Postpartum Depression For Dummies, 2nd Edition

Penulis: Chow, Cheryl
Impresum: HOBOKEN: WILEY PUBLISHING; 2007
Kolasi: xii, 276 hlm.
Keyword: Postpartum, Depression
ISBN:    978-0-470-12170-2
Tebal    362 halaman

   It's a great blessing when a new mom with postpartum depression (PPD) is fortunate enough to be diagnosed early by a knowledgeable medical practitioner or therapist. But without guidance, it isn't always clear where the boundary between normal baby blues and PPD lies. As with any other illness, the quicker that PPD is identified and treated, the faster the woman will recover.
   Postpartum Depression For Dummies can help you begin the process of determining what’s going on with you and give you a better idea of where you fall so that you can get yourself into proper treatment right away. The book covers all aspects of PPD, from its history and its origins to its effects on women and their families to the wide variety of treatments available—including conventional Western medicine, psychological therapy, alternative medical treatments, and self-care measures. Postpartum Depression For Dummies reveals:

- Why some doctors may be hush-hush about PPD
- How to distinguish between pregnancy hormone changes, "baby blues," and PPD
- The difficulties of getting a proper diagnosis
- The role and importance of a therapist
- The benefits of medication for depression
- Alternative treatments with  a successful track record
- How to find the right balance of psychological, medical, and alternative treatment
- Ways you can help foster recovery
- The nutrition you need to care for yourself properly
- How to help your partner help you

   Postpartum Depression For Dummies also provides the additional resources you need—web sites, organizations, and further reading—to help avoid the unnecessary suffering caused by undiagnosed and untreated PPD and survive and thrive as a new mom

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Therapy And The Postpartum Woman: Notes On Healing Postpartum Depression For Clinicians And The Women Who Seek Their Help

Penulis:Kleiman, Karen R
Impresum:NEW YORK: TAYLOR & FRANCIS GROUP; 2009
Kolasi:xxi, 334 hlm.
Keyword:Postpartum
ISBN:978-0-415-98996-1;1135856338
Tebal    250 halaman

   This book provides a comprehensive look at effective therapy for postpartum depression. Using a blend of professional objectivity, evidence-based research, and personal, straight-forward suggestions gathered from years of experience, this book brings the reader into the private world of therapy with the postpartum woman. Based on Psychodynamic and Cognitive-Behavioral theories, and on D.W. Winnicott's "good-enough mother" and the "holding environment" in particular, the book is written by a therapist who has specialized in the treatment of postpartum depression for over 20 years. Therapy and the Postpartum woman will serve as a companion tool for clinicians and the women they treat.

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Nursing Care Plan for Retinal Detachment

Retinal detachment is the separation of the the retina from the choroid (the middle vascular coat of the eye between the retina and sclera). It occurs when the retina develops a hole or tear and the vitreous seeps between the retina and choroid. If left untreated, retinal detachment can lead vission loss.

The possible causes of retinal detachment are Trauma, Hemorrhage, Myopia, Tumor, Aging, Diabetic neovascularization, Inflammatory process and Familial tendency.

Assessment findings of retinal

detachment :

• Painless change in vision (floaters caused by blood cells in the vitreous and flashes of light as the vitreous humor pulls on the retina).
• Photopsia ( recurrent flashes of light).
• Blurred vision worsening as detachment increases.
• with progression of detachment, painless vision loss that may be described as veil, curtain or cobweb that eliminates part of the visual field.

Diagnostic evaluation for Retinal Detachment :

• Indirect opthalmoscopy shows retinal tear or detachment.
• Slit-lamp examination reveals retinal tear or detachment.
• Ultrasound shows retinal tear or detachment in presence of cataract.

Treatment for Retinal Detachment :

• Complete bed rest and restriction of eye movement to prevent further detachment.
• Laser theraphy, if there's a hole in the posterior portion of the retina
• Scleral buckling to reattach the retina, It is a surgical procedure, which a silicone band or sponge is sewn around the eyeball a little behind the visible portion or the eye. Exactly locates the hole and places the band and tightens it creating a buckle effect and then the outer coats of the eye are indented and in this way the hole in the retina approximates the outer scleral coat.



• Pneumatic Retinopexy, It is a short simple procedure, where a fixed amount of air is injected in the posterior part of the eye, which the air acts as an internal tamponade that helping to push and approximate the tear with the outer coat of the eye ball. Following the tear is sealed with cryo or laser therapy. Post-operatively the patient is advised rest in a specified position, in order to facilitate the air bubble to push the desired area of the retina with the tear against the sclera.





• Sub-retinal fluid drain : make seep the fluid out through the hole behind the retina that can be drained with a small slit made in the outer coats of the eye to flatten the retina. This procedure is usually done along with sclera bucking to flatten the retina.
• Vitrectomy: The procedure involves cutting and removal of the vitreous gel along with removal of all the fibrous tissue causing traction (pull) on the retina and detaching it, or sometimes the space is replaced with gas or silicon oil. ussually the procedure is done with the help of micro instruments and a fiberoptic light source. The procedure is combined with sclera buckling.



• Cyropexy, if there's a hole in the peripheral retina.

Nursing diagnoses for Retinal Detachment :

• Disturbed sensory perception (visual).
• Anxiety.
• Risk for injury.

Planning and goals nursing care plan for Retinal Detachment :

• The client will remain free from injury.
• The client will be free from permanent visual impairment.
• The client will understand the treatment options.

Implementation nursing care plan for Retinal Detachment :

• Asses visual status and functional vision in the unaffected eye to determine self care needs.
• Prepare the client for surgery by explaining possible surgical interventions and technique to alleviate some of the client's anxiety.
• Discourage straining during defecation, bending down and hard coughing, sneezing or vomiting to avoid activities that increase intraocular pressure.
• Assist with ambulation, as needed, to help the client remain independent.
• Approach the clients from the unaffected side to avoid startling him.
• Provide assistance with activities of daily living to minimize frustation adn strain.
• Orient the client to his environment to reduce the risk of injury.
• Posoperatively instruct the client to lie on his back or on his unoperated side to reduce intraocular pressure in the affected area.

Evaluation nursing care plan for Retinal Detachment :

• The client's vision is restored.
• The client will remains free from injury.
• The client will understands all discharge instructions.

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Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease, also knwon as chronic airflow limitation (CAL), chronic obstructive lung disease (COLD), chronic obstructive respiratory disease (CORD), chronic obstructive airway disease(COAD) is a group of conditions that obstruct pulmonary airflow, resulting in air being trapped in the alveoli and then make difficult to breathe.

There are two main forms of COPD :

Chronic obsturctive bronchitis, a productive cough that persisting for 3 months of the year for at least 2 consecutive years, causes inflamed airways that lead to increased mucus production and bronchospasms. Mucus plugs entrap air and result in alveolar hyperventilation. Patient will have severe hypoxemia and polycythemia, with hematrocit values from 50 % to 55 %.

Emphysema, characterized by enlargment of the alveoli distal to the terminal bronchioles, leads to alveolar wall destruction. obstructed expiratory airflow and irreversible loss of the lung elasticity. It is causes less hypoxemia and hematrocit values commonly normal.

The causes COPD :

• Allergens.
• Smoking.
• Alpha-1 antitrypsin deficiency.
• Chronic respiratory tract infection.
• Airborne irritants and pollutants, like certain gases or fume in the workplace and using cooking fire without proper ventilation.

Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD).

Assesment findings in COPD :

• Anatomic changes (such as barrel chest and clubbing) in late disease.
• Cough (evaluate characther, frequency and time of day).
• Decreased breath sounds, hyperresonant breath sounds on percussion and wheezing.
• Cor pulmonale (right-sided heart failure).
• Prolonged expiration.
• Dyspena.
• Jugular vein distention.
• Peripheral edema.
• Use of accessory muscles.
• Pursed-lip breathing.
• Sputum (amount, color and consistency).
• Use of accessory muscles.
• Risk factors.

Diagnostic evaluation for COPD :

• ABG levels show hypercapnia and hypoxemia. Bicarbonate levels may increase to compensate for chronic hypercapnia and the resultant respiratory acidosis.
• Pulmonary function test, especially spirometry, reveal diminished lung function.
• Pulse oximetry may show a decrease in arterial oxygen saturation, which indicates impending hypoxia.
• Complete blood count shows elevated hemoglobin level and hematocrit.
• Chest X-ray provides baselines norms; in late disease, the patient's diaphragms appears flat.
• ECG shows signs of right ventricular hyperthrophy in late disease.

Treatment for COPD :

• O2 therapy at 2 to 3 L per minute and transtracheal therapy for home O2 therapy.
• Fluid intake up to 3 L per day if not contraindicated by heart failure.
• Chest physiotherapy, postural drainage and incentive spirometry.
• Diet high in protein, vitamin C. calories and nitrogen. Patients with advanced disease may require a diet thats's low in carbohydrates and higher in fats.

Drug therapy option for COPD :

• Antibiotic : infecting organism determines which drugs is used.
• Bronchodilator : aminophylline, terbutaline, theophylline; by nebulizer: albuteral (proventil), ipratropium bromide (atrovent), metaproterenol sulfate (alupent).
• Expectorant : guaifenesin.
• Steroid : hydrocortisone, methylprednisolone sodium succcinate; by nebulizer : beclomethasone, triamcinolone.
• Antacid : aluminum hydroxide gel.
• Diuretic : furosemide (lasix).
• Alpha-1 antitrypsin.
• Vaccine : influenza, pneumovax.

Nursing Diagnoses for COPD :

1.Ineffective airways clearance.
2.Impaired gas exchange.
3.Fatigue.
4.Chronic low self esteem.

Planning and goals of nursing care plan for COPD :

• The client will have an adequately clear airway.
• The client will establish an effective breathing pattern.
• The client will maintain adequate gas exchange.
• The client will remain free from infection.
• The client will understand why he should avoid respiratory irritants.

Nursing intervention for COPD :

• Assess respiratory status and ABG and pulse oximetry studies to evaluate oxygenation.
• Administer low-flow oxygen, if indicated, ussually 1 to 2 L per minute in 24 % to 28 % concentrations (Client with emphysema respond only to low oxygen tension, if it too much oxygen reduces the drive to breathe and contributes to respiratory failure)
• Monitor cardiovascular status to detect arrhythmias related to hypoxia or adverse response to medications.
• Monitor and record amount, color and consistency of sputum.
• Encourage the cllient to drink plenty of fluids and weight patient daily to monitor for fluid overload and right -sided heart failure.
• Monitor electrolytes levels, blood counts and drug levels for indications of possible toxic reaction.
• Encourage activity as tolerated to help the client to avoid fatigue.
• Provide chest physiotherapy, including postural drainage and percussion, incentive spirometry and suction as needed- to aide in removal of secretions.
• Administer medications as prescribed to relieve symptoms and prevent complications.

Nursing evaluation for COPD :

• The patient remain free from respiratory tract infection.
• The patient will regularly practices breathing exercises and his breathing efficiency increases.
• The patient will stop smoking and obtains a job with little or no exposure to respiratory irritants.

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Best Practices: Tube Thoracostomy Insertion

Sarah L. Melendez, MD; Mark A. Silverberg, MD Contributor Information


 Tube thoracostomy is the insertion of a tube (chest tube) into the pleural cavity to drain air, blood, bile, pus, or other fluids. Whether the accumulation is the result of rapid traumatic filling or insidious malignant seepage, placement of a chest tube allows for continuous, large volume drainage until the underlying pathology can be more formally addressed. The list of specific treatable etiologies is extensive, but without intervention, patients are at great risk for major morbidity or mortality.


ndications for chest tube placement (thoracostomy) include the following:
- Pleural effusion (shown)
- Spontaneous or traumatic pneumothorax
- Tension pneumothorax (should be treated first with needle decompression and then with tube thoracostomy)
- Empyema
- Hemothorax
- Chylothorax


Standard instrumentation for tube thoracostomy is shown. To perform a chest tube placement, the following equipment is needed: sterile gloves, preparatory solution (chlorhexidine and/or Betadine), sterile drapes, surgical marker, two 10- to 20-mL syringes, a 25-gauge 5/8" needle, a 23-gauge 1.5” needle or 27-gauge 1.5” needle (for instilling local anesthesia), no. 10 blade on a handle, Vaseline gauze, ten 4×4 inch gauze squares, sterile adhesive tape (4" wide), 0 or 1-0 silk or nylon suture, large and small needle drivers, large and medium Kelly clamps, large curved Mayo scissors, large straight suture scissors, lidocaine, and a drainage device (with suction source and tubing).


Standard instrumentation for tube thoracostomy is shown. To perform a chest tube placement, the following equipment is needed: sterile gloves, preparatory solution (chlorhexidine and/or Betadine), sterile drapes, surgical marker, two 10- to 20-mL syringes, a 25-gauge 5/8" needle, a 23-gauge 1.5” needle or 27-gauge 1.5” needle (for instilling local anesthesia), no. 10 blade on a handle, Vaseline gauze, ten 4×4 inch gauze squares, sterile adhesive tape (4" wide), 0 or 1-0 silk or nylon suture, large and small needle drivers, large and medium Kelly clamps, large curved Mayo scissors, large straight suture scissors, lidocaine, and a drainage device (with suction source and tubing).


To begin the procedure, place the patient in a supine position or at a 45-degree angle, to reduce the risk of diaphragm elevation and improper chest tube placement. Abduct and externally rotate the arm on the patient’s affected side, so that the patient’s palm lies behind his or her head. A chest tube is typically inserted in the triangle of safety, a region delineated by the anterior border of latissimus dorsi, the lateral border of pectoralis major, and a horizontal line lateral at the level of the nipple, or about the 5th intercostal space. The tube insertion area is between the midaxillary and anterior axillary lines at the level of the nipple. Prepare and mark the skin (shown) to demarcate the relevant anatomy


nject a systemic analgesic (shown), unless contraindicated. Using the 25-gauge needle, inject 5 mL of local anesthetic solution into the skin that will overlie the initial incision. Using the 23-gauge or, preferably, 27-gauge needle, infiltrate approximately 5 mL of the anesthetic solution to a wide region of subcutaneous tissue that is superior to the targeted site of initial incision. Redirect the needle along the expected course of the chest tube. Inject approximately 10 mL of anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and pleura. Look for aspiration of air, blood, or pus into the syringe, to verify that the needle entered the pleural cavity.

With the no. 10 blade, make a 4-cm horizontal skin incision (shown) above the rib that is below the desired intercostal level of entry.


Use a Kelly clamp to bluntly dissect through subcutaneous tissue and fascia (shown), creating a tract by intermittently advancing the closed instrument and opening it.


Use an index finger to palpate the tract (shown) and tunnel upward over the rib that is above the skin incision. Inject additional local anesthetic into the intercostal muscles and pleura.


Using the closed Kelly clamp, apply some force and a twisting motion to pass through the intercostal muscles and parietal pleura and enter into the pleural space (shown). Be careful to perform this motion with a controlled approach, to prevent the clamp from entering too far into the chest and potentially injuring the lung or diaphragm. Listen and feel for a pop (resulting from a rush of air or fluid) to confirm the entry of the Kelly clamp into the pleural space.


Within the pleural space, open the Kelly clamp and then withdraw it so that its jaws enlarge the dissected tract through all layers of the chest wall (shown). This will make it easier to insert the chest tube. When opening and withdrawing the Kelly clamp, the orientation of the clamp should be parallel (as opposed to perpendicular) to the rib space, in order to minimize morbidity associated with damage to the neuromuscular bundle.


Use the index finger to palpate the tract and feel for adhesions (shown). Rotate the finger by 360 degrees, to confirm the tract and try to loosen and break easily disrupted adhesions. Do not try to lyse significant, organized adhesions manually, as doing so may cause significant bleeding. Determine the distance between the incision and the apex of the lung, in order to know how far to advance the chest tube.

 Clamp the fenestrated proximal end of the chest tube with a Kelly clamp (shown) and introduce it through the tract. Next, clamp the distal end of the chest tube until it can be connected to a drainage system, in order to prevent blood from pouring out of the tube onto the floor.

 

Hold the chest tube in one hand and direct it through the incision (shown), releasing the Kelly clamp proximally and pushing in posteriorly and superiorly using a circular motion.


Use the index finger of the other hand to help guide the chest tube posteriorly and superiorly (shown), using circular motion and making sure all holes are within the thoracic cavity


Make certain that the final hole is inside the thoracic cavity. This hole crosses the white line on the tube (shown) and aids in detecting it on x-rays.


Connect the chest tube’s distal end to a drainage device (shown). To make it easier to connect to the drainage device, some practitioners cut the distal end of the tube. Once the chest tube and drainage device are connected, release the cross clamp that is on the chest tube. To confirm proper intrathoracic placement, look for a respiration-related swing in the fluid level of the drainage device and for respiration-related condensation levels in the tube.


Suture the tube securely to the patient’s chest with 1-0 silk or nylon sutures (shown), using a curved or straight needle.


To secure sutures, use 2 distinct through-and-through, simple, interrupted stitches on each side of the chest tube (shown). Ensure that there are no possible areas for air to leak. Each stitch should be tied tightly to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again without breaking suture. Some physicians favor locking sutures to secure a large-bore thoracostomy tube.


Place Xeroform gauze (shown) over the skin incision. Fold the gauze on itself, wrap it around the thoracostomy tube, and then push it down to the skin insertion site to create an additional barrier

Make an occlusive dressing to cover the chest tube. Turn regular 4×4 inch gauze squares into Y-shaped fenestrated gauze squares (shown), and secure them to the chest wall with 4-inch adhesive tape.

 To create adequate padding, place multiple gauze sponges over the chest tube (shown) as well as between the chest tube and chest wall. To minimize how much tube movement and traction is directly transmitted to the insertion site, many practitioners create a tape “tether.”

Place tape over gauze on the chest (shown). Tape the tube along the chest wall in an “umbilicated” fashion to prevent kinking of the tube as it passes through the chest wall. This will also help to reduce wound site pain and discomfort for the patient.

Check to make sure that the chest tube is still working. Then, tape the distal end of the tube to the drainage system (shown). Be sure to tape along the long axis, so as not to obstruct your ability to see the tube and its drainage. The most common area for clots to form is at the connecting ends of the tubes


Confirm tube placement with chest x-ray (shown). Notice the final hole (arrow) is in the thoracic cavity and is seen as an interruption in the white line of the chest tube.

Complications of chest tube placement include horizontal placement over the diaphragm (acceptable for hemothorax; tube should be repositioned for pneumothorax), placement in subcutaneous tissue outside thoracic cavity (shown; note the subcutaneous emphysema), final hole outside of thoracic cavity, and kinked tube. Once sterility has been broken, it is never appropriate to advance the chest tube; it may only be withdrawn. Sterility is broken when the chest x-ray is performed. It is not permissible to withdraw and readvance the existing tube in a new position. If the tube needs to be repositioned by withdrawing and readvancing, then a new tube must be placed through a new incision.

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Nursing Care Plan For Sickle Cell Anemia

Sickle cell anemia or sickle cell disease a genetic blood disorder, which passed down through families, characterized by red blood cells that assume an abnormal, rigid, sickle shape. Red blood cells contain an iron-rich protein called hemoglobin. This protein carries oxygen from the lungs to the rest of the body.

In sickle cell anemia, hemoglobin, in the presence of low oxygen tension (caused by hypoxia, acidosis, dehydration or fever), it's crystallizes quickly, causing RBCs to bend in to crescent (or sickle) shape. The sickle cells accumulate then obstructing capillary flow throughout the body.

The thickened blood results in capillary stasis, obstructed blood flow and thrombosis. Ischemia occurs distal to thrombosis, causing further oxygen depletion and sickling, which can lead necrosis. The body hemolyzes the fragile sickle cells, quickly producing severe anemia.

Possible causes of sickle cell anemia is

genetic inheritance, that the child inherits the gene that produces hemoglobin S from two healthy parents who carry the defective gene.

Nursing Care Plan For Sickle Cell Anemia:

Assessment findings in sickle cell anemia is vary with the child's age. Before age 4 months, symptoms are rare (because fetal hemoglobin prevents excessive sickling).

• Infants: Splenomegaly from sequestered RBCs, Colic from pain caused by an abdominal infarction and Dactylitis or hand-foot syndrome from infarction of the small bones of the hands and feet.
• Toddlers and preschoolers: Hypovolemia and shock from sequestration of large amounts of blood in spleen and Pain at site of vaso-occlusive crisis.
• School age children and adolescents: Enuresis, Extreme pain at crisis site, Poor healing of leg wounds from inadequate peripheral circulation of oxygenated blood, Delayed growth and development and delayed sexual maturity, History of pneumococcal pneumonia and other infection due to atrophied spleen and Priapism.

Diagnostic evaluation for sickle cell anemia:

• Laboratory studies show hemoglobin level is 6 to 9 g/dl (in toddler).
• RBCs are crescent-shaped and prone to agglutination.
• Less than 50 % hemoglobin S indicates sickle cell trait, but if more than that indicate sickle cell disease.

Nursing Diagnosis for sickle cell anemia:

1. Acute pain.

2. Ineffective tissue perfusion (peripheral).

3. Risk for infection.

4. Deficient knowledge.

5. Ineffective individual coping.

6. Compromised family coping.

Treatment for sickle cell anemia:

• Bed rest.
• Hydration with I.V fluid (may be increased to 3 L {2.8 qt} per day during crisis).
• Short term oxygen therapy (long term oxygen decreases bone marrow activity, further aggravating anemia).
• Treatment of acidosis as necessary.
• Transfusion therapy as necessary

Planing and goals of nursing care plan for sickle cell anemia:

• The child will maintain adequate levels of blood oxygen concentration.
• The child's progressive sickling process will be halted.
• The child will receive pain relief.
• The child will be free from infection.
• The parents and child will verbalize knowledge about the condition, treatment and option for genetic counseling.

Nursing Intervention for sickle cell anemia:

• Administer sufficient pain medication to promote comfort (lack of pain relief can cause further sickling).
• Assess cardiovascular, respiratory and neurologic status.
• Assess vision to monitor for retinal infarction.
• Assess for symptoms of acute chest syndrome from a pulmonary infarction to identify early complications.
• Give large amount of oral or I.V fluids, to prevent fluid volume deficit, induce hemodilution and prevent further sickling and additional complications.
• Maintain the child's normal body temperature, to prevent stress and maintain adequate metabolic state.
• Monitor vital sign and intake-output to assess renal function and hydration status.
• Reduce the child's energy expenditure to improve oxygenation.
• Provide proper skin care to prevent skin breakdown.
• Remove tight clothing to prevent inadequate circulation.
• Teach the child relaxation techniques to decrease the child's stress level.
• Suggest family screening and initiate genetic counseling to identify possible carries of the disease.

Health teaching to child with sickle cell anemia and family members to ensure adequate knowledge about condition and treatment:

• Avoiding high altitudes.
• Avoiding activities that promote the crisis, such as excessive exercise, deep sea diving or mountain climbing.
• Avoiding aspirin use, which enhances acidosis and promotes sickling.
• Recognizing sign of infection and action should take to prevent infection.
• Seeking early treatment of illness to prevent dehydration.

Nursing Evaluation for sickle cell anemia:

• The child will improved hemoglobin level without sign and symptoms of sickle cell crisis.
• The child will be infection-free at discharge.
• The child will continue to perform age-appropriate developmental task.
• The child's parents will monitor child health status, avoid situations that precipitate a crisis and seek early aggressive medical care for infection or sign of crisis.
• The parents relate an awareness of the child's condition, the importance of early treatment and option for genetic counseling.

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Assessment of Acute Pain

Assessment of Acute Pain

   Accurate assessment of acute pain is essential for the development of an effective pain management plan. Nurses play a pivotal role in the assessment of pain, owing to the nature of their relationship with patients. Pain assessment can be challenging because of the subjectivity and multidimensionality of the pain experience. The patient's self-report of pain includes the sensory, emotional, psychological, and cultural components of the pain experience, which cannot be captured on the unidimensional tools typically used in practice. A comprehensive pain assessment includes pain location and quality, aggravating and alleviating factors, timing and duration, pain relief and functional goals, and intensity. The effectiveness of any previous pain treatment, as well as the effects of pain on quality of life, should also be determined.

   The comprehensive pain assessment should be performed when patients present with pain to the healthcare setting and at the onset of new acute pain. To determine treatment effectiveness and guide further interventions, subsequent pain assessments should focus on the nature of the pain, pain intensity, and responses to treatment. Pain assessment tools should be valid and reliable for the patient population in which they are used.

Unidimensional pain intensity scales.

   Unidimensional scales are quick and easy to use, provide rapid feedback about the effectiveness of interventions, and are valid and reliable measures of pain intensity. Because the unidimensional scales measure only intensity, they cannot substitute for a comprehensive pain assessment. The unidimensional pain intensity scales used most often in the clinical setting are:

- Numeric Rating Scale (NRS), also known as the Numerical Pain Intensity Scale (NPI);
- Visual Analog Scale (VAS); and
- Verbal Descriptor Scale (VDS).

Numeric Rating Scale.

   The NRS can be used graphically (visually) or verbally. When used graphically, the NRS consists of a vertical or horizontal line that is anchored by the number 0 on the bottom or the left side and the number 10 on the top or the right side. Patients are instructed to rate the intensity of their pain on this scale, with "0" indicating no pain, and "10" indicating the worst pain imaginable.

Visual Analog Scale.

   The VAS is a 10-cm (100-mm) line on which the patient is asked to place a mark that corresponds with his or her current pain intensity. The line is then measured from the beginning to the patient's mark, and this distance is translated into a pain intensity score ranging from 0 to 10. The format of scale, coupled with the need for a marking implement and for the patient to be able to clearly visualize and mark the line, make the VAS impractical to use in the clinical setting.

Verbal Descriptor Scale.

   The VDS uses the verbal descriptors "no pain," "mild pain," "moderate pain," "severe pain," "very severe pain," and "worst pain possible." This scale can be administered verbally or visually, and the patient is instructed to pick the words that best describe his or her current pain intensity.

Pain assessment in older adults.

   Older adults deserve special consideration in a discussion of pain assessment. As the number of older adults in society increases, it is important to understand the effect of pain on this population and determine the appropriate assessment and management techniques. Older adults with mild to moderate cognitive impairment can self-report pain. Many unidimensional pain tools have been tested in older adults, and several of these tools, including the NRS, have been validated for use in this population. In addition to the NRS, the Faces Pain Scale-Revised (FPS-R) and the Iowa Pain Thermometer (IPT) have been validated for use with older adults. When compared with other commonly used pain intensity scales (NRS, VAS, VDS, and FPS-R), the IPT was the scale most preferred by both younger and older adults, supporting findings that older adults prefer scales with verbal descriptors.

Hierarchy of Importance of Pain Measures

   In many situations, particularly in the acute care setting, it is not possible to obtain a patient self-report of pain intensity. Patients who are critically ill, sedated, confused, delirious, or otherwise cognitively impaired may be unable to report pain. The assessment of pain in this population is challenging because no single objective strategy, such as observation of behaviors or vital signs, provides sufficient information to assess pain. Nurses often rely on heart rate, respiratory rate, blood pressure, and other physiologic data to confirm the presence of pain; however, these variables are the least sensitive indicators of pain and may be affected by many other factors.

   In response to this challenge, the ASPMN published a position statement that recommends a comprehensive, hierarchical approach to the assessment of pain in nonverbal patients, which provides the framework for a decision-making process that can be used to manage pain in nonverbal patients. The hierarchical approach has 5 key steps:

1. When possible, obtain self-report.
2. Look for possible pathologies, procedures, or other causes of pain.
3. Observe for behaviors that may indicate the presence of pain.
4. Obtain input from caretakers who know the patient and the patient's usual behaviors and responses
    to pain.
5. Use an analgesic trial and observe for changes in behavior.

Step 1: Patient self-report of pain.

   The hierarchy affirms that the patient's self-report is the most reliable indicator of pain and the sole indicator of pain intensity. Ascertaining the patient's report of pain should always be attempted first. Reliability of the patient's self report may diminish with advancing cognitive impairment, but many valid and reliable tools are available that may be effectively used with cognitively impaired persons. No method has been identified to establish a patient's ability to reliably use a self-report tool; it is therefore helpful to have several tools available in the clinical setting so that the tool that yields the most consistent results for the individual patient may be selected. Once identified, this tool should be used at each assessment.

Step 2: Assumption of pain.

   If a reliable self-report of pain cannot be elicited, the next step in the hierarchy is to consider whether the patient has a condition that is typically associated with pain or is undergoing procedures that are generally considered painful. In such cases, the nurse should "assume that pain is present" (abbreviated "APP" for documentation when approved by facility policy and procedure) and provide the appropriate treatment. It is never appropriate to assume that a patient who is unresponsive, nonverbal, confused, demented, or delirious cannot feel or is not feeling pain. Similarly, pain must be assumed to be present and treated if the patient who is receiving paralytics or sedatives has an underlying painful condition or is undergoing painful procedures.

Step 3: Behavioral indicators of pain.

   The third step in the hierarchy requires the nurse to observe the patient for possible indicators of pain, such as grimacing or other indicative facial expressions, bracing, rocking, or changes in activity. Recognizing that certain behaviors may indicate pain, researchers have developed behavioral pain assessment tools for use in patients who cannot self-report. Many of these tools yield a behavioral score that can help determine the presence of pain, and when changes are noted, can be used to evaluate the effectiveness of interventions; however, a behavioral score is not a pain intensity score. If the patient cannot report the intensity of his or her pain, then the intensity is unknown.

Tools for pain assessment include:

1.  The Critical Care Pain Observation Tool (CPOT) was designed to assess pain in critically ill adults.

     It uses facial expression, body movement, muscle tension, and ventilator compliance or

     vocalization as pain indicators.

2. The Payen Behavioral Pain Scale, which uses facial expression, upper extremity movement, and

     ventilator compliance as pain indicators, may also be used for critically ill adults who are intubated.

3. The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in patients who have

    dementia or Alzheimer's disease and are nonverbal. It uses breathing, negative vocalization, facial

    expression, body language, and consolability as pain measures.

   City of Hope Research (Visit&Contact: cityofhope.org) provides a brief summary and critique of many of the tools that have been developed for the assessment of pain in nonverbal patients. Validity and reliability have not yet been fully established for some of these tools. As with pain intensity scales, behavioral tools should be used only in the patient populations for which they were intended and in patients who are able to respond with the requisite behaviors for each tool. Although many tools have been developed to aid in the assessment of pain, the patient's self-report of pain intensity remains the most dependable method of pain assessment.

Step 4: Solicit information from caregivers and family members.

   A surrogate who knows the patient's usual behavioral responses can provide input about pain behaviors, which can be valuable in identifying the patient's unique responses to pain.

Step 5: Analgesic trial.

   The last step of the hierarchy of measures is an analgesic trial, which involves observing the patient's behavior before and after administration of a low dose of analgesic medication. An improvement in behaviors after the analgesic dose helps confirm the presence of pain and serves as the basis for a pain treatment plan. If the patient does not respond to the trial, an increase of the analgesic dose or trial of a different analgesic should be attempted. If the behaviors do not improve despite optimal titration of the analgesic regimen, causes of the behaviors other than pain should be considered

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Feeling Your Patient's Pain

   For most of us, medical students and physicians alike, treating patients in pain can be, well, a pain. Aside from having to know which medicines to use and how to use them, there's the issue of not being able to objectively measure what we're treating, as well as the unfortunate reality that some patients abuse narcotics. Patients in pain can really put our bedside manners to the test.

   The following are some pearls, from the perspective of a general internist who works with medical students and who was a medical student himself not all that long ago, on how you can interact with people who are hurting. By "pain" I'm referring to the physical kind, although the same principles may apply for emotional pain.

1. Address pain before you address anything else.

   As a medical student, you may be the first person on your team to sit down with a patient to interview and examine him. If you are pressed for time, you may be tempted to proceed with this even if the patient is in pain. It's easy to justify; after all, the sooner you get information from the patient, the sooner you can help him, right?

   While there are certain situations where pain has to be put on the back burner, these are very rare. Imagine how distressing it must be for the patient to be asked questions about family history or to get a full neurological exam when writhing from abdominal pain. (Believe me, I've seen it happen.) Show the patient that you care by getting your resident or attending physician and making sure that the person's pain is addressed first and foremost.
2. When a patient says he's in pain, even if he has a history of substance abuse, believe him.
If you haven't seen a situation like this yet, you will:

"A patient comes in to the hospital after a fall and complains of excruciating leg pain – "15 out of 10," he says. He looks uncomfortable but not that uncomfortable. The leg is visibly bruised but, according to the x-ray, not broken. The patient is a "frequent flyer" with a history of substance abuse. Your resident's or attending physician's assessment? He's exaggerating, probably playing the system for pain meds."

   In general, if a patient has reason for pain and says that he's in pain, I believe him. I call this the "innocent until proven guilty" principle. Nothing is potentially more toxic to the therapeutic relationship than questioning the veracity of what a patient is telling us from the very beginning.

   Pain is, by its very nature, subjective. There is no way for us to definitively know if another person is in pain. That said, just because we can't objectively quantify pain doesn't mean we should dismiss it.

   Don't get me wrong; I'm always on the look-out for narcotic abuse. If a patient says he is in pain but he seems completely comfortable, or if I know the patient is getting narcotics from multiple providers, I'll respectfully question the claim of pain. Otherwise, I'm going to take his word for how he feels. Keep in mind that even people with a history of substance abuse can experience excruciating pain. Between the 2 evils of undertreating pain or inadvertently indulging addiction, I'd much rather err on the side of the latter.

3. Empathize, but realize that you don't really know how the patient feels.

   When faced with someone who is suffering, many medical students want to share their own struggles as a way of trying to empathize with that person. For instance, if you have a patient who broke her arm and is in pain, and you once broke your arm, it's only natural to want to talk about your experience.

   Tread carefully here. This goes back to the point that pain is an intensely personal experience. While some patients might find it comforting to hear someone who isn't in pain say that he's been through something similar, others might find it isolating or condescending.

   I encourage my medical students to let the patient take the lead. Share a personal experience only if the patient gives you an opening, and only if you are comfortable sharing it. Otherwise, keep the focus on the patient. Show her you care by giving her space to talk. One of the most meaningful things that we as healthcare providers can do for someone in pain is just be there, and listen.

   In summary, treating a patient in pain can be challenging. But, like with most obstacles, the flipside is that it presents an opportunity to make a difference. As a medical student and later on as a doctor, if you give patients the benefit of the doubt, realize that you don't know exactly how they feel, and address their pain first, you'll go a long way toward establishing a strong relationship.

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Assessing Pain When the Patient Cannot Self-report

   Pain is completely subjective, and the gold standard of pain assessment is self-report by the patient. Several assessment tools can facilitate determining the patient's assessment of pain intensity, and hospitals nationwide have implemented policies and procedures outlining the use of these instruments.

   The most commonly used self-report tools in patients who are able to quantify their pain are the 0-10 numerical pain rating scale and the 0-10 Wong-Baker FACES pain rating scale or the Faces Pain Scale-Revised; many patients who can self-report pain but are unable to quantify it may be able to select the face that best characterizes their pain on a faces pain rating scale. However, not all patients are able to report pain using customary assessment tools, and this presents a significant challenge for the healthcare team who must ensure that pain is recognized and treated appropriately.

   For patients unable to report pain through traditional methods, an alternative approach based on the Hierarchy of Pain Measures is recommended (Table). The key components of the hierarchy are as follows:

- Attempt to obtain self-report;
- Consider underlying pathology or conditions and procedures that might be painful;
- Observe behaviors;
- Evaluate physiologic indicators; and
- Conduct an analgesic trial.

Table. Hierarchy of Pain Measures

   1. Attempt to obtain the patient's self-report, the single most reliable indicator of pain. Do not assume that a patient cannot report pain; many cognitively impaired patients are able to use a self-report tool, such as the Wong-Baker FACES Scale, Faces Pain Scale-Revised, or Verbal Descriptor Scale.

   2. Consider the patient's condition or exposure to a procedure that is assumed to be painful. If appropriate, assume pain is present (APP) and document APP when approved by institution policy and procedure.

   3. Observe behavioral signs (eg, facial expressions, crying, restlessness, and changes in activity). Many available behavioral pain assessment tools will yield a pain behavior score and may help to determine whether pain is present. However, a behavioral score is not the same as a pain intensity score. Pain intensity is unknown if the patient is unable to provide it. A surrogate who knows the patient well (eg, parent, spouse, or caregiver) may be able to provide information about underlying painful pathology or behaviors that may indicate pain.

   4. Evaluate physiologic indicators with the understanding that they are the least sensitive indicators of pain and may signal the existence of conditions other than pain or a lack of it (eg, hypovolemia, blood loss). Patients may have normal or abnormal vital signs in the presence of severe pain. The absence of elevated blood pressure or heart rate does not mean the absence of pain.

   5. Conduct an analgesic trial to confirm the presence of pain and to establish a basis for developing a treatment plan if pain is believed to be present. An analgesic trial involves administration of a low dose of nonopioid or opioid and observing patient response. The initial low dose may not be enough to elicit a change in behavior and should be increased if the previous dose was tolerated, or another analgesic may be added. If behaviors continue despite optimal analgesic doses, other possible causes should be investigated. In patients who are completely unresponsive, no change in behavior will be evident and the optimized analgesic dose should be continued.

Pain Assessment Options in the Absence of Self-report

   Evidence-based guidelines recommend against the rating of pain intensity by anyone other than the person who is experiencing the pain. The importance of relying on self-report has been underscored by research over the years, which has shown a lack of correlation between the patient's perception of pain and that of nurses and other members of the healthcare team. Furthermore, the greatest discrepancies often occur at the highest pain levels.

   Various explanations for such discrepancies have been proposed, including care provider experience, patient gender, language barriers, and ability to distinguish pain behaviors from other behaviors. A principle of pain management is that the patient is the authority on pain intensity, and if he or she cannot report the intensity, then it is unknown.

   Estimation of pain by others. Research has shown that individuals who know the patient well (eg, parents, caregivers) often overestimate or underestimate the patient's pain. Discrepancies are influenced by a various factors, including the presence and level of cognitive impairment in the patient, caregiver gender, perceived burden of caregiving, preconceived ideas of acceptable pain relief, and fear of analgesic side effects. A concern has been raised that discrepancies occur when pain is more severe. Although individuals who know the patient should not be asked to rate pain intensity, they can facilitate assessment by providing the healthcare team with information about underlying painful pathology or behaviors that may indicate the presence of pain.

Exposure to painful procedures.

   When self-report cannot be obtained, the Hierarchy of Pain Measures calls for consideration of any potentially painful underlying conditions or procedures that the patient might be experiencing (Table). In this case, the patient has sustained painful traumatic injuries. He is also being subjected to endotracheal intubation, mechanical ventilation, and suctioning, all of which have been identified as painful procedures. However, he cannot report pain and is unable to demonstrate pain behaviors.

   According to the Hierarchy of Pain Measures, pain should be assumed to be present in such patients and treatment should be initiated with recommended starting doses of appropriate analgesics. The subanesthetic doses of propofol that are used for goal-directed sedation produce negligible analgesia. This underscores the importance of co-administering appropriate analgesics, such as nonopioids and opioids. Reassessing analgesic treatment may yield no change in behavior in unresponsive patients; therefore, the optimized analgesic dose should be continued.

   The patient's ability to self-report or the appropriateness of using a behavioral pain assessment tool should be evaluated regularly (eg, every shift). The decision to switch from assessment based on assumption of painful pathology to the use of behavioral tools or the patient's report of pain always depends on the patient's ability to demonstrate pain behaviors or report pain.

Patient behaviors.

   Patient behaviors often provide clues about whether a patient has pain. For example, facial expressions, restlessness, bracing, and changes in activity have been shown to be indicators of pain. Behavioral pain assessment tools facilitate pain assessment. One of the most commonly used tools in the ICU setting is the Critical-Care Pain Observation Tool (CPOT), which has been shown to be reliable and valid in a variety of critically ill patient populations. The tool requires evaluation of the following 4 categories:

   - Facial expression;
   - Body movements;
   - Muscle tension; and
   - Compliance with ventilator (intubated patients) or vocalization (extubated patients).

   A score of 0-2 is assigned to each category, depending on the degree of the patient's response. The maximum total score is 8. A limitation of many of the behavioral tools, such as the CPOT, is that they designate specific behaviors that must be observed, making it essential for nurses to carefully evaluate each patient for the patient's ability to demonstrate the requisite behaviors in the tool. In patients such as the one described above, behaviors are absent, rendering behavioral tools ineffective.

   Although it is tempting to rely on physiologic indicators, such as heart rate and blood pressure, vital signs have been shown to be the least sensitive indicators of pain and are known to be influenced by a variety of factors other than pain (eg, hypovolemia, blood loss, hypothermia, and anesthetic and analgesic agents).

Outcomes of Pain Assessment

   The healthcare team caring for this patient used the Hierarchy of Pain Measures as a framework for pain assessment. The patient was unresponsive, unable to self-report pain, and did not demonstrate any pain behaviors. As directed by the Hierarchy, those caring for him assumed that he had pain on the basis of his underlying painful pathology (eg, head trauma and ulnar fracture) and painful procedures (eg, endotracheal intubation, mechanical ventilation, and suctioning). A continuous IV morphine infusion at 2.5 mg/hour was initiated. Bolus doses of 1 mg IV morphine were administered before painful procedures. In addition, scheduled doses of IV acetaminophen and IV ibuprofen were administered around-the-clock.

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Universal HIV Screening Recommended by USPSTF

   The US Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all people aged 15 to 65 years for HIV infection, according to a draft recommendation statement posted online November 20. The statement also recommends HIV screening for all pregnant women, including those who present at the time of labor, and for younger adolescents and older adults who are at increased risk.

   "The draft recommendation reflects new evidence that demonstrates the benefits of both screening for and earlier treatment of HIV," task force member Douglas K. Owens, MD, said in a USPSTF news release. "Because HIV infection usually does not cause symptoms in the early stages, people need to be screened to learn if they are infected. People who are feeling well and learn they are infected with HIV can begin treatment earlier, reduce their chances of developing AIDS and live longer and healthier lives."

   Although US prevalence of HIV infection is nearly 1.2 million and annual incidence is about 50,000, nearly one quarter of those infected are unaware that they are HIV-positive. Since the first reports of AIDS in 1981, more than 1.1 million people have been diagnosed with AIDS and nearly 595,000 have died from it.

   Combined antiretroviral therapy (ART) has been shown to reduce the likelihood of HIV transmission, and earlier initiation of treatment lowers the risk for AIDS-related complications.

In issuing this recommendation, the task force hopes to improve and maintain the health of persons who are already infected with HIV, to delay the onset of AIDS, and to lower the risk for HIV transmission. The USPSTF is offering the public an opportunity to comment on this draft recommendation until December 17 and will consider all public comments when writing its final recommendation.

   Clinicians should screen adolescents and adults aged 15 to 65 years for HIV infection, as well as younger adolescents and older adults who are at increased risk (grade A recommendation).

Although evidence is insufficient to define optimal time intervals for HIV screening, the statement suggests that a reasonable strategy would be 1-time screening of adolescent and adult patients to identify those who are already HIV-positive and repeat screening of those known to be at risk for HIV infection, those who are actively engaged in high-risk behaviors, or those living in a high-prevalence setting.

   Clinicians should screen all pregnant women for HIV, including those of unknown HIV status who present in labor (grade A recommendation).

Evidence and Rationale

   The USPSTF updated their 2005 review on the benefits and harms of HIV screening in adolescents and adults by searching MEDLINE (2004 - June 2012) and the Cochrane Library (through the second quarter of 2012). Inclusion criteria were English-language randomized trials and observational studies comparing HIV screening approaches and reporting clinical outcomes, assessing the effect of initiating ART at different CD4 cell count thresholds and long-term harms, or reporting the effect of interventions on transmission risk.

   "Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency," the USPSTF task force writes in its systematic review. "New evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV."

   Evidence was convincing that standard and rapid HIV antibody tests are both highly accurate in diagnosing HIV infection.

   Evidence also was convincing that identifying and treating HIV infection in individuals with immunologically advanced disease (CD4 count <200 cells/mm 3) is associated with a substantially lower risk for progression to AIDS, AIDS-related events, and death.

   Evidence was adequate that starting ART earlier (at CD4 counts of 200 - 500 cells/mm 3) is associated with a lower risk for AIDS-related events or death.

   Finally, evidence was convincing that ART is associated with a markedly lower risk for transmission from HIV-positive persons to uninfected heterosexual partners and that identifying and treating HIV-positive pregnant women substantially lowers rates of mother-to-child transmission. Therefore, there are significant overall benefits of screening for HIV infection in adolescents, adults, and pregnant women.

   Although evidence is convincing that individual antiretroviral drugs, drug classes, and combinations are all associated with short-term adverse events, many are transient or self-limited, and there are often effective alternatives. Long-term use of certain antiretroviral drugs is linked to a small increase in risk for cardiovascular and other adverse events.

   "The overall harms of screening for and treatment of HIV infection in adolescents, adults, and pregnant women are small," the task force writes in its draft guidelines.

   "The USPSTF concludes that there is high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial."

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Lung Screening May Encourage Smoking Cessation CME

News Author: Damian McNamara

CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures

CME Released: 11/08/2012; Valid for credit through 11/08/2013

CLINICAL CONTEXT
There are more than 200,000 new cases of lung cancer diagnosed annually in the United States. However, effective screening strategies for lung cancer have remained elusive. Two major studies have recently evaluated the efficacy of lung cancer screening programs, and Barry and colleagues provide a review of this research. The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) trial did not find a difference in the rate of lung cancer mortality in comparing a screening group receiving annual chest X-rays with a control group. However, the National Lung Screening Trial demonstrated that individuals receiving lung cancer screening with computed tomography experienced a 20% reduction in the risk for mortality compared with adults screened with chest X-ray alone.

Smoking is the most important risk factor for lung cancer, and previous research suggests that false-positive screening tests for lung cancer are associated with a higher rate of cessation from smoking. The authors of the current study examined variables associated with smoking outcomes in the PLCO study.

STUDY SYNOPSIS AND PERSPECTIVE
Former smokers are more likely to relapse if they are young; black or Hispanic; less educated; unmarried; have a lower income, lower body mass index, and no family history of lung cancer; or have smoked light or ultralight cigarettes, according to a secondary analysis of participants in the PLCO Screening Trial.

Of the 31,694 self-reported former smokers at baseline in the PLCO, 3.3% relapsed and reported on follow-up that they currently smoked, report Samantha A. Barry, BA, from the Prostate Cancer Decision Making and Quality of Life Research Department at Georgetown University Medical Center, Washington, DC, and colleagues in an article published online October 26 in the Journal of the National Cancer Institute.

In addition, long-term smokers and recent quitters were statistically significantly more likely to relapse (both P < .001), according to this secondary analysis of PLCO trial data.

"This relapse prediction model may be useful for identifying former smokers who may benefit most from relapse prevention interventions," the authors note.

Of the 6807 people who reported smoking at baseline, 65.2% said they still smoked on their subsequent questionnaire a median of 8.5 years later (range, 4 - 14 years). Those who were younger, black or Hispanic, or had a lower income or a lower body mass index were more likely to have continued smoking.

"Continued smoking was also more likely among heavier smokers, smokers of light or ultralight cigarettes, and those with greater secondhand smoke exposure," the authors write. "However, current smokers with higher body mass index or new tobacco-related diseases and smokers of unfiltered cigarettes were less likely to continue smoking. These characteristics may be useful in identifying smokers who are most in need of a smoking cessation intervention."

In terms of trial variables, only participation in the PLCO trial for a shorter time was associated with continuation of smoking (odds ratio, 0.85; 95% confidence interval, 0.82 - 0.88). The trial group randomization (screening vs control), screening center, and screening result were not significant factors.

Participants were approximately 60 years old, 50% were men, 90% were white, and about 50% had 2 or more comorbidities. They started smoking at an average age of 18 or 19 years. In addition, 10% reported receiving at least a single false-positive screening result, defined as a positive chest X-ray at 1 or more of the 4 annual assessments that was not followed by a lung cancer diagnosis within 3 years.

Receipt of a false-positive screen was not significantly associated with lower likelihood of smoking relapse or greater likelihood of smoking cessation, however, "suggesting that screening results may have only a short-term effect on smoking behavior," the authors note. "However, we found that being diagnosed with a new noncancer, tobacco-related disease was inversely associated with continued smoking, suggesting another possible teachable moment for altering smoking behaviors: Upon receiving a new diagnosis, smokers may be motivated to quit smoking and become more amenable to formal cessation programs."

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Smoking and Risk on Women’s Mortality Rates

CLINICAL CONTEXT
Smoking is widely recognized as the most important modifiable risk factor in preventing adult mortality in Western countries, but there has been little attention paid overall to sex-based differences in health outcomes of smokers. Huxley and Woodward addressed this issue in a systematic review comparing cardiovascular outcomes associated with smoking among women and men. Their results, which were published in the October 8, 2011, issue of the Lancet, demonstrate that the risk for cardiovascular events associated with current smoking was more profound among women compared with men. There was no sex-based difference in the cardiovascular risk of former smokers.

Long-term data analysis on the health risks of smoking among very large groups of women has only recently been possible. The current study reports on mortality outcomes based on cigarette use in the Million Women Study.

STUDY SYNOPSIS AND PERSPECTIVE
Women who smoke lose at least 10 years from their lifespan. In particular, women who continue smoking past the age of 40 years have 10 times the hazards of those who quit smoking before that age.

Kirstin Pirie, MSc, from the Cancer Epidemiology Unit at the University of Oxford in the United Kingdom, and colleagues presented results from the Million Women Study in an article published online October 27 in the Lancet. Women were recruited for the study between the ages of 50 and 65 years and were followed up for between 9 and 15 years. The women in the study had a relatively low absolute death rate, possibly because various previous illnesses were excluded and possibly because the study included relatively healthy volunteers.

The study examined women in the United Kingdom and found that smoking accounted for two thirds of all deaths of smokers in their 50s, 60s, and 70s. Women smoking at baseline had a 12-year mortality rate of 2.76 (95% confidence interval, 2.71 - 2.81) when compared with never-smokers. For smokers younger than 70 years, the probability of death was 24% compared with 9% for never-smokers of the same age (absolute difference, 15%).

Women who stopped smoking by age 30 years avoided more than 97% of the lifetime hazard from smoking. Women who smoked until age 40 years and stopped had substantial hazards but were able to avoid more than 90% of the excess mortality caused by continuing to smoke. Women who stopped smoking at age 50 years avoided approximately two thirds the excess mortality seen in women who continue smoking at a later age. Women who quit smoking at the age of 40 years still have a mortality rate 1 to 2 times that of the never-smokers, however, and this increased mortality rate lasts for the next few decades of life.

Smokers typically experienced excess mortality from lung cancer, chronic lung disease, heart disease, and stroke, as well as other neoplastic, respiratory, or vascular conditions. For many of these diseases, the study identified a proportional excess risk in smokers that was even higher than that identified in previous studies.

The UK population was useful for studying because it includes a generation of women who smoked through adult life and reached old age. The authors seek to use the data from this study to predict the effect of smoking on female mortality outside the United Kingdom.

In a linked comment, Rachel Huxley, DPhil, from the University of Minnesota in Minneapolis and Mark Woodward, PhD, from Johns Hopkins University in Baltimore, Maryland, write, "The substantial hazards of smoking and the remarkable benefits of stopping now being seen among women in the UK emphasise the need for effective sex-specific and culturally-specific tobacco control policies that encourage adults who already smoke to quit and discourage children and young adults from starting to smoke."

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