Pain Treatment for Cancer in Minorities
It has already been observed that minority patients are substantially less likely to receive analgesics after trauma or surgery than non-minorities. Whether such disparities exist in provision of analgesia to persons with recurrent or metastatic cancer is the subject addressed in this study. A patient population (n = 281) included 106 blacks, 94 Hispanics, and 16 other minorities.
Almost two-thirds of patients reported inadequate analgesia in the previous week. Centers treating primarily minority persons provided inadequate analgesia more often than community settings that provided treatment to dominantly nonminority populations (77% vs 55%). Inadequate treatments more prevalent in minority groups than nonminority groups included undermedication (65% vs 50%) and underestimation of pain severity.
Although pain relief in cancer patients was demonstrated to be clearly inadequate, with at least 50% of all persons reporting uncontrolled pain, minority groups shoulder a greater proportion of this burden. Such disparities may arise from clinician perception of increased abuse potential among minorities, fewer economic resources to pay for prescriptions, poorer access to care or ability to fill prescriptions, or communication barriers between nonminority clinicians and minority patients.
Cleeland CS, et al. Ann Intern Med 1997;127:813-816.
Clinical Scenario: A healthy 30-year-old woman was seen in the office for her "routine city physical." She is found to be surprisingly bradycardic, as shown in the figure below. What is the cause of her "bradycardia?"
Interpretation: On initial inspection, the rhythm in the figure appears to be sinus bradycardia with one early occurring beat (complex #3). The most helpful clue to the true etiology of the rhythm resides in analysis of this early beat. Although widened, it is not a premature ventricular contraction (PVC). Instead, beat #3 is preceded by a telltale premature P wavethat defines this beat as a premature atrial contraction (PAC). The reason the QRS complex of beat #3 is wide is that the impulse is conducted with aberration. Practically speaking, most aberrant beats are conducted with a pattern of either left or right bundle branch block and/or a hemiblockreflecting whatever part of the conduction system is delayed in recovering and still refractory at the time the electrical impulse arrives at the AV node.
The morphologic appearance of the QRS complex of the PAC in the figure suggests that this beat is conducted with a bifascicular pattern of aberrancy (i.e., the S wave of beat #3 in lead I is consistent with right bundle branch block; the marked negativity in leads II and III is consistent with left anterior hemiblock).
Keeping in mind that when there is one PAC, there will often be more, provides the next clue to the events in this tracing. Close inspection of the T wave, especially in lead III reveals notching after beat #1 and variable peaking after beats #4, 5, and 6. This changing T wave morphology is a result of hidden premature P waves that occur so early in the refractory period that they are not conducted (i.e., "blocked"). Thus, the rhythm is not sinus bradycardia after allbut, instead, reflects atrial bigeminy in which each PAC is either blocked or conducted with aberration. Note how the blocked PACs are less evident in lead II than they are in lead III, and not evident at all in lead I. Clinically, no treatment is needed for a patient with PACs other than to advise about factors that may precipitate this rhythm (i.e., excess caffeine, alcohol, over-the-counter sympathomimetics, diet pills, etc.).
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