Chronic Pain and Associated Factors in India and Nepal: A Pilot Study of the Vanderbilt Global Pain Survey.

BACKGROUND: Evaluation and treatment of chronic pain worldwide are limited by the lack of standardized assessment tools incorporating consistent definitions of pain chronicity and specific queries of known social and psychological risk factors for chronic pain. The Vanderbilt Global Pain Survey (VGPS) was developed as a tool to address these concerns, specifically in the low- and middle-income countries where global burden is highest. METHODS: The VGPS was developed using standardized and cross-culturally validated metrics, including the Brief Pain Inventory and World Health Organization Disability Assessment Scale, as well as the Pain Catastrophizing Scale, the Fibromyalgia Survey Questionnaire along with queries about pain attitudes to assess the prevalence of chronic pain and disability along with its psychosocial and emotional associations. The VGPS was piloted in both Nepal and India over a 1-month period in 2014, allowing for evaluation of this tool in 2 distinctly diverse cultures. RESULTS: Prevalence of chronic pain in Nepal and India was consistent with published data. The Nepali cohort displayed a pain point prevalence of 48%-50% along with some form of disability present in approximately one third of the past 30 days. Additionally, 11% of Nepalis recorded pain in 2 somatic sites and 39% of those surveyed documented a history of a traumatic event. In the Indian cohort, pain point prevalence was approximately 24% to 41% based on the question phrasing, and any form of disability was present in 6 of the last 30 days. Of the Indians surveyed, 11% reported pain in 2 somatic sites, with only 4% reporting a previous traumatic event. Overall, Nepal had significantly higher chronic pain prevalence, symptom severity, widespread pain, and self-reported previous traumatic events, yet lower reported pain severity. CONCLUSIONS: Our findings confirm prevalent chronic pain, while revealing pertinent cultural differences and survey limitations that will inform future assessment strategies. Specific areas for improvement identified in this VGPS pilot study included survey translation methodology, redundancy of embedded metrics and cultural limitations in representative sampling and in detecting the prevalence of mental health illness, catastrophizing behavior, and previous traumatic events. International expert consensus is needed.

Hypnosis for refractory severe neuropathic pain: A case study.

Chronic pain not only has the greatest negative effect on quality of life compared with other chronic health problems but also contributes to the greatest disability worldwide. Management of chronic neuropathic pain is particularly challenging given its association with other pain processes, the fact that less than half of patients respond to a single pain medication, and the lack of evidence regarding combination therapy (i.e. a treatment regimen that combines several scheduled pain medications) safety and efficacy. Given these challenges, there is a growing interest in the application of complementary and alternative medicine (CAM) therapies such as yoga, acupuncture, and hypnosis. We present the case of a 67-year-old male with severe diabetic neuropathy refractory to first, second, and third-line treatments. His disabling pain precipitated premature retirement, contributing to severe depression with suicidality requiring hospitalization. Ultimately, he experienced relief through an integrative health regimen, and he identified hypnosis as the most effective therapy for his pain. Through individual and group sessions, recordings, and daily self-hypnosis, he improved both his chronic pain symptomatology and quality of life, simultaneously decreasing opioid use. Simulation modeling analysis of his pain ratings over time showed that they reliably decreased after engaging in hypnosis, r = -.33, p =.001. A growing body of research suggests that hypnosis is beneficial as part of an integrative treatment approach to chronic pain and enhances the efficacy of other therapies. Our medically challenging case study supports that hypnosis may serve as a viable and durable treatment for chronic neuropathic pain.

Idiopathic peripheral neuropathy responsive to sympathetic nerve blockade and oral clonidine.

A 52-year-old female presented with idiopathic stocking-glove neuropathy. She underwent a series of right and left stellate ganglion blocks with ropivacaine and clonidine, followed by lumbar sympathetic blocks. This resulted in complete symptom relief for two weeks. These procedures were repeated after a two-month interval; at that time she was still experiencing partial relief from the first series. She again remained completely pain free for several weeks following the injections. As the pain partially returned, daily oral clonidine was initiated and resulted in almost complete cessation of her symptoms, which persisted at a three-month follow-up examination.

Validation of a detailed scoring checklist for use during advanced cardiac life support certification.

INTRODUCTION: Defining valid, reliable, defensible, and generalizable standards for the evaluation of learner performance is a key issue in assessing both baseline competence and mastery in medical education. However, before setting these standards of performance, the reliability of the scores yielding from a grading tool must be assessed. Accordingly, the purpose of this study was to assess the reliability of scores generated from a set of grading checklists used by nonexpert raters during simulations of American Heart Association (AHA) Megacodes. METHODS: The reliability of scores generated from a detailed set of checklists, when used by 4 nonexpert raters, was tested by grading team leader performance in 8 Megacode scenarios. Videos of the scenarios were reviewed and rated by trained faculty facilitators and a group of nonexpert raters. The videos were reviewed "continuously" and "with pauses." The grading made by 2 content experts served as the reference standard, and 4 nonexpert raters were used to test the reliability of the checklists. RESULTS: Our results demonstrate that nonexpert raters are able to produce reliable grades when using the checklists under consideration, demonstrating excellent intrarater reliability and agreement with a reference standard. The results also demonstrate that nonexpert raters can be trained in the proper use of the checklist in a short amount of time, with no discernible learning curve thereafter. Finally, our results show that a single trained rater can achieve reliable scores of team leader performance during AHA Megacodes when using our checklist in a continuous mode because measures of agreement in total scoring were very strong [Lin's (Biometrics 1989;45:255-268) concordance correlation coefficient, 0.96; intraclass correlation coefficient, 0.97]. CONCLUSIONS: We have shown that our checklists can yield reliable scores, are appropriate for use by nonexpert raters, and are able to be used during continuous assessment of team leader performance during the review of a simulated Megacode. This checklist may be more appropriate for use by advanced cardiac life support instructors during Megacode assessments than the current tools provided by the AHA.