Predictors of outcome for orofacial pain in the general population: a four-year follow-up study.

Orofacial pain is often persistent, but it is not clear why it lasts in some patients but not in others. We aimed to describe the natural course of orofacial pain in a general population sample over a four-year period and to identify factors that would predict the persistence of pain. A cross-sectional population-based survey was conducted in the United Kingdom, involving 2504 participants (participation rate 74%), of whom 646 (26%) reported orofacial pain. Overall, 424 (79% adjusted participation rate) of these individuals participated at the four-year follow-up, of whom 229 (54%) reported orofacial pain and 195 (46%) did not report such pain. Persistent orofacial pain was associated with females, older age, psychological distress, widespread body pain, and taking medication for orofacial pain at baseline. These findings may have implications for the identification and treatment of patients with orofacial pain.

Patient communication during cataract surgery.

PURPOSE: Most cataract surgery is now performed under local anaesthesia on a day-case basis. As patients are fully conscious during the procedure, it is important that they remain still. There are a variety of reasons why patients may need to move, and it is important that the surgeon is made aware that this may happen. Some centres offer a nurse's hand as a means of perioperative patient communication. We sought to study the safety and efficacy of using an electronic patient-controlled alert device. METHOD: We compared hand-holding with the use of a patient alert device, and with both communication methods at the same time, on 150 subjects undergoing cataract surgery under local anaesthesia. Assessment of pre- and postoperative state anxiety was undertaken and patients' satisfaction with the communication strategies was assessed. RESULTS: There was a significant difference between pre- and postoperative state anxiety for each group (P<0.001) but no significant differences in pre-, peri-, or postoperative state anxiety between groups. There were no significant differences in confidence, pain, understanding, satisfaction, memory, and reassurance between the three groups. A total of 46% of all patients reported experiencing one or more of the potential problems enquired about, during the operation. Significant correlations were also identified between some of the psychological variables investigated. CONCLUSIONS: An electronic patient alert device is as effective a means of perioperative patient communication as holding a nurse's hand, during cataract surgery under local anaesthesia. It is safe, reassuring and it allows patients to communicate directly with the surgeon.

Factors associated with health care seeking behaviour for orofacial pain in the general population.

OBJECTIVE: To describe the health care seeking behaviour associated with orofacial pain (OFP) and determine factors associated with such behaviour. DESIGN: Cross-sectional population-based study using postal questionnaires. PARTICIPANTS: Adults aged 18-64 years from a general medical practice in south-east Cheshire, UK (participation rate 74%). RESULTS: Of the 2,504 respondents to the questionnaire 646 reported OFP, of whom 555 (86%) indicated whether or not they sought professional help. A total of 255 (46%) responded that they had sought advice. The majority had sought advice from their medical practitioner (57%) or dentist (51%), and 64% had taken medication because of OFP. The likelihood of seeking treatment increased linearly with age (p < 0.001) while gender, education and psychological distress did not show a significant association with seeking treatment. Persons who were regular dental attenders had an increased likelihood of seeking treatment for OFP (RR 1.4; 95% CI 1.1,1.8). Perception of illness had moderate association with healthcare seeking (RR 0.8; 95% CI 0.7,0.96). There was a significant trend of increasing RR with increasing total number of pain symptoms (p < 0.001), frequency of pain, duration of pain episodes, pain intensity and disability associated with pain. Participants who reported pain duration of more than three months had almost double the likelihood (RR 1.8; 95% CI 1.4,2.3) of seeking treatment. Decrease in self-reported control over pain and ability to decrease pain were both associated with an increased likelihood of seeking professional care (p < 0.001). CONCLUSIONS: The strongest predictors of health care seeking behaviour were different characteristics of pain.

Association between female hormonal factors and oro-facial pain: study in the community.

The aim of this study was to determine the relationship between the prevalence of oro-facial pain (OFP) in the population and female hormonal factors. The cross-sectional population study was conducted in a general medical practice in the north-west of England. A random sample of 4000 adults aged 18-65 years were mailed questionnaires, of whom 2504 responded (adjusted participation rate 74%). Of these 1245 women provided information on both OFP and hormonal factors. For pre- or peri-menopausal women, there was no relationship between oral contraceptive use and OFP (age-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.81, 1.45), whilst a high score on a pre-menstrual symptom questionnaire was associated with an age-adjusted RR of 1.87 (95% CI 1.36, 2.57). Those who reported menstruating for 6 days or longer had moderate increase in risk of OFP (age-adjusted RR 1.39; 95% CI 1.01, 1.91). In post-menopausal women, there was a moderate relationship between hormone replacement therapy use and OFP (age-adjusted RR 1.46; 95% CI 1.02, 2.08). For women overall, there was an increased risk of OFP in those who reported ever having had painful periods (age-adjusted RR 1.47; 95% CI 1.20, 1.80), but no association was found with the number of children. This cross-sectional community-based study adds important information on the relationship between female hormonal factors and OFP. Women who report OFP are more likely to report symptoms associated with menstruation. This may indicate either the importance of hormones per se or identify a group of women who are more likely to report symptoms in general.

Factors associated with the temporomandibular disorder, pain dysfunction syndrome (PDS): Manchester case-control study.

OBJECTIVES: To determine the individual and combined effects of potential risk factors in relation to the temporomandibular disorder, Pain Dysfunction Syndrome (PDS). DESIGN: Case-control study. MATERIAL AND METHODS: Cases were new referrals to the temporomandibular disorder clinic of the University Dental Hospital of Manchester, diagnosed with PDS. Controls were randomly selected from 24 dental practices. Using a postal questionnaire information was collected on socio-demographic, local mechanical, psychological factors, co-morbidities and illness behaviour. The adjusted participation rate was similar in cases and controls (64%), and 131 cases and 196 controls finally participated in the study. RESULTS: Compared with the controls, the cases were more likely to report that their teeth felt as though they did not fit together properly [odds ratio (OR) 8, 95% Confidence Interval (CI) 6-13] and report history of facial trauma (OR 3, 95% CI 2-6). Both diurnal and nocturnal grinding were significantly associated with PDS, and individuals who reported grinding their teeth both during the day and at night had a risk of 6; 95% CI 3-13 for PDS compared with those who did not. A history of orthodontic treatment, having any dentures, having missing teeth, use of chewing gum or biting the fingernails did not show any relationship with PDS. People who took medication for the bowels had a higher risk of PDS (OR 2, 95% CI 1-4). Participants with frequent headaches had a threefold increase in risk of having PDS (OR 3, 95% CI 2-5) while having pain in parts of the body other than the head was associated with an OR of 3 (95% CI 2-5). An increased propensity to have PDS was seen in those individuals with higher levels of psychological distress (OR 3; 95% CI 1-4 in the highest category, test for trend P < 0.001) and sleep disturbance (OR 5; 95% CI 2-94 in the highest category, test for trend P < 0.001). Aspects of illness behaviour, such as disease conviction (OR 4; 95% CI 2-9 in the highest category) and perception of illness (0.3; 95% CI 0.2-0.5) were associated with PDS. The result for the denial scale became statistically significant after adjustment for age and gender (2; 95% CI 1-3). CONCLUSIONS: The current case-control study provides complementary epidemiological information on oro-facial pain (OFP) and supports a multifactorial aetiology of PDS, with factors from many domains, including local mechanical factors, psychological and co-morbidities. People with PDS were characterized by frequent headaches, history of facial trauma, teeth grinding, sleep problems, pain elsewhere in the body and high levels of psychological distress. From the results of current study and available evidence it seems inappropriate to consider PDS in isolation and future research should adopt a multidisciplinary approach to OFP.

Low-dose midazolam infusion for oculoplastic surgery under local anesthesia.

PURPOSE: Oculoplastic surgery with infiltration of local anaesthesia at the operative site performed as a day-case procedure is both efficient and cost-effective. Patients considered unsuitable for this because of fear or apprehension may, however, benefit from per-operative conscious sedation. We sought to study the efficacy and safety of this using midazolam, a water-soluble benzodiazepine. METHOD: We have performed a controlled clinical trial comparing the effect of a low-dose intravenous infusion of midazolam (0.2 mg/ml of normal saline at a rate of 1 mg/h) with saline placebo on 48 subjects undergoing oculoplastic surgery with local anaesthesia. Patients were given pre- and post-operative questionnaires assessing, amongst other factors, anxiety levels, pain, degree of reported amnesia and psychomotor recovery. RESULTS: Using the low-dose midazolam infusion no adverse cardiorespiratory reactions occurred. Patients receiving midazolam reported remembering significantly less about their operation than controls (p = 0.04) and showed significantly lower state-anxiety after their operation than before (p < 0.02). This change was not noted in the placebo group. There was no significant difference in the psychomotor performance of patients given midazolam compared with controls 2 h after surgery. CONCLUSIONS: A low-dose continuous infusion of midazolam can be used to safely provide effective anxiolysis and conscious sedation with good psychomotor recovery during oculoplastic procedures in a day-case setting.

Anxiety levels, patient satisfaction and failed appointment rate in anxious patients referred by general practitioners to a dental hospital unit.

OBJECTIVE: To reduce the high failed appointment rate and anxiety levels among previously identified anxious new patients referred by general practitioners to a unit of restorative dentistry. A letter was drawn up which contained more explanatory information about the purpose and content of the initial dental appointment. DESIGN: The study was a single centre, double blind trial. SETTING: Referrals of nervous/anxious patients from general practitioners to the Manchester Dental Hospital. SUBJECTS: 185 patients were randomly allocated to the control group (n = 94) who received the standard hospital appointment information and the experimental group (n = 91) who received the new more informative letter. MAIN OUTCOME MEASURES: The effect of the new letter on patient attendance was recorded and anxiety levels were measured before and after seeing the clinician. RESULTS: 70 patients attended from the control group and 58 patients from the experimental group, giving 59 and 44 fully completed forms respectively. Both groups of patients were generally happy with the information that they were given. The attendance of patients in the experimental group and the control group were not significantly different. Preconsultation state anxiety levels were not reduced in the experimental group by the provision of the additional information but after the consultation both groups showed a significant reduction in state anxiety (P < 0.001). CONCLUSION: The new more informative letter did not improve attendance among this group of nervous patients. Other strategies for increasing initial attendance will therefore need to be identified and evaluated. In this study, the most important factor in reducing anxiety levels during the consultation appeared to be contact with the clinician rather than preparatory written postal information.

Familial Incidence and Influence on the Development of Obesity.

BACKGROUND: The prevalence of obesity in families of patients seeking surgical treatment for their severe obesity was investigated. METHODS: Patients listed for surgery (vertical gastroplasty) for severe obesity (BMI > 35) were interviewed and asked for details of the numbers of members of the immediate family who were at least 6.5 kg overweight. The data collected on 87 morbidly obese patients were compared to data from a group of 50 patients, all of whom had a BMI of less than 25 and were not overweight, who were acting as controls. RESULTS: Obese patients had significantly more overweight family members than normal weight controls,(p = 0.004). CONCLUSION: The prevalence of overweight in the families of obese patients may be genetically and environmentally influenced.

Psychological status of diabetic people with or without lower limb disability.

The aim of this study was to compare the quality of life between diabetic people with chronic foot ulceration or lower limb amputation and diabetic controls. Each participant was interviewed using the Psychosocial Adjustment to Illness Scale, the Hospital Anxiety and Depression (HAD) scale, a specifically designed foot questionnaire and a quality of life ladder. Thirteen diabetic unilateral lower limb amputees (DA) were matched for age and sex with 13 unilateral diabetic patients with chronic foot ulceration (DU). Twenty six age- and sex-matched diabetic people with no history of foot ulceration were the controls (DC). Significantly poorer psychosocial adjustments to illness were found in DU and DA compared to diabetic controls (both P < 0.05). DU were also significantly more depressed than the DC (P < 0.05) using the HAD scale. The quality of life ladder revealed that DU were significantly more dissatisfied with their personal lives than DC (P < 0.05). Finally, the foot questionnaire showed that DU had a significantly more negative attitude towards their feet than DC and DA (P < 0.05). This study showed that the psychological status of mobile amputees was better than that of the diabetic foot ulcer patients but not as good as diabetic controls.

Reversal of Hair Loss following Vertical Gastroplasty when Treated with Zinc Sulphate.

BACKGROUND: Nutritional complications following surgery for morbid obesity include both vitamin and mineral deficiency. Severe cases of zinc deficiency can lead to alopecia, diarrhea, emotional disorders, weight loss, intercurrent infection, bullous-pustular dermatitis and hypogonadism in males. Hair loss may occur after vertical gastroplasty (VG). METHODS: Diffuse hair loss occurred in 47 out of 130 patients who underwent VG. All patients had been routinely advised to take a multivitamin supplement, but 47 developed hair loss despite taking the supplement. These patients were then prescribed Zinc Sulphate 200 mg three times a day. There was no alteration in the vitamin supplementation. RESULTS: Arrest of hair loss and regrowth occurred in all patients. However, five patients reported recurrence of hair loss after stopping zinc. This loss was reversed within 6 months of recommencing zinc 600 mg daily. Ten control patients had no hair loss after gastrointestinal surgery. CONCLUSION: Significant hair loss occurred in about one-third of patients after VG, and was reversed by zinc supplementation.

Biochemical Changes after Vertical Banded Gastroplasty.

A prospective study of biochemical changes after vertical banded gastroplasty for morbid obesity, in 94 patients (10 males and 84 females, ages ranging from 18 to 59 years) has been carried out. Liver function tests and electrolyte estimations were performed preoperatively, during hospitalization for surgery, at 6 weeks and at 6 months postoperatively, and demonstrated no significant changes in liver function in these patients 6 months after surgery. The study concludes that there is no increase in the risk of liver damage or electrolyte disturbance after vertical gastroplasty, but that there may be subtle hepatic changes present as gall bladder disease developed in 18 patients postoperation (19%).

Resolution of Diabetes Following Vertical Gastroplasty in Morbidly Obese Patients.

Case reports are presented in three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery, the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly

General practitioner referral rates to district psychiatry and psychology services.

The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.

The Oxford-Manchester study of dialysis patients. Age, risk factors and treatment method in relation to quality of life.

A retrospective study of 159 patients who started Haemodialysis (HD) or Continuous Ambulatory Peritoneal Dialysis (CAPD), between 1981 and 1984 was carried out in two UK Renal Units. An extension of the study was carried out in one unit during 1985, gathering data on 30 patients aged greater than 65. The aim was to assess whether age, medical or social risk factors, or treatment method, affected perceived quality of life. Assessment was by standardised self-report questionnaire. The overall life satisfaction, measured on Cantril's ladder scale, showed no significant difference between dialysis patients and a normal population. On a quality of life semantic differential scale CAPD patients scored significantly better than HD patients. Satisfaction with sexual relationships showed marked deterioration in all age groups, but this did not seem to affect reported satisfaction with marriage. Those aged greater than 65 scored significantly better than younger patients on dialysis stress scales, and were generally more satisfied with life. When the study population was sub-divided into four groups, by age (less than or greater than 60) and presence or absence of additional factors, were seen to be those least satisfied with life on several different assessment scales.

Psychological factors in recovery from myocardial infarction: preliminary communication.

A small consecutive series of 27 myocardial infarction patients were interviewed at approximately 10 and 40 weeks after infarction to obtain data concerning the psychological aspects of rehabilitation. The results emphasized the need for consistency in imparting information and advice, and suggested the value of joint cardiological and clinical psychological assessment where patients fail to make expected progress. They pointed to a simple framework for intervention which is capable of further development and evaluation.

Does prostacyclin prevent cognitive deficits after open heart surgery?

Two groups of open heart surgery patients, one receiving prostacyclin and one placebo, were assessed one week pre-operatively and 3 months post-operatively, using a battery of clinical tests measuring a variety of cognitive functions. No significant differences between the groups were detected, apart from a visual retention deficit at 3 months in the prostacyclin group. The results cast doubt on previous findings suggesting that prostacyclin reduces cognitive deficits following open heart surgery.

Locus of control and cognitive behaviour therapy with mastectomy patients: a pilot study.

A cognitive behaviour therapy programme was designed for use with mastectomy patients, and a pilot study performed to test the efficacy of the programme. This article reports the locus of control data collected during the pilot study and the relationship between these data and the clinical assessment measures. Lower chance scores at pre-treatment are associated with greater clinical improvement as predicted. Surprisingly, however, there is an increase in chance scores over treatment although this disappears at follow-up. Patients who also received medication scored higher on internal control than those who did not. These results are discussed and it was concluded that antidepressant medication may assist the cognitive therapy programme.