Pain management 2: the use of pyschological approaches to pain

This article is the second of a two-part series looking at the psychological and social factors which affect pain perception. The first article (Vol 10(14): 903-11) examined neurophysiological and psychological factors of pain perception. This article considers the importance of the nurse-patient interaction in the management of patients' pain. It outlines the adoption of several psychological approaches which could be utilized by nurses when dealing with patients in pain. The need to encourage a feeling of control over pain is discussed in relation to the use of patient-controlled analgesia and the development of positive coping skills. The value of good communication skills is emphasized as being essential in encouraging patients in pain to utilize these psychological approaches.

Pain management 1: psychological and social aspects of pain

This two-part article presents psychological and social factors which affect pain perception and response and the implications of these for nursing practice. In this article, the complex interactions between neurophysiological and psychological factors are outlined and theories of pain perception and ways in which the pain experience can be modulated are presented. The role of psychological factors, attitudes, beliefs and expectations of both patient and practitioner, pain behaviours and ability to cope are discussed. In the second part, these are further elaborated with particular reference to the nurse-patient interaction. The use of psychological approaches to augment clinical practice, such as education, reduction of anxiety and improving coping ability, are suggested. Finally, the importance of communication skills in pain management is addressed.

Cell transplantation as future therapy for cardiovascular disease?: A workshop of the National Heart, Lung, and Blood Institute

Despite the development of improved therapies and the significant advances in the understanding of the basis of disease pathogenesis, millions of Americans continue to live with life-threatening cardiovascular diseases. Recent breakthroughs suggest exciting directions that are likely to produce more effective therapies for the treatment of cardiovascular disease. One such area, cell transplantation (grafting of healthy cells into the diseased heart), holds enormous potential as an approach to cardiovascular pathophysiology. Once thought to be a scientific long shot, cell transplantation is becoming recognized as a viable strategy to strengthen weak hearts and limit infarct growth. The technology could also be used for the long-term delivery of beneficial recombinant proteins to the heart, which is a strategy to complement molecular biology advances and provide an alternative strategy for gene therapy. On August 24, 1998, the National Heart, Lung, and Blood Institute convened a workshop to discuss the current status of this fast-moving line of research and to explore its promise for treating cardiovascular disease. The participants included basic and clinical researchers, with representatives from academic and commercial research settings. The workshop was designed to establish the state-of-the-art and to equate current research with practical clinical application. The group recommended short- and long-term goals to assist in realizing, in the most expedient manner, the potential utility of cell transplantation for the treatment of cardiovascular disease. A summary of the meeting discussions and recommendations for future areas of research is presented.

Inhibition of multiple phases of human immunodeficiency virus type 1 replication by a dithiane compound that attacks the conserved zinc fingers of retroviral nucleocapsid proteins

The human immunodeficiency virus type 1 (HIV-1) nucleocapsid p7 protein contains two retrovirus-type zinc finger domains that are required for multiple phases of viral replication. Chelating residues (three Cys residues and one His residue) of the domains are absolutely conserved among all strains of HIV-1 and other retroviruses, and mutations in these residues in noninfectious virions. These properties establish the zinc finger domains as logical targets for antiviral chemotherapy. Selected dithiobis benzamide (R-SS-R) compounds were previously found to inhibit HIV-1 replication by mediating an electrophilic attack on the zinc fingers. Unfortunately, reaction of these disulfide-based benzamides with reducing agents yields two monomeric structures (two R-SH structures) that can dissociated and no longer react with the zinc fingers, suggesting that in vivo reduction would inactivate the compounds. Through an extensive drug discovery program of the National Cancer Institute, a nondissociable tethered dithiane compound (1,2-dithiane-4,5-diol, 1,1-dioxide, cis; NSC 624151) has been identified. This compound specifically attacks the retroviral zinc fingers, but not other antiviral targets. The lead compound demonstrated broad antiretroviral activity, ranging from field isolates and drug-resistant strains of HIV-1 to HIV-2 and simian immunodeficiency virus. The compound directly inactivated HIV-1 virions and blocked production of infectious virus from cells harboring integrated proviral DNA. NSC 624151 provides a scaffold from which medicinal chemists can develop novel compounds for the therapeutic treatment of HIV infection.

Genesis, a winged helix transcriptional repressor with expression restricted to embryonic stem cells

A novel member of the winged helix (formerly HNF-3/Forkhead) transcriptional regulatory family, termed Genesis, was isolated and characterized. Putative translation of the complete cDNA revealed the winged helix DNA binding domain to be centrally located within the protein, with regions on either side that contain known transcriptional regulatory motifs. Extensive Northern analysis of Genesis found that the message was exclusively expressed in embryonic stem cells or their malignant equivalent, embryonal carcinoma cells. The Genesis transcript was down-regulated when these cells were stimulated to differentiate. DNA sequences that Genesis protein would interact with were characterized and were found to contain a consensus similar to that found in an embryonic stem cell enhancer sequence. Co-transfection experiments revealed that Genesis is a transcriptional repressor. Genesis mapped to mouse chromosome 4 in a region syntenic with human chromosome 1p31, a site of nonrandom abnormalities in germ cell neoplasia, neuroblastoma, and acute lymphoblastic leukemia. Genesis is a candidate for regulating the phenotype of normal or malignant embryonic stem cells.

Factors influencing nurses' analgesia decisions

The first article in this two-part series (Vol 5(13): 778-84) presented an empirical study of nurses' and patients' pain following surgery. Results indicate that nurses give consistently lower pain ratings for patient's pain than do patients. The main implication of this research is that nurses continue to underestimate the severity of pain suffered by patients postoperatively. This article considers a second empirical study, the objectives of which were to determine which methods nurses use to assess and monitor pain relief and which factors influence their decision to give or withhold analgesia. Results reveal that while nurses claim to rely on patients' self-reports of pain, the most influential factors in the decision whether or not to give analgesia are the dosage, type and frequency of drug prescribed. The main reason for withholding analgesia is that the patient reacted adversely to the medication. Student nurses placed more emphasis than trained nurses on the timing and amount of analgesia given. Nurses had a good knowledge of pain assessment tools, although few had used them.

Are nurses still underestimating patients' pain postoperatively?

This article presents an empirical study of nurses' and patients' assessment of patients' pain following surgery. The study aimed to replicate and extend previous research which indicated that nurses tend to underestimate patients' pain. The independent variables were type of operation, patient gender, time since surgery and nurses' experience. Results confirmed that nurses give consistently lower pain ratings than patients. The prediction that nurses' pain ratings would be influenced by the type of operation was not confirmed. Not surprisingly, pain ratings were lower on day four than on day one. The data failed to confirm previous findings that the more junior the nurses the greater pain they infer in their patients. The main conclusion of this research is that nurses continue to underestimate the severity of pain suffered by patients postoperatively.

An elaborate tension receptor system highlights sensory complexity in the hind leg of the locust

The tibia of each leg of the locust is moved by two antagonistic muscles, the extensor and flexor tibiae. A variety of sense organs on and in each leg provide feedback about this joint's position and movement and about forces acting on the exoskeleton and muscles. One such organ is a muscle tension receptor found within the flexor tibiae muscle of the mesothoracic leg. We now show that an apparently homologous multipolar receptor is present in the hind leg, but that here it is associated with a specialised flexor muscle, the accessory flexor. This muscle comprises 13 fibres, innervated by five of the thirteen motor neurones that innervate the main flexor muscle and, since these are slow motor units, the response properties of the receptor are constrained. The multipolar receptor attaches to the muscle fibres near their proximal insertion onto the femoral cuticle. It generally has four primary dendrites, which do not branch extensively within the muscle. We show that the receptor responds strongly to active, isometric contractions but only poorly to imposed changes of accessory flexor muscle length (i.e. passive changes in tibial position). It does not respond to tension generated by the main flexor muscle or by the extensor muscle. The tension receptor causes short-latency (0.9­1.8 ms) excitatory inputs onto the three common inhibitory motor neurones and longer-latency (3.7­8.1 ms) inhibitory inputs onto the slow extensor tibiae motor neurone. In quiescent animals, it causes excitatory inputs onto flexor tibiae motor neurones (2.2­3.8 ms) but, in more active animals, its inputs onto these neurones are often inhibitory, with delays of 6­10 ms. The slow nature of the accessory flexor muscle and the pattern of central connections of the receptor suggest that together they are involved in the control of slow movements or posture, potentially acting through a servomechanism.

THE POSITION-DEPENDENT NATURE OF POSTURAL RESISTANCE REFLEXES IN THE LOCUST

The resistance reflexes of tibial extensor and flexor muscles, of all six legs in the locust, show changes in gain at different femur­tibia angles (FTA). In all muscles the gain is high for small angles (near full flexion) and low for large angles (near full extension, approximately 160 °). An exception occurs in the mesothoracic flexor muscle, which shows two modes: one as above and another in which maximum gain occurs at 100­120 ° FTA. The position-dependent character is evident at each stage of the reflex pathway: motor neurone, non-spiking interneurone and femoral chordotonal organ (the afferent source of the reflex). We conclude that position-dependency originates from a decrease in the number of phasic femoral chordotonal organ neurones sensitive to joint movement as larger FTAs are approached. Position-dependency is only roughly correlated with the postural FTAs most commonly observed in the meso- and metathoracic legs of unrestrained resting locusts; no such correlation was evident for prothoracic legs. We propose that the major role of position-dependency is to allow resistance reflexes efficiently to counter torque introduced onto the femur­tibia joint by perturbations in the horizontal plane when the insect rests on a horizontal substratum and in the vertical plane when it rests on a vertical substratum.

Correlates of nonadherence to hypertension treatment in an inner-city minority population

OBJECTIVE

Adherence to treatment is a key factor in achieving blood pressure control among hypertensives. We examined correlates of nonadherence to hypertension treatment in an inner-city minority population.

METHODS

Subjects (n = 202) were interviewed as part of a case-control study of severe, uncontrolled hypertension conducted in two New York City hospitals in 1989-91. All subjects were African American or Hispanic. Self-reported nonadherence to drug treatment for hypertension was measured using a five-item scale, and the sample was dichotomized as more (n = 87) or less (n = 115) adherent. Multiple logistic regression analysis was used to adjust for demographic and other covariates.

RESULTS

Nonadherence was associated with having blood pressure checked in an emergency room (adjusted odds ratio [OR] = 7.9; 95% confidence interval [CI] = 1.75, 35.77; P < .01), lack of a primary care physician (adjusted OR = 2.9; 95% CI = 1.37, 6.02; P < .01), current smoking (adjusted OR = 2.4; 95% CI = 1.10, 5.22; P = .03), and younger age (adjusted OR = 1.03, 95% CI = 1.00, 1.06; P = .03).

CONCLUSIONS

Changing the locus of care for hypertension from emergency rooms to primary care physicians may improve adherence to hypertension treatment in minority populations.

Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population

BACKGROUND

Hypertensive emergency and urgent hypertension are the most severe forms of uncontrolled hypertension and are now seen predominantly in poor, minority populations. We studied the characteristics of the medical care received by patients with these conditions in order to identify risk factors for severe, uncontrolled hypertension.

METHODS

Using a case-control study design, we interviewed 93 patients with severe, uncontrolled hypertension who presented in the hospital emergency room and 114 control patients with hypertension; both groups were seen at two New York City hospitals from 1989 through 1991. All the patients were black or Hispanic. Multiple logistic-regression models were used to adjust for age, sex, race or ethnic background, education, smoking status, alcohol-related problems, and use of illicit drugs during the previous year.

RESULTS

After additional adjustment for lack of health insurance, severe, uncontrolled hypertension was found to be more common among patients who had no primary care physician (adjusted odds ratio, 3.5; 95 percent confidence interval, 1.6 to 7.7) and among those who did not comply with treatment for their hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval, 1.4 to 2.5). Lack of health insurance was marginally associated with severe, uncontrolled hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval, 0.8 to 4.6) after adjustment for lack of a primary care physician and noncompliance with antihypertensive treatment. Patients without a primary care physician and without health insurance were more likely to have their blood pressure checked and receive prescriptions for blood-pressure medications in emergency rooms than in physicians' offices or clinics.

CONCLUSIONS

Characteristics of both the health care system and patients' behavior are associated with severe, uncontrolled hypertension. Improving access to primary care physicians, through health insurance or other means, may be an effective strategy for improving control of hypertension in disadvantaged minority populations.

The effects of common movement and spatial separation on position- and motion-based judgements of relative movement

When common movement is superimposed on relative movement (changes in separation between two dots), relative movement thresholds increase nonlinearly as a function of initial dot separation. For large separation (greater than 2.0 deg), thresholds increase gradually with increased separation. It is shown that this reflects judgments based on perceived relative motion. For small separations (less than 2.0 deg), thresholds increase sharply with increased separation. It is shown that this reflects judgments based on perceived changes in relative position. Evidence is presented that superimposed common movement reduces sensitivity to relative movement by reducing sensitivity to relative motion. This provides a "window", in the range of small dot separations, for relative movement judgements to be based on the perception of changes in relative position, even though motion is perceived for individual dots.

Coadministration of dimethyl sulfoxide reduces cisplatin nephrotoxicity

The administration of dimethyl sulfoxide with cisplatin at a mole ratio of 200:1 results in a considerable reduction in the nephrotoxicity produced when cisplatin alone is administered to Sprague-Dawley rats at 7.5 mg/kg. Observed measures of nephrotoxicity which were significantly improved by the coadministration of cisplatin and DMSO over the values found for cisplatin alone include BUN, serum creatinine, creatinine clearance and histopathological evidence of renal damage. The weight loss associated with cisplatin administration was also significantly reduced by DMSO coadministration. The use of DMSO did not result in any observable loss in antitumor activity of cisplatin against the Walker 256 carcinosarcoma.

Evidence for the abstractive encoding of superficial position information in visual patterns

When presented a series of patterns inside a frame, subjects unintentionally retained information concerning the frame-relative location of the elements composing the patterns; they could use this superficial information to estimate the frequency with which the elements occurred at various locations within the frame. There were two aspects of the results that supported the hypothesis that this superficial element-location information was abstractively encoded and, therefore, retrievable independent of the patterns comprising the elements: (1) Correlations between actual and estimated frequency remained significant after the effects of pattern recall were partialled out, and (2) correlations were enhanced by assuming that the frequency estimate for each location was affected by the imprecise coding of position for elements falling in surrounding locations. Additional experiments indicated that an orienting task emphasizing pattern recall resulted in very inaccurate estimation of element-location frequency, and intentional instructions improved the precision of position coding for individual elements.

Potential antiradiation drugs containing no nitrogen, and related compounds

Capabilities are reported of di- and higher sulfides (RSnR') terminated by sulfinate functions [-S(O)O-] for protecting mice against otherwise lethal effects of ionizing radiation. With the use of congeners, structure-activity correlations are developed for the effects of esterification of the sulfinate function, of changing the length of the chain of sulfur atoms, of reduction to a mercapto sulfinate, and of changing the substituents R and R' to chiral and other types of groups. Neither a trisulfide nor a sulfinate by itself was significantly radioprotective. The key requirement for radio-protection in the series appears to be the presence of a sulfur function (-Sn-) from which a thiol can be engendered by a neighboring-group effect of an electron-donating group; sulfoxide functions may afford alternatives to sulfinate functions as such neighboring groups. The relevance of structure-activity relations to the chemical and biological mechanisms involved in the radioprotective activities is discussed.

A linkage analysis of the Gm locus and multiple sclerosis

We conducted linkage analyses of immunoglobulin G heavy chain marker (Gm) phenotypes and multiple sclerosis (MS) in 30 families, each having at least two first-degree relatives with definite/probable MS. These families yielded positive evidence for linkage to human leukocyte antigen (HLA) loci in previous analyses. In the present analysis, however, the results for Gm were negative. Most lod scores were negative, particularly at the smaller recombination values (theta). We explored the possibility of heterogeneity by subgrouping our data on the basis of specific HLA types (A3, B7) and Gm types (Gm1, Gm1,2) within the pedigrees. The results were again negative with no substantial differences in estimates of theta between subgroups.

Mutagenic and cell transformation activities of representative phosphorothioate esters in vitro

Five alkyl and five aryl phosphorothioates are ranked relative to parathion in effectiveness as base-pair mutagens in the Ames mutagenic assay. Three in each series were mutagenic. Two commercial insecticidal phosphates, included for comparison, were mutagenic. The mutagenic phosphorothioates contained a strong electron-withdrawing and/or a good leaving group, together with two other groups small enough to permit nucleophilic attack by a biomacromolecule on the electrophilic phosphorus atom. All but one of the phosphorothioates [i.e., O,O,O-tris(2,2,2-trifluoro)ethyl phosphorothioate, VI] required metabolic activation for mutagenicity to be manifested; hence most of the phosphorothioates per se evidently are not ordinarily sufficiently electrophilic to be mutagenic but must instead be transformed to more electrophilic oxygen-containing products. In evaluation for cell-transformation properties, methyl parathion was inactive, in contrast to VI. The phosphorothioates that were novel were synthesized by formation of the phosphite from the appropriate alcohol or phenol, followed by reaction of the phosphite with sulfur.