) Congress 2013, included 573 patients with early inflammatory arthritis.

Our study shows that whether patients with early RA consider applying for a disability pension is more dependent on depression than disease activity. Dr. Angela Zink

At baseline, 82% were either working, on sick leave, or actively employed. About half the sample reported mild to moderate or severe depression, as reflected by responses to the statement: "I have little pleasure or interest in doing things some or most days during the past 2 weeks."

The mean duration of disease was 13 weeks; 67% were rheumatoid factor– or anti-citrullinated protein antibody–positive; 65% fulfilled the 2010 American College of Rheumatolog–EULAR RA criteria at baseline; and 87% were taking disease-modifying antirheumatic drugs (DMARDs).

At 12 months, 12% of patients were actively considering or receiving a disability pension less than 18 months after the onset of arthritis. Of these, 2.6% retired early.

A univariate analysis found several baseline predictors of early retirement within the first year of treatment, including age, low education level, fatigue, disease activity, and chronic pain. But the strongest predictors were moderate and severe depression.

Those with severe depression with little or no interest in daily activities on most days were 4.4 times more likely to seek early retirement than those without depression. Those with mild to moderate depression were 3.1 times more likely to seek early retirement.

A multivariate analysis revealed that both age and functional level were somewhat associated with early retirement, but the link was most robust for severe depression, with an 8.7 times greater likelihood of seeking early retirement.

"Depression is the elephant in the room for patients with RA, and rheumatologists are reluctant to ask about it," said news conference moderator Christopher Buckley, PhD, from the University of Birmingham in the United Kingdom.

"It is not news to us that patients with RA are often depressed. We see a lot of depression in patients with chronic diseases," added Eric Ruderman, MD, from Northwestern University in Chicago, Illinois, who was not involved in the study.

Dr. Ruderman said that it can be challenging to assess depression in a new patient but that it is somewhat easier in patients you have been treating for a while.

"If you do identify a depressed patient, another hurdle is knowing where to refer them for help or which of the many available antidepressants to suggest," he said. "I generally refer the patient back to the primary care doctor, who can take it from there."

Dr. Zink, Dr. Buckley, and Dr. Ruderman have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2013. Abstract OP0092. Presented June 13, 2013.

Medscape Medical News © 2013 WebMD, LLC

Send comments and news tips to news@medscape.net.

Cite this article: Depression Predicts Early Retirement in Patients With RA. Medscape. Jun 15, 2013.

Colorado Docs on Medical Marijuana: Taking the High Road

Charles P. Vega, MD

DisclosuresJun 13, 2013

Medical Marijuana in Colorado: The Study and Background

The use of marijuana as medicine has taken off in the past decade, as 18 states now feature laws that legalize its use for medical purposes. Although marijuana is a charged political and social issue, physicians have been relatively silent in their views on using this substance in treating patients.

Kondrad and Reid's study addresses physicians' attitudes toward medical marijuana in Colorado, a frontline state in the battle over the use of cannabis. This review describes the findings from their study and examines possible reasons why the majority of physicians have unfavorable views of medical marijuana.

Reference

Kondrad E, Reid A. Colorado family physicians' attitudes toward medical marijuana. J Am Board Fam Med. 2013;26:52-60.

Background

Cannabis has been used both as medicine and for recreation for centuries, yet marijuana been controversial in the United States at least since the turn of the 20th century. The use and regulation of medicinal marijuana remains contentious in many states. The arguments for and against the legal status of marijuana grew even hotter last fall, when the voters of Washington and Colorado approved initiatives to broadly legalize the possession of marijuana.

To many, the line between authorization of the use of medical marijuana and outright legalization is already blurred. As of now, 18 states and the District of Columbia have passed laws legalizing the use of medical marijuana.^[1] The current study describes how its use can explode when restrictions are lifted. The researchers note that the number of applications to Colorado's medical marijuana registry was 300 per month before October 2009, when the US Department of Justice published a directive that it would not pursue convictions for individuals who used marijuana for medical reasons. After this announcement, the rate of registry applications skyrocketed to 1000 per day, so that now more than 2% of Colorado's population is part of the registry.^[2]

Estimates of medical marijuana use are more difficult in other states. For example, California does not operate a patient registry. However, the National Organization for the Reform of Marijuana Laws, hardly a nonpartisan group, estimates that 2%-3% of Californians use medical marijuana.^[3] This translates into a possible 1 million individuals.

Whereas the prevalence of medical marijuana use remains a little hazy, there are some good data on why patients are prescribed cannabis. The most common indications for the use of medical marijuana among 1700 patients in California were pain, insomnia, and anxiety.^[4] These data are mirrored in the current study: In Colorado, 94% of patients receiving medical marijuana have chronic pain, and 17% have muscle spasms.

Although the past decade has seen a strong increase in the use of medical marijuana, between 1991-1992 and 2001-2002 the rate of overall marijuana use among all US adults had remained steady at an estimated 4%.^[5] Nonetheless, the rate of marijuana abuse or dependence increased by 25% during this same period to 1.5% of all US adults, with higher rates among persons of color accounting for nearly all of this increase.

The use of marijuana is particularly concerning among adolescents. In a nationwide survey taken between 2005 and 2008 of adolescents aged 12-17 years, the prevalence of marijuana use was 13%.^[6]One quarter of adolescents who used marijuana met criteria for either marijuana abuse or dependence. Native Americans were at particularly high risk for abuse and dependence, whereas African Americans had lower rates of these outcomes than both Native American and white adolescents.

There are no definitive data that the passage of medical marijuana laws in certain states has increased the overall use of marijuana or the risk for marijuana abuse or dependence, although one study found that adolescents in these states have a more accepting view of marijuana and use it at higher rates than in states without these laws.^[7,8] The lack of solid data regarding the wider implications of medical marijuana use allows advocates on either side of the marijuana debate to make sweeping, yet poorly informed, statements in support of their positions.

Physicians' voices have been largely missing from the medical marijuana debate, even though they are the ones writing the prescriptions. The current study examines attitudes and beliefs regarding medical marijuana from one of the nation's hotbeds of cannabis controversy: Colorado.

Jason Becker

http://jasonbeckerguitar.com/not_dead_yet.html

ALS

What is ALS?

Amyotrophic lateral sclerosis (ALS), often referred to as "Lou Gehrig's Disease," is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.

A-myo-trophic comes from the Greek language. "A" means no or negative. "Myo" refers to muscle, and "Trophic" means nourishment–"No muscle nourishment." When a muscle has no nourishment, it "atrophies" or wastes away. "Lateral" identifies the areas in a person's spinal cord where portions of the nerve cells that signal and control the muscles are located. As this area degenerates it leads to scarring or hardening ("sclerosis") in the region.

As motor neurons degenerate, they can no longer send impulses to the muscle fibers that normally result in muscle movement. Early symptoms of ALS often include increasing muscle weakness, especially involving the arms and legs, speech, swallowing or breathing. When muscles no longer receive the messages from the motor neurons that they require to function, the muscles begin to atrophy (become smaller). Limbs begin to look "thinner" as muscle tissue atrophies.

What Types of Nerves Make Your Body Work Properly?

(from Living with ALS, Manual 1: What's It All About?)

The body has many kinds of nerves. There are those involved in the process of thinking, memory, and of detecting sensations (such as hot/cold, sharp/dull), and others for vision, hearing, and other bodily functions. The nerves that are affected when you have ALS are the motor neurons that provide voluntary movements andmuscle power. Examples of voluntary movements are your making the effort to reach for the phone or step off a curb; these actions are controlled by the muscles in the arms and legs.

The heart and the digestive system are also made of muscle but a different kind, and their movements are not under voluntary control. When your heart beats or a meal is digested, it all happens automatically. Therefore, the heart and digestive system are not involved in ALS. Breathing also may seem to be involuntary. Remember, though, while you cannot stop your heart, you can hold your breath - so be aware that ALS may eventually have an impact on breathing.

Although the cause of ALS is not completely understood, the recent years have brought a wealth of new scientific understanding regarding the physiology of this disease.

While there is not a cure or treatment today that halts or reverses ALS, there is one FDA approved drug, riluzole, that modestly slows the progression of ALS as well as several other drugs in clinical trials that hold promise.

Importantly, there are significant devices and therapies that can manage the symptoms of ALS that help people maintain as much independence as possible and prolong survival. It is important to remember that ALS is a quite variable disease; no two people will have the same journey or experiences. There are medically documented cases of people in whom ALS ‘burns out,’ stops progressing or progresses at a very slow rate. No matter what your individual course or situation may be, The ALS Association and your medical team are here to help.

To learn more about the personal stories of people who are living fully, click here. As one man put it, “I’ve made ALS part of my life, not my whole life.”