Pain Among an Inpatient Complex Chronic Care Population of Residents with and without Missing Limbs.

PURPOSE: Limb loss occurs for various reasons (trauma, infection, vascular diseases, tumors, congenital absence). Limb loss is known to result in several types of pain. Little is known about pain in residents with missing limbs admitted to complex chronic care (CCC) facilities. This study examined the presence of pain and its intensity in CCC residents with and without missing limbs. METHODS: The Continuing Care Reporting System was accessed for data from residents admitted to Ontario com\plex chronic care facilities assessed with the Resident Assessment Instrument Minimum Data Set, V2.0. Propensity score matching (1:1 ratio) was used to identify a control resident without missing limbs for each case. McNemar's test was used for dichotomous pain (Y/N) and Wilcoxon Signed Ranks test for ordinal pain (4-level and 7-level pain variables). Binary and multinomial logistic regression were used to quantify the relationship between missing limbs and reports of pain. RESULTS: Missing limbs were reported by 2961 residents (2.1%, original n=139,920) resulting in 2212 propensity matched pairs. A significantly higher proportion of missing limb cases had pain (80%) versus controls (70%), χ 2=64.43, p<0.001. Significantly higher pain levels were found in cases versus controls (z=8.47, p<0.001 for 4-level pain; z=8.57, p<0.001 for 7-level pain). Residents with missing limbs were 1.46 (95% CI: 1.26-1.70) times more likely to report pain than controls, p<0.001. CONCLUSION: The results point to the need to better manage pain in CCC residents with missing limbs.

Hypertensive Hypoalgesia in a Complex Chronic Disease Population.

Hypertension-related hypoalgesia, defined as lower pain sensitivity in individuals with high blood pressure, has yet to be examined in a large-scale study of complex care residents. Here, the Continuing Care Reporting System database, which contains health information on residents of Canadian complex chronic care facilities, was used for assessment. Hypertension was reported among 77,323 residents (55.5%, total N = 139,920). Propensity score matching, with a 1:1 ratio, was used to identify a control record without hypertension for each case. Multinomial logistic regression was used to quantify the effects of hypertension and sex on four-level ordinal pain variables, controlling for potential confounders. The matched dataset included n = 40,799 cases with hypertension and n = 40,799 without hypertension, with 57% female. Residents with hypertension had significantly lower odds of reporting pain (yes/no) (OR = 0.85, 95% CI 0.81-0.90, p < 0.001), including on measures of severe pain (OR = 0.69, 95% CI 0.63-0.76, p < 0.001). A significant interaction between hypertension and sex (OR = 1.17, 95% CI 1.03-1.32, p = 0.014) indicated that a significantly greater proportion of females without hypertension reported severe pain (8.71%). The results confirm the relationship between hypertension and reduced pain sensitivity on a population level.

Association Between Multimorbid Disease Patterns and Pain Outcomes Among a Complex Chronic Care Population in Canada.

PURPOSE: Disease multimorbidity and pain is a complex, yet common, problem for the aging population, and a significant burden on the health-care systems around the world. Despite this, disease comorbidity and the association with pain in a complex chronic care population is not well understood. This study examined the most prevalent disease combinations and their association with pain. PATIENTS AND METHODS: The study initially included 139,920 residents, aged 18-101 years, admitted to publicly funded hospital facilities for complex chronic care in Canada between the years 2006 and 2016. Data were acquired through the Canadian Institute for Health Information (CIHI) Facility-Based Continuing Care Reporting System (CCRS). Descriptive and chi-square statistics were used to summarize and compare the sample characteristics. Binary logistic regression analyses were used to examine the association between multimorbid disease categories and pain outcomes. RESULTS: The sample consisted of 139,573 residents (57% female), mostly older (mean age = 77.32 years), married (40%), or widowed (36%). Residents took an average of 11.9 medications and 77% were using analgesic medications. On average, residents had diagnoses from 3.06 disease categories (SD = 1.43). Heart/circulation diseases were the most prevalent among the sample (73%), with neurological second (46%) and musculoskeletal third (44%). Overall, 73% of residents reported pain, with 43% reporting moderate pain severity. Residents with multiple disease categories were more likely to report the presence of pain (OR = 1.08, 95% CI: 1.07-1.08, p < 0.001), with each additional disease category associated with an 8% increase in the odds of reporting pain. CONCLUSION: The findings from this study help identify common comorbid disease patterns related to pain in an institutionalized, complex chronic care population. This information contributes to both the pain and multimorbidity literature, and is invaluable for creating care plans to meet the demands of a challenging population.

An Integrated Adult Congenital Heart Disease Psychology Service.

OBJECTIVE: North American adults with congenital heart disease (CHD) are at increased risk of mood and anxiety disorders, although there are no published data on psychological treatment. In order to provide guidance to adult CHD (ACHD) programs considering the integration of psychological care, the aim of this study was to provide a comprehensive description of a specialized ACHD psychological service. DESIGN: At a large tertiary hospital, a retrospective review of 100 ACHD clinic patient psychology files was performed. The following data were abstracted: sociodemographic and medical background, presenting psychological concerns, and the course and outcome of psychological intervention. RESULTS: Of 100 patients, the mean age was 33 ± 11 years and 51% were female. Prevalent psychological concerns were generalized anxiety (82%), health-/heart-related anxiety (71%), depressed mood (60%), and difficulty coping with a medical condition (49%); 65% of patients met diagnostic criteria for a mood or anxiety disorder. Following assessment, individual psychotherapy was offered to 87 patients, of whom 75 opted to proceed with treatment. The median number of psychotherapy sessions was 8 and treatment most frequently included cognitive therapy (92%), relaxation skills training (57%), and communication skills training (46%). Of 64 patients for whom a course of psychotherapy had ended at the time of data abstraction, 54 (88%) had reduced or absent psychological distress. CONCLUSIONS: Reduced psychological distress can be achieved among adults with CHD who receive targeted psychological intervention. Consistent with the emerging field of behavioral cardiology, other ACHD programs as well as general cardiovascular programs are encouraged to integrate cardiac psychology services in order to provide comprehensive patient care.

Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review.

BACKGROUND: Total knee arthroplasty (TKA) is a common and costly surgical procedure. Despite high success rates, many TKA patients develop chronic pain in the months and years following surgery, constituting a public health burden. Pain catastrophizing is a construct that reflects anxious preoccupation with pain, inability to inhibit pain-related fears, amplification of the significance of pain vis-à-vis health implications, and a sense of helplessness regarding pain. Recent research suggests that it may be an important risk factor for untoward TKA outcomes. To clarify this impact, we systematically reviewed the literature to date on pain catastrophizing as a prospective predictor of chronic pain following TKA. METHODS: We searched MEDLINE, EMBASE, and PsycINFO databases to identify articles related to pain catastrophizing, TKA, risk models, and chronic pain. We reviewed titles and abstracts to identify original research articles that met our specified inclusion criteria. Included articles were then rated for methodological quality. including methodological quality. Due to heterogeneity in follow-up, analyses, and outcomes reported across studies, a quantitative meta-analysis could not be performed. RESULTS: We identified six prospective longitudinal studies with small-to-mid-sized samples that met the inclusion criteria. Despite considerable variability in reported pain outcomes, pain catastrophizing was identified as a significant predictor of chronic pain persisting ≥3 months following TKA in five of the studies assessed. Limitations of studies included lack of large-scale data, absence of standardized pain measurements, inadequate multivariate adjustment, such as failure to control for analgesic use and other relevant covariates, and failure to report non-significant parameter estimates. CONCLUSION: This study provides moderate-level evidence for pain catastrophizing as an independent predictor of chronic pain post-TKA. Directions for future research include larger, well-controlled studies with standard pain outcomes, identification of clinically-relevant catastrophizing cut-offs that predict pain outcomes, investigation of other psychosocial risk factors, and assessment of interventions aimed to reduce pain catastrophizing on chronic pain outcomes following TKA surgery.

Mental health diagnoses and recidivism in paroled offenders.

Although the issue of mental illness among offender populations has received attention in the last number of years, there are a number of issues related to mental illness among such groups that require more study. One such topic relates to the association between mental illness, actuarially assessed risk of recidivism, and observed rates of reoffending. In the present investigation, file information was reviewed to determine the presence of a variety of mental health conditions. Actuarially based risk assessment data were also collected for participants as well as information regarding suspension, new charges, and convictions. A sample of 136 offenders housed in a halfway house operated by Correctional Service of Canada was included in the present investigation. Results indicated very high rates of serious mental illness in this high-risk population. Offenders with borderline personality disorder and attention deficit hyperactivity disorder were significantly more likely to recidivate or be suspended. Suspensions refer to administrative decisions to place an offender in jail due to problematic behaviour (typically involving a breach of his release conditions or new charges/convictions). Offenders with a diagnosis of paraphilic disorder were significantly less likely to recidivate or be suspended. Results are discussed in light of the available literature.

Quality of life in children and young adults with cardiac conditions.

PURPOSE OF REVIEW: Unequivocal conclusions regarding the quality of life (QOL) of children, adolescents, and young adults with heart disease cannot be drawn because results vary across studies and between patient and parent-proxy reports. This review focuses on the recent studies that help us understand this variability and why subgroups of young cardiac patients do appear at increased risk of impaired QOL. RECENT FINDINGS: The age at which QOL is assessed might contribute to variability in reported QOL outcomes, with the greatest QOL impairment tending to occur with the youngest patients. Adolescents and young adults with heart disease often report positive QOL outcomes. Recent studies have furthered our understanding of the determinants of impaired QOL, including low social support, emotional instability, developmental disabilities, poorer subjective health status, and lower exercise capacity. Certain cardiac treatments, such as transplantation and implantable cardioverter defibrillator implantation, warrant special attention for potential QOL impairment. SUMMARY: Future research should move beyond cross-sectional studies and include longitudinal assessment of QOL. In addition, given the success with extending the lives of young patients with cardiac conditions, it is important that strategies focused on patient and family QOL are also advanced.

Pedophilia: an evaluation of diagnostic and risk prediction methods.

One hundred thirty child sexual abusers were diagnosed using each of following four methods: (a) phallometric testing, (b) strict application of Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]) criteria, (c) Rapid Risk Assessment of Sex Offender Recidivism (RRASOR) scores, and (d) "expert" diagnoses rendered by a seasoned clinician. Comparative utility and intermethod consistency of these methods are reported, along with recidivism data indicating predictive validity for risk management. Results suggest that inconsistency exists in diagnosing pedophilia, leading to diminished accuracy in risk assessment. Although the RRASOR and DSM-IV-TR methods were significantly correlated with expert ratings, RRASOR and DSM-IV-TR were unrelated to each other. Deviant arousal was not associated with any of the other methods. Only the expert ratings and RRASOR scores were predictive of sexual recidivism. Logistic regression analyses showed that expert diagnosis did not add to prediction of sexual offence recidivism over and above RRASOR alone. Findings are discussed within a context of encouragement of clinical consistency and evidence-based practice regarding treatment and risk management of those who sexually abuse children.