Pain management at home in children with cancer: a daily diary study.

BACKGROUND: With the transition of care of cancer patients from the hospital to the home setting, parents are largely responsible for children's pain management. Children's cancer pain is undermanaged, yet, there is little empirical data on the occurrence and management of cancer pain in the home setting. The purpose of the present study, therefore, was to employ a daily diary protocol to examine barriers to pain management of children's cancer pain by parents at home. PROCEDURE: Parent-child dyads were recruited from the Cancer Institute at a major children's hospital in Southern California. A total of 45 patient/parent pairs completed baseline data on demographic and personality characteristics, children's quality of life, and parental beliefs regarding analgesic use for children and then completed daily diaries of pain and analgesic administration for 14 consecutive days. RESULTS: Most children were reported to experience chronic pain while undergoing treatment for cancer, yet overall analgesic administration at home was low. Parents who reported misconceptions regarding analgesic use for children were less likely to administer pain medication to children. Children who were less shy, more social, or had lower quality of life were more likely to receive analgesics. CONCLUSIONS: A significant proportion of children receiving outpatient treatment for cancer were rated as experiencing chronic pain and pain was not optimally managed in the home setting. Further understanding and addressing barriers to children's cancer pain management in the home setting will aid in alleviating unnecessary pain in this vulnerable patient population.

Attitudes regarding analgesic use and pain expression in parents of children with cancer.

BACKGROUND: Children with cancer often experience significant levels of pain and their pain is generally undermanaged. Management of care to patients with cancer has shifted from the hospital to the home, and as such parents are charged with managing children's pain. However, parents may have misconceptions of analgesic use, which can lead to undertreatment of pain in children. The purpose of this study is to examine attitudes toward pain medication and perceptions of pain expression among parents of children undergoing cancer treatment. PROCEDURE: Parents of children who were undergoing cancer treatment at a hospital were recruited to take part in a survey study. A total of 187 parents completed a survey examining their attitudes toward medication and perceptions of pain expression in children. RESULTS: Many parents reported concerns regarding analgesic use to treat their children's pain and misconceptions about how children can express pain. Regression analyses noted that parental perceptions of pain expression were related to children's experience of chronic or recurring pain and the 2 dimensions of child temperament: emotionality and sociability. CONCLUSIONS: Many parents of children with cancer have misconceptions regarding issues of pain management; these misconceptions can potentially lead to undertreatment of pain in children. These misconceptions are associated with aspects of children's temperament.

Sleep, rhythms and women's mood. Part II. Menopause.

This review summarizes studies of sleep and other biological rhythms in menopausal women with major depression compared with healthy control subjects. Where feasible, we focused on studies in women who met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for a major depressive episode (MDE) compared with matched normal control subjects and the Staging System for Reproductive Aging in Women (STRAW) criteria. The aim was to review supporting evidence for the hypothesis that a disruption of the normal temporal relationship between sleep and other biological rhythms, such as melatonin, cortisol, thyroid stimulating hormone (TSH) or prolactin, occur during the menopausal transition. As a result, depressive disorders occur in predisposed women. Treatment strategies, designed to correct these altered phase (timing) or amplitude abnormalities, thereby improve mood. Although there may be some common features to menopausal depression compared with other depressive disorders related to the reproductive cycle (e.g. premenstrual dysphoric disorder or postpartum major depression), such as increased morning melatonin secretion, a specific profile of sleep and biological rhythms may distinguish healthy from depressed women during menopause. Further work is needed to characterize more fully the particular abnormalities associated with well-defined menopausal depression in order to develop treatment strategies targeted more specifically to pathogenesis.

Sleep, rhythms and women's mood. Part I. Menstrual cycle, pregnancy and postpartum.

This review summarizes studies of sleep and other biological rhythms during the menstrual cycle, pregnancy and the postpartum period, focusing, where feasible, on studies in women who met DSM-IV (Diagnostic and Statistical Manual for Mental Disorders, 4th edition) criteria for a depressive disorder compared with healthy controls. The aim was to review supporting evidence for the hypothesis that disruption of the normal temporal relationship between sleep and other biological rhythms such as melatonin, core body temperature, cortisol, thyroid stimulating hormone (TSH) or prolactin occurring during times of reproductive hormonal change precipitates depressive disorders in predisposed women. Treatment strategies, designed to correct these altered phase (timing) or amplitude abnormalities, thereby improve mood. Although there may be some common features to premenstrual, pregnancy and postpartum depressive disorders (e.g. elevated prolactin levels), a specific profile of sleep and biological rhythms distinguishes healthy from depressed women during each reproductive epoch. Further work is needed to characterize more fully the particular abnormalities associated with each reproductive state to identify common versus distinctive features for each diagnostic group. This information could serve as the basis for developing more targeted treatment strategies.

Light treatment of mood disorders.

In 1981, seven patients with nonseasonal depression were treated with bright white light in 1982, bright artificial light was used to treat a manic-depressive patient with a seasonal mood cycle. In the last 20 years, a plethora of studies have further defined the depressive populations, who are responsive to light treatment; the optimal timing, intensity, spectral frequency, and duration of treatment; its comparison with other pharmacological interventions; predictors of response; side-effect profiles; viable placebo-control conditions; alternative devices and forms of administration; potential mechanisms and anatomical pathways mediating light's physiological effects; and its application to other disorders and subsyndromaI states. These studies have been conducted across multiple countries with surprisingly consistent results. Further work is needed, as highlighted in this review, to clarify the specific mechanism of action in subtypes of depressive disorders and differential age and gender effects. Although the majority of work in this area is relatively new, it behooves the reader to remember that Solomon, almost 3000 years ago, wrote in Ecclesiastes: "Truly the light is sweet and a pleasant thing it is for the eyes to behold the sun" (11:7).

Acute to chronic postoperative pain in children: preliminary findings.

BACKGROUND/PURPOSE: Chronic postoperative pain is a well-established clinical phenomenon that is associated with adverse outcomes. The incidence of this clinical phenomenon in children, however, is not well established. The purpose of this study was to identify the incidence of chronic pain in children after surgery. METHODS: Following a screening process, a total of 113 children and their parents were enrolled in this cross-sectional study. Data regarding persistence and characteristics of pain after surgery were obtained. RESULTS: Approximately 13% of the children, most of whom underwent orthopedic procedures, reported the existence of symptoms of chronic postoperative pain. Most of the children indicated that the pain started immediately after surgery, was localized to the surgery site, and was intermittent. Children reported a median duration of pain of 4.1 months, and approximately half of the children experienced pain most days of the week. Up to 30% of the children reported interference of pain in functioning in areas such as extracurricular activities and sleep. DISCUSSION: Given the large number of children at risk for experiencing chronic postoperative pain, preventative efforts are necessary. Large-scale cohort prospective studies are needed to confirm the results of this cross-sectional study.

Menopause: neuroendocrine changes and hormone replacement therapy.

OBJECTIVE: We evaluated the effects of hormone replacement therapy (HRT) alone and in combination with a selective serotonin reuptake inhibitor on mood, cognition, and neuroendocrine parameters in peri- and postmenopausal women. METHODS: We measured neuroendocrine variations in peri- and postmenopausal depressed patients (DP) and postmenopausal normal control (NC) women (45 to 72 years old) before and after treatment with HRT alone and HRT combined with antidepressant medication. All subjects were without significant medical illness and off psychoactive or other medication that would interfere with neuroendocrine measures. RESULTS: Menopausal DP women reported greater severity of hot flashes, were less likely to be "morning" types, and had relatively good neuropsychological function compared with NC. DP and NC had comparable levels of reproductive hormones, with the exception of elevated prolactin levels, which increased, as did thyroid-stimulating hormone levels, in response to estradiol treatment. DP had poor sleep quality as measured both by subjective ratings and objective polysomnographic measures compared with NC. In DP estradiol did not enhance the effect of antidepressant alone on mood ratings. CONCLUSION: These findings may differ from other reports in the literature as a function of diagnoses of major depressive episode, randomized controlled trials, or dose and preparation of HRT. Further work is needed on the differential effect of treatment regimens in these disturbances that are evident primarily in baseline neuroendocrine function.