The Association between Educational Attainment and Patterns of Emergency Department Utilization among Adults with Sickle Cell Disease.

PURPOSE: Patients with low educational attainment may be at increased risk for unplanned health care utilization. This study aimed to determine what factors are related to emergency department (ED) visits in hopes of guiding treatments and early interventions. METHODS: At two medical centers in the Mid-Atlantic United States, 258 adults with sickle cell disease aged 19-70 years participated in a retrospective study where we examined whether education level is independently associated with ED visits after accounting for other socioeconomic status (SES) variables, such as pain and disease severity and psychosocial functioning. RESULTS: The data showed that patients without a high school education visited the ED three times as frequently as patients with post secondary education. Controlling for poverty and employment status decreased the effect of education on ED visits by 33.24 %. Further controlling for disease severity and/or psychosocial functioning could not account for the remaining association between education and ED visits, suggesting that education is independently associated with potentially avoidable emergency care. CONCLUSIONS: Early interventions addressing disparities in academic performance, especially for those children most at risk, may lead to improved long-term health outcomes in this population.

Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status.

PURPOSE: Research examining effects of ostomy use on sexual outcomes is limited. Patients with colorectal cancer were compared on sexual outcomes and body image based on ostomy status (never, past, and current ostomy). Differences in depression were also examined. METHODS: Patients were prospectively recruited during clinic visits and by tumor registry mailings. Patients with colorectal cancer (N = 141; 18 past ostomy; 25 current ostomy; and 98 no ostomy history) completed surveys assessing sexual outcomes (medical impact on sexual function, Female Sexual Function Index, International Index of Erectile Function), body image distress (Body Image Scale), and depressive symptoms (Center for Epidemiologic Studies Depression Scale-Short Form). Clinical information was obtained through patient validated self-report measures and medical records. RESULTS: Most participants reported sexual function in the dysfunctional range using established cut-off scores. In analyses adjusting for demographic and medical covariates and depression, significant group differences were found for ostomy status on impact on sexual function (p < .001), female sexual function (p = .01), and body image (p < .001). The current and past ostomy groups reported worse impact on sexual function than those who never had an ostomy (p < .001); similar differences were found for female sexual function. The current ostomy group reported worse body image distress than those who never had an ostomy (p < .001). No differences were found across the groups for depressive symptoms (p = .33) or male sexual or erectile function (p values ≥ .59). CONCLUSIONS: Colorectal cancer treatment puts patients at risk for sexual difficulties and some difficulties may be more pronounced for patients with ostomies as part of their treatment. Clinical information and support should be offered.

Photopsias are related in part to perceived stress and positive mood in retinitis pigmentosa.

PURPOSE: We measured the relationship between the occurrence of photopsias (spontaneous phosphenes), and retinitis pigmentosa (RP) subjects' level of vision, light exposure, and psychosocial factors to attempt to confirm RP patients' previous reports of these associations. METHODS: A total of 36 RP subjects self-administered PC-based binocular visual acuity, contrast sensitivity, and visual field tests at home twice a week, for 16 sessions in 2-3 months. After each session, subjects reported photopsias during the vision tests and completed questionnaires: Epworth Sleepiness Scale, Stanford Sleepiness Scale, Perceived Stress Scale, and Positive and Negative Affect Schedules. RESULTS: Across all subjects, photopsias occurred during 47% of sessions. Five (14%) subjects never noted photopsias, while five others noted photopsias at every session. Two-thirds of subjects experienced photopsias frequently (>20% of sessions). On average, the odds of noticing photopsias increased by 57% for every 1-point increase in mean perceived stress (OR = 1.57; 95% CI: 1.04, 2.4; P = 0.03) or reduced by 38% for every 1-point increase in positive mood (OR=0.62; 95% CI: 0.39, 0.98; P = 0.04), after adjusting for age, gender, and vision. Similarly, the odds of experiencing photopsias during a session increased by 16% for every 3-point increase in perceived stress and decreased by 17% for every 3-point increase in positive mood, after adjusting for age and gender (OR = 1.16; 95% CI: 1.01, 1.33; P = 0.048)(OR = 0.83; 95% CI: 0.73, 0.94; P = 0.004), respectively. Frequency of photopsias was not statistically significantly related to other factors measured. CONCLUSIONS: Increased photopsias appear to be related to times when subjects report increased perceived stress and/or decreased positive mood, rather than RP patients' age, level of vision, reported light exposure, or sleepiness.

IMMPACT recommendations for clinical trials: opportunities for the RDC/TMD.

The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations for core domains and measures of outcome in clinical trials complement the parallel work completed on Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). The overall approach of the RDC/TMD is consistent with the IMMPACT recommendations, although the specific tools used to quantify clinical presentation are appropriately different based on the precedents established in the TMD literature. The IMMPACT recommendations, while directed at clinical trials, have broad utility for all clinical research in TMD. Future TMD studies should consider including a measure of health-related quality of life and tracking participant disposition, as well as tracking adverse events from treatment and assessing the participant's global assessment of change in clinical trials. The RDC/TMD methodology provides a rich basis upon which to develop standards for quantifying the clinical significance of treatment outcomes across multiple domains, an area ripe for development. Axis II may benefit from a shift in conceptualisation in which measurement focuses on screening for depression and somatisation to a new, dimensional approach in which Axis II domains are measured and evaluated on a continuum of symptom severity. Combined with the expansion of Axis II to include measures of catastrophising and sleep disturbance, the resulting approach may provide a powerful method for evaluating risk profiles associated with poor outcomes in TMD.

Sleep continuity and architecture: associations with pain-inhibitory processes in patients with temporomandibular joint disorder.

Recent research suggests bi-directional interactions between the experience of pain and the process of sleep; pain interferes with the ability to obtain sleep, and disrupted sleep contributes to enhanced pain perception. Our group recently reported, in a controlled experimental study, that sleep fragmentation among healthy adults resulted in subsequent decrements in endogenous pain inhibition. The present report follows up that observation by extending this line of research to a sample of patients experiencing persistent pain. Patients with chronic temporomandibular joint disorder (TMD) pain were studied using polysomnography and psychophysical evaluation of pain responses. We assessed whether individual differences in sleep continuity and/or architecture were related to diffuse noxious inhibitory controls (DNIC), a measure of central nervous system pain inhibition. Among 53 TMD patients, higher sleep efficiency and longer total sleep time were positively associated with better functioning of DNIC (r=0.42-0.44, p<0.01; ps<0.05 for the multivariate analyses). These results suggest the possibility that disrupted sleep may serve as a risk factor for inadequate pain-inhibitory processing and hint that aggressive efforts to treat sleep disturbance early in the course of a pain condition might be beneficial in reducing the severity or impact of clinical pain.

Fatigue: an overlooked determinant of physical function in scleroderma.

OBJECTIVES: To examine the frequency and correlates of fatigue and its impact on physical and social functioning in patients with scleroderma, and to investigate whether fatigue mediates an association between pain and physical function. METHODS: One hundred and seven scleroderma patients attending an academic scleroderma specialty centre completed measures of fatigue, sleep, pain, depressive symptoms, and physical and social functioning. Patients had received a comprehensive clinical assessment with a diagnosis of limited or diffuse scleroderma from their attending rheumatologist. RESULTS: In this sample of scleroderma patients, 76% reported experiencing fatigue and 61% of these patients reported fatigue as one of their three most distressing symptoms. Patients endorsing greater pain had higher levels of self-reported fatigue, as did those reporting greater depression and poorer functioning. Multiple regression analyses indicated that global fatigue was a significant cross-sectional correlate of physical, but not social, functioning after controlling for depressive symptoms, level of education, poor sleep quality and disease subtype. However, global fatigue did not predict physical function when pain was included in the analyses. CONCLUSIONS: Our findings indicate that fatigue is common in scleroderma and that pain and fatigue are significant determinants of physical functioning for patients with limited and diffuse disease subtypes. Future research should investigate whether effective pain treatments reduce symptoms of fatigue, as well as identify other possible causes of fatigue in order to improve quality of life for scleroderma patients.

A systematic comparison of fatigue levels in systemic sclerosis with general population, cancer and rheumatic disease samples.

OBJECTIVES: There are no studies of fatigue levels in patients with SSc. The objective of this study was to compare fatigue in SSc to general population samples and patients with rheumatic diseases and cancer, where fatigue has been researched extensively. METHODS: SSc patients completed the General Fatigue Index (GFI) of the Multidimensional Fatigue Inventory. A systematic review was conducted to select comparison samples. Mean GFI scores from SSc patients were compared with mean scores from comparison samples with t-tests and Bonferroni corrections (family-wise P < 0.05). RESULTS: A total of 106 SSc patients were sampled (97 females; 28 diffuse SSc; 11.9 +/- 7.9 yrs since diagnosis). Based on comparisons from the systematic review, mean GFI scores in SSc (13.3 +/- 4.6) were significantly higher (greater fatigue; P < 0.05) than in two large population samples (8.7 and 9.6) and than in two samples of cancer patients in remission (9.4 and 10.0). Scores for the SSc sample were significantly lower (less fatigue) compared with two samples of cancer patients in palliative care (16.8 and 17.0). SSc GFI scores were similar to scores from patients with RA (13.4), AS (13.0) and SLE (13.1) and to scores from six studies of cancer patients in active treatment (11.1-13.5). CONCLUSIONS: The high levels of fatigue reported in SSc were similar to patients with varying types and treatment stages of cancer and patients with other rheumatic diseases when assessed with the GFI, demonstrating that fatigue warrants greater attention in SSc.

Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial.

BACKGROUND: Tricyclic antidepressants (TCA) provide less than satisfactory pain relief for postherpetic neuralgia (PHN), and the role of opioids is controversial. OBJECTIVE: To compare the analgesic and cognitive effects of opioids with those of TCA and placebo in the treatment of PHN. METHODS: Seventy-six patients with PHN were randomized in a double-blind, placebo-controlled, crossover trial. Each subject was scheduled to undergo three treatment periods (opioid, TCA, and placebo), approximately 8 weeks' duration each. Doses were titrated to maximal relief or intolerable side effects. The primary outcome measures were pain intensity (0 to 10 scale), pain relief (0 to 100%), and cognitive function. Analyses included patients who provided any pain ratings after having received at least a single dose of a study medication. RESULTS: Fifty patients completed two periods, and 44 patients completed all three. Mean daily maintenance doses were morphine 91 mg or methadone 15 mg and nortriptyline 89 mg or desipramine 63 mg. Opioids and TCA reduced pain (1.9 and 1.4) more than placebo (0.2; p < 0.001), with no appreciable effect on any cognitive measure. The trend favoring opioids over TCA fell short of significance (p = 0.06), and reduction in pain with opioids did not correlate with that following TCA. Treatment with opioids and TCA resulted in greater pain relief (38 and 32%) compared with placebo (11%; p < 0.001). More patients completing all three treatments preferred opioids (54%) than TCA (30%; p = 0.02). CONCLUSIONS: Opioids effectively treat PHN without impairing cognition. Opioids and TCA act via independent mechanisms and with varied individual effect.

Coping with the stress of a painful medical procedure.

To evaluate its effect on procedure-related distress, the focus of attention was manipulated by providing training to hospitalized acute burn patients (n=42). Participants were randomly assigned to attention focusing (i.e. attending to procedural sensations) or music distraction (i.e. attention diverting) coping interventions, or to usual care during the target dressing change. Coping behavior (i.e. distraction, focusing, and three confounding methods, ignoring, catastrophizing, reinterpreting), tension and intrusiveness were evaluated 24 h retrospectively (i.e. for the prior procedure), during the targeted procedure, and 30 min after the target procedure. When coping during the target procedure by ignoring, reinterpreting, and catastrophizing were covaried, the music distraction group experienced significantly fewer intrusions, and the attention focus group had more intrusions. Additionally, secondary analyses revealed that coping by ignoring during the prior day's procedure significantly predicted higher procedural tension during, and more intrusions following, the targeted procedure. Suppression-based forms of emotion-focused coping may be enhanced by training in the use of an explicit distractor.

The effects of stress, anxiety, and outdoor temperature on the frequency and severity of Raynaud's attacks: the Raynaud's Treatment Study.

It was expected that stress and anxiety would be related to Raynaud's phenomenon (RP) attack characteristics when mild outdoor temperatures produced partial or no digital vasoconstriction. Hypotheses were that in warmer temperature categories, compared to those below 40 degrees F, higher stress or anxiety would be associated with more frequent, severe, and painful attacks. The Raynaud's Treatment Study recruited 313 participants with primary RP. Outcomes were attack rate, severity, and pain. Predictors were average daily outdoor temperature, stress, anxiety, age, gender, and a stress-by-temperature or an anxiety-by-temperature interaction. Outcomes were tested separately in multiple linear regression models. Stress and anxiety were tested in separate models. Stress was not a significant predictor of RP attack characteristics. Higher anxiety was related to more frequent attacks above 60 degrees F. It was also related to greater attack severity at all temperatures, and to greater pain above 60 degrees F and between 40 degrees and 49.9 degrees F.

Theoretical perspectives on the relation between catastrophizing and pain.

The tendency to "catastrophize" during painful stimulation contributes to more intense pain experience and increased emotional distress. Catastrophizing has been broadly conceived as an exaggerated negative "mental set" brought to bear during painful experiences. Although findings have been consistent in showing a relation between catastrophizing and pain, research in this area has proceeded in the relative absence of a guiding theoretical framework. This article reviews the literature on the relation between catastrophizing and pain and examines the relative strengths and limitations of different theoretical models that could be advanced to account for the pattern of available findings. The article evaluates the explanatory power of a schema activation model, an appraisal model, an attention model, and a communal coping model of pain perception. It is suggested that catastrophizing might best be viewed from the perspective of hierarchical levels of analysis, where social factors and social goals may play a role in the development and maintenance of catastrophizing, whereas appraisal-related processes may point to the mechanisms that link catastrophizing to pain experience. Directions for future research are suggested.

Psychological assessment and treatment of patients with neuropathic pain.

Studies on the psychological assessment and treatment of neuropathic pain conditions, including postherpetic neuralgia (PHN), diabetic neuropathy, complex regional pain syndrome, post spinal cord injury, post amputation, and AIDS-related neuropathy, are reviewed. Although limited information is currently available, the findings are consistent with the larger literature on chronic pain and indicate that the assessment of neuropathic pain needs to include measurement of multiple dimensions of quality of life. Mood, physical and social functioning, and pain-coping strategies such as catastrophizing and social support are all important domains. Clinical trials of psychological interventions have not been reported in the scientific literature. Case series of successful treatment of neuropathic pain are reported, primarily in the area of biofeedback. As with other chronically painful conditions, it is likely that cognitive-behavioral interventions will improve the quality of life in neuropathic pain conditions.

Suicidal intent in patients with chronic pain.

Suicidal ideation among individuals suffering from chronically painful conditions has not been widely studied, although rates of completed suicide are believed to be elevated in this population relative to the general population. The psychiatric literature on suicide documents the importance of controlling for the severity of depression when studying factors associated with suicidal ideation, attempts, or completion. The present study examined the relationships between suicidal ideation and the experience of pain, pain-related disability, and pain coping efforts among a sample of individuals experiencing chronically painful conditions. Of 200 patients evaluated on an inpatient rehabilitation unit in a psychiatric service, 13 individuals (6.5%) reported suicidal intent on a commonly used self-report measure of symptoms of depression, the Beck Depression Inventory. This group was compared to a matched (age, sex, pain duration) group of similarly depressed individuals (N=13) and a matched group of non-depressed individuals (N=13) on measures of pain, disability, pain beliefs, and pain coping strategies. A history of a suicide attempt was associated with suicidal intent. Family history of substance abuse was significantly more prevalent among the depressed groups, regardless of suicidal thinking. The depressed/suicidal group and depressed/non-suicidal groups reported higher levels of pain, higher levels of pain-related disability, lower use of active coping, and higher use of passive coping compared to the non-depressed group. The depressed groups did not differ from one another on any of the measures of pain experience. Depression, not suicidal status, consistently predicted level of functioning. The prevalence of suicidal intent was comparable to rates observed in other studies and relatively low. When individuals with chronic pain report suicidal intent, it is imperative that measures preventing self-harm be implemented immediately and the patient's depression be treated aggressively.

The Raynaud's Treatment Study: biofeedback protocols and acquisition of temperature biofeedback skills.

The Raynaud's Treatment Study (RTS) compared temperature biofeedback training and a behavioral control procedure (frontalis EMG biofeedback) with nifedipine-XL and a medication placebo for treatment of primary Raynaud's phenomenon (RP) in a large (N = 313) multicenter trial. The present study describes the RTS biofeedback protocols and presents data on the acquisition of digital skin temperature and frontalis EMG responses in the RTS. The findings point to substantial problems with acquisition of physiological self-regulation skills in the RTS. Only 34.6% of the Temperature Biofeedback group (N = 81) and 55.4% of the EMG Biofeedback group (N = 74) successfully learned the desired physiological response. In contrast, 67.4% of a Normal Temperature Biofeedback group (N = 46) learned hand warming. Multivariate analysis found that coping strategies, anxiety, gender, and clinic site predicted acquisition of hand-warming skills whereas variables related to RP disease severity did not. Physiological data showed vasoconstriction in response to the onset of biofeedback and also found that performance in the initial sessions was critical for successful acquisition. These findings indicate that attention to the emotional and cognitive aspects of biofeedback training, and a degree of success in the initial biofeedback sessions, are important for acquisition.

Psychological aspects of neuropathic pain.

Studies on the psychosocial impact of neuropathic pain conditions, including postherpetic neuralgia, diabetic neuropathy, complex regional pain syndrome, post spinal cord injury, postamputation, and AIDS-related neuropathy, are reviewed. Although limited, data are consistent with the larger literature on chronic pain and indicate that neuropathic pain reduces quality of life, including mood and physical and social functioning. Depression and pain coping strategies such as catastrophizing and social support predict pain severity, and a single diary study demonstrates a prospective relation between depressed mood and increased pain. Clinical trials of psychological interventions have not been reported, although some case series of successful treatment of neuropathic pain are reported, primarily in the area of biofeedback. Given the evidence indicating the broad impact of neuropathic pain on many areas of function, it is surprising that so few studies have investigated the impact of psychological interventions in these populations.

Psychiatric symptoms and distress differ between patients with postherpetic neuralgia and peripheral vestibular disease.

OBJECTIVE: No previous studies have investigated the psychiatric characteristics of patients with postherpetic neuralgia (PHN). Similarly, no studies have been performed on patients with different chronic somatic symptoms due to a defined medical disease to compare the characteristics of psychiatric morbidity associated with each etiology. METHODS: After completing the subscales of the Symptom Checklist 90-R, a psychiatrist administered the Diagnostic Interview Schedule to all subjects. The psychiatric comorbidity in 35 patients with pain due to PHN was compared with a control group of 34 patients with the nonpainful aversive symptom of vertigo due to a peripheral vestibular disorder that caused unilateral hypofunction. RESULTS: PHN patients had significantly more symptoms of major depression and somatization disorder. No significant differences were found between groups for psychiatric diagnoses. Patients with PHN reported significantly less acutely distressing somatic symptoms. CONCLUSION: These results suggest that the psychiatric symptoms of patients with PHN are distinct from nonspecific acute distress and may be related to the experience of suffering from chronic neuropathic pain. Patients with PHN may not meet criteria for a psychiatric diagnosis, but their psychiatric comorbidity places them at substantial risk for increased pain, suicidal ideation, sustained disability, and the numerous complications of excessive medical evaluation and treatment. Patients with PHN should be evaluated specifically for psychiatric symptoms to reduce potential negative consequences through appropriate treatment.

Pain and quality of life following radical retropubic prostatectomy.

PURPOSE: We assess pain and quality of life following radical retropubic prostatectomy and determine whether intraoperative anesthetic management has any long-term effects on outcomes. MATERIALS AND METHODS: A total of 110 patients undergoing radical retropubic prostatectomy were randomly assigned to receive epidural and/or general anesthesia. Patients responded to a questionnaire mailed 3 and 6 months following surgery that assessed prostate symptoms, pain related to surgery, quality of life and mood. RESULTS: No long-term effects of anesthesia were observed. Of the 103 respondents (94%) at 3 months 49% had some pain related to surgery. Although pain was not related to anesthesic technique, patients who had it at 3 months used significantly more pain medication on postoperative day 3. Pain at 3 months was mild, averaging 1.5 on a scale of 0 to 10, and associated with poor perceptions of overall health (p <0.02), and reduced physical (p <0.01) and social (p <0.01) functioning. Pain at 3 months was associated with higher levels of preoperative anxiety (p <0.05). At 6 months 36 of 90 patients (35%) had some pain related to surgery and the impact was similar. CONCLUSIONS: Long-term effects of intraoperative anesthesic technique were not apparent. Mild pain following radical retropubic prostatectomy was common and associated with reduced quality of life, particularly social functioning. Affective distress, particularly anxiety, before surgery and use of pain medications following surgery may be predictors of chronic pain following radical retropubic prostatectomy.

Outcome of chronic opioid therapy for non-cancer pain.

Potential iatrogenic mood and cognitive declines associated with long-acting opioid therapy were examined in 19 patients receiving long-acting oral opioid medications and compared to ten patients receiving usual care. Pain, mood, and cognitive function were measured before and after achieving stable doses. In addition to reducing pain, long-acting opioid medication reduced anxiety and hostility. No declines in cognitive function were associated with the long-acting opioid medications, and the group receiving long-acting opioid medications showed significant improvement on a measure of psychomotor speed and sustained attention. Both patient groups reported significant reductions in perceived impairment in daily activities due to pain. Treatment responders taking long-acting opioid medications (63%) were taking a significantly lower dose at follow-up than the treatment non-responder group. These findings suggest that long-acting opioid medications can improve mood and do not impair cognitive functioning in patients with chronic non-cancer pain.