Use of focus groups for pain and quality of life assessment in adults with sickle cell disease

This study assessed the effectiveness of using focus groups to obtain information about the characteristics of pain and quality of life in adults with sickle cell disease and their families. Five focus group sessions were held. Four groups consisted of adults diagnosed with sickle cell disease and one was composed of family members. Although focus groups were useful for addressing the purposes of the study, several volunteers in the patient group were unable to attend due to the occurrence of pain episodes. Adults with sickle cell disease identified recurring disabling pain and its consequences as interfering with their physical, emotional, and social quality of life. Several reported a pain aura that signaled the initiation of a painful episode. Useful self-care techniques and coping strategies were also identified. Common emotional responses included anger, hostility, depression, disenfranchisement, death anxiety and fatalism. The belief by those with sickle cell disease that health professionals viewed them as drug dependent often fueled angry and hostile responses. Religion was a major source for coping. Family members' quality of life was affected and they felt the negative impact of sickle cell disease on family relationships. Family members also reported feelings of helplessness, guilt, and parental self-blame. Health care providers could use information gained through this study to positively influence the care of adults with sickle cell disease.

Cardiac instrument development in a low-literacy population: the revised Chest Discomfort Diary

OBJECTIVE

The purpose of this study was to pilot test a self-administered chest pain questionnaire, a revised version of the Chest Discomfort Diary (CDD-R), in a sample of patients with chronic angina selected from a population known to have low literacy.

DESIGN

The study design was descriptive and correlational.

SAMPLE

The study used a convenience sample of 27 subjects with documented history of coronary artery disease and angina. Characteristics of the sample included a mean age of 56.3 years (SD, 12.4 years), 88.9% African-American, and 56.3% male, and 59.3% had a history of acute myocardial infarction. Approximately 28% had achieved a 9th-grade education or less, and reading levels ranged from 4th grade to 12th grade. Subjects completed the CDD-R, a 36-item instrument reflecting multiple dimensions of anginal chest pain.

RESULTS

Descriptions of the location (left chest, 66.6%), character (pressure, 59.2%), and precipitants of chest pain (walking, 51.8%) were consistent with clinical descriptions of "typical angina." Other physical symptoms such as shortness of breath (88.8%) and fatigue (85.1%) were reported. Walking (55.5%) was the activity most frequently described as difficult to perform because of chest pain, with sublingual nitroglycerin (77.7%) the most frequently used and most effective chest pain relief strategy.

CONCLUSION

The CDD-R adequately measured multiple characteristics of anginal chest pain. Further research is needed to establish construct validity of the CDD-R and to determine the feasibility of using the instrument to monitor changes over time in patients' chronic angina.

Development and validation of the satisfaction with pharmacist scale

To assess patients' satisfaction with pharmacists, seven questions were developed with semistructured input from 5 pharmacy practice faculty members and 11 patients with cancer. The study identified 1617 English- and Spanish-speaking patients with cancer or human immunodeficiency virus infection or acquired immunodeficiency syndrome who participated in a multisite validation of the Functional Assessment of Cancer Therapy Scale. Of these, 1124 had seen a pharmacist in the past 7 days and therefore were eligible; 608 spoke English and 516 Spanish. The seven items on the Satisfaction with Pharmacist (SWiP) scale were rated on a five-point Likert scale (0 = not at all to 4 = very much). The reliability of the English and Spanish versions was evaluated by Cronbach's alpha coefficients. The unidimensionality and construct validity were analyzed with the Rasch rating scale model. The alpha coefficients for the English and Spanish versions were 0.90 and 0.92, respectively. Rasch analyses of item responses showed that none of the items in either language was a misfit, which supported their ability to measure a unidimensional construct. Item difficulty plots revealed that no item exhibited differential functioning, indicating that the items performed the same in both languages. The SWiP scale has reliable and valid psychometric properties in English and Spanish and can be used to document the value of the pharmacist-patient relationship. It is easy to administer and is ready for further use and evaluation to determine and document outcomes of pharmaceutical care.

Maintaining study validity in a changing clinical environment

BACKGROUND

Nurse scientists who conduct intervention research in a variety of clinical settings find themselves facing numerous challenges posed by today's changing and sometimes complex health care environment. Maintaining study validity thus becomes a major focus of interventional research, but existing literature does not fully address challenges to study validity nor offer potential solutions.

OBJECTIVES

The purposes of this paper are to 1) discuss methodologic challenges to maintaining study validity of intervention research that is conducted in a changing clinical environment, and 2) share strategies for maximizing study validity.

METHODS

A recently completed intervention study is used as an example to discuss two specific areas that affected study validity, provide examples of selected threats to validity, and outline strategies used to minimize these threats.

RESULTS

Careful definition of goals, thoughtful decision making, and implementation of specific strategies to maintain study validity helped increased the rigor of the research.

CONCLUSIONS

Investigators conducting intervention research in changing clinical settings can reduce threats to study validity and increase design rigor by considering clinical realities (e.g., clinician-researcher role conflict) when making methodologic decisions, becoming familiar with the setting, and involving clinicians in the research.

Research and oncology nursing practice

OBJECTIVE

To trace the evolution of oncology nursing research and to discuss its contribution to oncology nursing practice and health care.

DATA SOURCES

Articles, textbooks, organizational documents, conference proceedings, and personal communication.

CONCLUSIONS

Placing research in perspective will help suggest where we should go as a nursing specialty to provide excellent cancer care to patients, families, communities, and populations. It will also suggest directions for research priorities and for conceptual, methodologic, and health policy activities.

IMPLICATIONS FOR NURSING PRACTICE

To influence oncology care, it is essential that oncology nurse researchers be responsive to trends that are relevant to both the conduct and utilization of oncology nursing research.

Implementation of an oral care standard for leukemia and transplantation patients

The purpose of this project was to develop an oral care standard on two nursing units in a university hospital where care was given to patients undergoing bone marrow or stem cell transplantation (BMSCT) and other treatments for leukemia. Strategies used in this interdisciplinary effort included collaboration, consultation, education, and evaluation. In the collaboration phase, a core group of nurses talked with staff about current practices, reviewed literature and published standards, examined protocols from other institutions, decided on goals, and developed the standard. Consultation with a dentist, pharmacist, and physician occurred before completion of the standard. The education phase included in-service sessions for nurses and technicians. The evaluation phase, which occurred in two phases, focused on checking to see if the goals had been met, including tolerability and adherence. The first phase allowed identification of problem areas and subsequent revisions, whereas the second phase evaluated adherence at a later time point. Overall, most of the patients adhered to the standard. Future implications include specific recommendations such as an emphasis on oral care, documentation, and patient and staff education. This project is an example of how nurses addressed the challenge of implementing an acceptable oral care standard to decrease patients' oral complications and distress.

Comparison of subjective sleep quality in patients with cancer and healthy subjects

PURPOSE/OBJECTIVES

To compare the subjective sleep quality of a group of patients with cancer undergoing treatment and a normative sample of healthy comparison subjects.

DESIGN

Secondary analysis of data from a single time point in a repeated measures descriptive-correlational study.

SAMPLE/SETTING

Convenience sample of 15 patients with cancer receiving antineoplastic therapy and admitted to a tertiary university medical center for fever or neutropenia and 52 healthy comparison subjects without sleep disturbances. Although both groups were of similar age, a higher percentage of men comprised the comparison group.

METHODS

Patients completed the Pittsburgh Sleep Quality Index (PSQI) on the first day of hospitalization to reflect their perceptions of sleep for the month prior to hospitalization. Healthy comparison subject scores on the PSQI were obtained from a published report outlining psychometric properties of the PSQI (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989).

MAIN RESEARCH VARIABLES

Sleep latency, sleep duration, sleep efficiency, sleep disturbances, medication use, daytime dysfunction, and global sleep quality.

FINDINGS

Patients with cancer reported significantly poorer overall sleep quality accompanied by more daytime dysfunction. The incidence of specific sleep disturbances, such as snoring and dyspnea, was not different between the groups.

CONCLUSIONS

This small sample of patients reported significantly poorer sleep quality than an historical comparison group. Specific sleep disturbances commonly seen in the general population were not problematic for the patients with cancer. Limited sample size and use of an historical comparison group need to be considered in interpreting and applying these findings. Additional research is needed to further characterize the nature of sleep problems in patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to assess sleep in their patients, including its impact on quality of life and functional status.

The impact of socio-cultural and clinical factors on health-related quality of life reports among Hispanic and African-American cancer patients

A hierarchical multiple linear regression approach (N = 761) was used to identify pertinent factors which influence health-related quality of life (HRQL) reports among Hispanic and African-American cancer patients. The independent variables include: performance status, disease site, disease stage, mode of administration, socio-economic status (SES), gender, age, living arrangement, race/ethnicity, religious affiliation, insurance status, and spiritual beliefs. The outcome measures, five subscales of HRQL (physical well-being, social well-being, satisfaction with treatment, emotional well-being, functional well-being) and overall HRQL (sum of the five subscales), were estimated using the Functional Assessment of Cancer Therapy (FACT) Scales. This study identified performance status and spiritual beliefs as consistent predictors of overall HRQL. This study also found no significant effects of SES, mode of administration, gender age, living arrangement and insurance status on the reporting of overall HRQL. Spiritual beliefs and performance status are important determinants of HRQL across a diverse group of cancer patients.

Building and maintaining an interdisciplinary research team

Successful grant-writing in Alzheimer disease research, as with many other diseases, requires collaborative work among a group of individuals who represent various disciplines of relevance to the research problem. Interdisciplinary teams in Alzheimer disease research have the potential to explore more facets of a given research problem than teams that are not interdisciplinary in nature. Such teams also have the potential to produce better science and to disseminate results to a wider spectrum of relevant groups, may be more successful in achieving funding, and are stimulating and growth-enhancing for members. Building and maintaining these teams is a complex and challenging process, but identification and proactive resolution of challenges is essential. Important elements of success include establishing common goals, using a democratic group process, maintaining open communication, developing mutually acceptable policies for disseminating research results, and facilitating achievement of team members' personal and professional goals.

Acute oral pain and mucositis in bone marrow transplant and leukemia patients: data from a pilot study

The purposes of this prospective, repeated-measures descriptive pilot study were to describe patterns of acute oral pain and mucositis in patients receiving a bone marrow transplant or high-dose chemotherapy for leukemia, and to test procedures and instruments before initiating a larger intervention study. A nonprobability, purposive selection process was used to enroll 18 patients admitted to two acute care inpatient hospital units for bone marrow transplantation or leukemia therapy at a university health sciences center in the southeastern United States. Data were collected at baseline, then daily through patient interviews, oral examination, and chart review for at least 3 weeks or until discharge. Research variables were pain intensity, intolerable pain, verbal descriptors of pain, pain relief, and use of pain relief strategies (Pain Assessment Form), mucositis (erythema and ulceration) in eight anatomic locations of the oral cavity (Oral Mucositis Index), voice/talking (Oral Assessment Guide), and mood states (11-item Brief Profile of Mood States). Mild to moderate pain occurred in nearly 70% of patients and was described as "tender," "irritating," and "sore." Patients used pain medicines, mouth care, and mental and physical activities to relieve pain, and reported partial overall relief of pain. Mucositis was mild, with the tongue and buccal and labial mucosa most commonly affected with erythema and the buccal mucosa with ulceration. Voice/talking were only mildly impaired, and mood disturbance was mild. Patterns of pain, mucositis, and mood disturbance were consistent with each other and followed the trajectory described in previous research. Results suggest that nurses should continue to assess these symptoms vigorously and assist patients in selecting multiple management strategies. Research using repeated-measures designs in this acutely ill inpatient population is challenging and needs careful attention by researchers. The results have been used to improve the ongoing larger intervention study.

Peer review, authorship, ethics, and conflict of interest

PURPOSE

To explore problems in peer review, authorship, ethics, and conflict of interest related to writing and publishing. Publishing and adhering to principles is critical as nurse researchers, educators, administrators, and practitioners participate in the development and dissemination of knowledge.

CONCLUSIONS

The quality and integrity of nursing publications are affected by peer review, author collaboration, and ethical conduct. Understanding the conflicts of interest inherent in each action and being committed to impartial review and meeting the requirements of authorship can ensure fewer difficulties for authors, publishers, and consumers.

Healthcare needs of HIV-infected persons in hospital, outpatient, home, and long-term care settings

In this descriptive study, healthcare needs reported by 386 HIV-infected persons from all risk categories and their primary nurses from four care settings (hospital, outpatient, long-term care, and home) are identified. Healthcare needs were classified into four domains of nursing practice using a conceptual framework from community health nursing--physiologic, psychosocial, health behaviors, environmental--and were assessed using the Healthcare Needs Scale for Patients with HIV/AIDS. Nurses' perceptions of major healthcare needs across all settings centered around decreased physical endurance, limited physical mobility, and sensory deficits. Patients' needs focused on financial issues. The results reflect the multidimensional nature of this infection and provide direction for clinical practice.

Patients' and healthcare providers' opinions regarding advance directives

PURPOSE/OBJECTIVES

To gain a better understanding of patients' and healthcare providers' preferences regarding when, how, and by whom advance directive information should be given and to explore the nursing role in advance directives.

DESIGN

A qualitative study using focus group methodology.

SETTING

A National Cancer Institute-designated comprehensive cancer center located within a large, university-affiliated, tertiary care hospital in the northeastern United States.

SAMPLE

Two samples participated in the study: eight adult ambulatory patients with cancer and 15 healthcare providers (4 physicians, 10 nurses, and 1 social worker).

METHODS

Separate patient and provider focus groups were conducted in private rooms by experienced facilitators using an interview guide with questions based on the literature, the hospital's advance directive materials, and the investigators' experience; sessions were audio-taped, transcribed, and analyzed using qualitative data analysis techniques.

FINDINGS

Patients and healthcare providers discussed focus group questions and commented that advance directive discussions should be provided early in the treatment or illness, presented in a short and simple format with reading materials at a level appropriate for the patient, and continued throughout the illness with those who desire follow-up. Nurses, doctors, social workers, or a designated/trained advance directive person were individuals that the patients identified as people with whom they could have advance directive discussions.

CONCLUSIONS

Results suggested that advance directive information should be given prior to hospital admission, be provided in a variety of formats, and that nurses, social workers, doctors, or designated staff representatives could all be part of the advance directive process.

NURSING IMPLICATIONS

Nursing roles should include early assessment of patients to determine needs for discussion, advocacy on behalf of patients, and provision of information. Future research should examine use of specific personnel for facilitating advance directives and compare different formats for presenting advance directive information to patients.

Development of a nursing research utilization program in a clinical oncology setting: organization, implementation, and evaluation

PURPOSE/OBJECTIVES

To describe a research utilization program in the nursing department of a National Cancer Institute-designated comprehensive cancer center, including prerequisites for its development, its relationship to the department's nursing research program, the research utilization model used in the program, and evolution, evaluation, and future directions of the program.

DATA SOURCES

Computerized literature searches; published articles, abstracts, and books; personal communications; departmental, committee, and task force meetings; nursing grand rounds; workshops; and inhouse surveys of nursing staff.

DATA SYNTHESIS

Review and use of available information led to a comprehensive, multicomponent, departmental research utilization program that addressed issues raised in both the literature and in clinical practice.

CONCLUSIONS

The nursing department was able to implement a research utilization program under the aegis of its research program that was consistent with the department's philosophy, goals, and organizational structure. Although many challenges and issues arose, ongoing evaluation measures indicate wide acceptance, successful implementation and direct influence on practice.

IMPLICATIONS FOR NURSING PRACTICE

With strong administrative support, a departmental nursing research utilization program that enables participation of nursing staff and results in research-based practice and professional development can be implemented.

A survey of research-related activities and perceived barriers to research utilization among professional oncology nurses

PURPOSE/OBJECTIVES

To identify nursing staff members' current research-related activities, knowledge of research utilization, and perceived barriers to using research in practice.

DESIGN

Descriptive, cross-sectional survey design with self-report questionnaires.

SETTING

National Cancer Institute-designated comprehensive cancer center located in a mid-Atlantic metropolitan area.

SAMPLE

Convenience sample of 82 registered nurses employed in the cancer center who completed and returned the questionnaire; the majority had baccalaureate degrees or higher, were an average of 33 years old, were nurses for a mean of 8.8 years, and worked at the center a mean of 5.6 years.

METHODS

Four-part, 38-item, self-report questionnaires were distributed to nursing staff and a leadership group by members of the departmental Nursing Research Committee; respondents returned completed questionnaires to designated locations in the center.

MAIN OUTCOME MEASURES

Knowledge and attitudes about research utilization, perceived barriers to using research in practice, and current research-related activities.

FINDINGS

Most respondents were familiar with the concept of research utilization and found research to be of value to their practice. They cited a number of barriers to using research findings and reported little participation in research-related activities. Advanced clinical practitioners with master's degrees tended to participate more frequently in research-related activities.

CONCLUSIONS

Although nurses appeared to be aware of research utilization and value it, they perceived barriers to using research findings in practice and did not routinely participate in research-related activities. The findings support other research in this area and reveal educational needs.

IMPLICATIONS FOR NURSING PRACTICE

The findings provided baseline information for a departmental research utilization program and suggested strategies and activities that could be incorporated into the program.

Patterns of mucositis and pain in patients receiving preparative chemotherapy and bone marrow transplantation

The purpose of this study was to describe the incidence, onset, duration, severity, and other relevant characteristics of mucositis and pain in patients undergoing bone marrow transplant (BMT) who were receiving high-dose chemotherapy (cytoxan, busulfan, and etoposide) without total body irradiation. A descriptive, longitudinal design was used to study a sequential sample of 47 patients undergoing allogeneic and autologous BMT. Each day, from 9 days prior to BMT through 21 days after BMT, nine anatomic regions of patients' mouths were assessed for extent and severity of mucositis. Oral pain was measured using the Short-Form McGill Pain Questionnaire. Forty-two patients (89%) developed mucositis, which, on average, began 3 days after transplant, lasted 9.5 days, and resolved by 12.6 days post-transplant. Thirty-six patients (86%) reported pain that began, on average, 4.5 days after transplant, lasted 6.5 days, and resolved by 11 days post-transplant. During the initial weeks following BMT, systematic assessment of the oral cavity areas that are at high risk for mucositis should assist nurses in detecting early oral complications and in initiating specific interventions. Additionally, attention needs to be given to the assessment and management of mucositis-related oral pain. Future nursing research should be conducted to examine efficient clinical methods of assessing mucositis and oral pain and to test prophylactic and therapeutic interventions.

Knowledge and beliefs regarding pain in a sample of nursing faculty

Pain is a significant problem impacting between 50 per cent and 80 per cent of cancer patients and affecting overall quality of life. Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in pain. Several reasons have been identified including inadequacies in nursing and medical education, absence of curriculum content related to pain management, and faculty attitudes and beliefs related to pain. This article presents data from a cross-sectional mall survey that consisted of a self-administered knowledge and beliefs questionnaire and a self-reported pain curriculum questionnaire. Faculty from 14 baccalaureate nursing schools in the United States participated in the study. The study suggests that in baccalaureate schools of nursing, faculty knowledge and beliefs about pain and the curriculum content related to pain may be less than optimal.

Analgesic decision-making skills of nurses

Administration of analgesics is a common nursing intervention for providing pain relief to patients with cancer. A sample of 177 nurses participated in a study to examine their decision-making skills when analgesic orders were changed. Nurses were given four clinical vignettes and reference materials to assist them in responding to the vignettes. Twenty-six percent of 708 responses provided by the nurses were answered correctly. Twenty-nine percent of the sample answered all four vignettes incorrectly. The majority (44%) answered only one vignette correctly. No statistically significant differences were found between correct answers and type of work setting, academic preparation, number of patients with cancer cared for per week, number of years employed as a nurse, recent clinical experience with the analgesics used in the vignettes, or the use of reference materials. These findings raise concerns that patients requiring analgesics may not receive an amount that adequately relieves their pain or avoids unnecessary toxicity.

Comprehensive and multidimensional assessment and measurement of pain

Current theories of pain and clinical experience support a multidimensional framework for the experience of pain that has implications for assessment and management in any setting. Six major dimensions have been identified: physiologic, sensory, affective, cognitive, behavioral, and sociocultural. Any clinical assessment process must address relevant dimensions of pain in the given setting. In acute care settings, for example, clinicians may focus on physiologic and sensory dimensions, whereas in chronic care settings, the affective, cognitive, and behavioral dimensions might assume priority. Various tools are available for multidimensional assessment of pain, spanning the dimensions of the experience from physiologic to sociocultural. The clinician in any setting must use appropriate tools that provide useful information. Guidelines helpful in a selection process include identification of relevant dimensions of pain, type of pain, patient population and setting, psychometric properties of the tool, and issues of time, clinical relevance, and feasibility. When a careful selection process occurs, the resulting data should simultaneously meet clinicians' needs for information as well as provide the foundation for initiation of multidisciplinary interventions.

A comparison of the Hopkins Pain Rating Instrument with standard visual analogue and verbal descriptor scales in patients with cancer pain

A self-contained, portable, pain rating instrument that provides an immediate result for documentation purposes was developed to improve pain assessment in cancer patients. The Hopkins Pain Rating Instrument (HPRI) is a 5 x 20 cm plastic visual analogue scale (VAS) with a sliding marker that moves within a groove that measures 10 cm. The side facing the patient resembles a traditional VAS while the opposite side is marked in cm to quantify pain intensity. This psychometric study, which employed a descriptive correlational design, evaluated the reliability and validity of the HPRI by comparing it with a traditional VAS and verbal descriptor scale (VDS). Outpatients with and without pain and inpatients with pain rated their major pain site with the three instruments, which were presented in random order. This was followed by a mental status exam and re-rating of pain with the same instruments to assess test--retest reliability. Completing the study were 71 patients with a variety of cancers and a mean age of 52.8 years. Of these patients, 68% had pain and 54% were receiving opioid analgesics. The most common pain sites were the back, leg, and epigastric areas. On initial and repeat testing, there were high correlations between the HPRI and the VAS (r = 0.99, P less than 0.0001) and the VDS (r = 0.85, P less than 0.0001). The correlation coefficients for test--retest reliability for the HPRI, VAS, and VDS were 0.97, 0.97, and 0.94 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Multidisciplinary management of vascular access devices

Many problems associated with the use of vascular access devices (VADs) can be circumvented with an organized, systematic approach to management. This paper describes an approach that includes several key components: 1) A nurse coordinator of parenteral therapy (CPT) follows all patients with a VAD; records demographic and clinical data on an ongoing basis; monitors complications and outcomes; serves as a consultant for VAD-related questions; develops policies, procedures, and guidelines for catheter care; and oversees inservice nursing and basic patient education. 2) A data coordinator enters all data into a data base management system, compiles complication and other statistics on a periodic basis, and retrieves selected data for specific purposes. 3) A VAD Committee, composed of the above two individuals, a nurse epidemiologist, and physicians representing medical oncology, hematology, transplantation, pediatrics, and surgery, meets monthly to collectively evaluate and assign cause for complications, consider new products, and discuss policy changes regarding VADs. As a result of this multidisciplinary process, responsibility and accountability for VAD insertion and care are appropriately placed, statistics on complications are compiled, and treatment and policy decisions are made. These outcomes have resulted in a significant reduction in complications, an increase in average catheter life, enhancement of quality assurance, and overall improved patient care.

Patient experiences with research in a tertiary care setting

Data from a number of studies indicate that patients' understanding and recall of information presented during the informed consent process are poor. The purpose of this survey was to determine patients' attitudes about, desired knowledge of, and involvement in clinical research in a tertiary medical care setting. A self-report questionnaire was completed by 277 patients on the oncology, obstetrics/gynecology, medicine, neurosciences, surgery, and ophthalmology services of a large tertiary care facility. While most respondents had generally positive attitudes about research, relatively few were aware that human subjects approval processes existed or that nurses conducted research. Areas of additional knowledge needed included specific information about purposes of research and risks and benefits. Individuals with higher levels of education appeared more willing to participate in clinical research even when personal benefit was minimal.

Advances in control of cancer pain

The wide variety of techniques and rapidly developing complex technologies currently available for managing pain, as well as the multidimensional nature of cancer pain, require that a multidisciplinary approach to treatment be used in virtually all health care settings. Members of each health care discipline have unique and very important contributions to make to the care of patients with cancer pain. This critical fact has only recently been recognized and incorporated into the management of persons with pain in inpatient, outpatient, and home settings. The development and refinement of multidisciplinary teams, coupled with the use of the most current and effective therapeutic interventions available, should result in better care of and quality of life for patients with cancer pain.

The measurement of clinical pain

Major problems in the measurement of clinical pain are created because of (1) its subjective nature, (2) a limited number of reliable and valid instruments that measure the experience, and (3) a multitude of clinical issues such as type of pain, cause, and patient sample characteristics. Instruments currently available measure intensity, behavioral and/or physiologic phenomena associated with pain, and multiple dimensions of the experience of clinical pain. Important factors the nurse must consider when selecting a measuring instrument are the various definitions of pain, the goals of the measurement problem, and the type of pain being measured. Additional factors are specific sample characteristics, ease of administration and scoring, and reliability and validity data. A careful and deliberative selection process should help provide useful and relevant information.

Waldenström's macroglobulinemia and autoimmune disease in a family

We diagnosed Waldenström's macroglobulinemia in a father and three offspring. Clinical and subclinical autoimmune disorders occurred excessively in the family. The HLA haplotype A2, B8, DRw3 was detected in all patients with Waldenström's macroglobulinemia and all but one family member with autoimmune manifestations. A lod score [log odds] of 4.86 favors linkage to the HLA complex of a gene predisposing to lymphoproliferative and autoimmune disorders. Associated with this HLA haplotype were the B-cell alloantigens Ia-172 and 350, previously reported in patients with the lymphoma-prone sicca syndrome.

Genealogy of cancer in a family

Three brothers had separate childhood cancers--osteogenic sarcoma, acute lymphoblastic leukemia, and bilateral malignant neurilemoma. Comprehensive family history showed a total of 16 cases of cancer among the descendants of the proband's great-great-great-grandmother, including a previously unsuspected cluster of similar neoplasms in an distant branch. The constellation of tumors in the family included bony and soft-tissue sarcomas, brain and neural tumors, leukemia, and breast carcinoma, occurring in a pattern suggesting the action of an incompletely penetrant autosomal dominant gene with pleiotropic effects. In some cases the genetic predisposition may have interacted with environmental determinants to produce particular tumors.