A daily process design study of attentional pain control strategies in the self-management of cancer pain

This study investigated the use of attentional control strategies in the self-management of pain using daily process design methodology. Twenty six cancer patients with pain completed diaries 3 times daily for 10 days. Diaries incorporated measures of pain intensity, affect, coping, coping efficacy, and the novelty and predictability of pain, and participants completed a cross-sectional measure of catastrophizing. At the across-person level, focusing on pain was associated with increased negative affect, and the use of pain focusing strategies was positively correlated with experiencing pain that was novel in its location or quality. Distractions that were interesting, important and pleasant were positively correlated with positive affect, perceptions of control over pain and ability to decrease pain. Over-prediction of pain was positively correlated with catastrophizing, and negatively correlated with perceptions of control over and ability to decrease pain. The within-person analysis (ARIMA modelling) showed that catastrophizing moderated the effects of pain focusing strategies, novel pain and over-predictions of pain. Meta-analysis of the ARIMA models revealed that the within-person effects of using attentional strategies did not generalize across the sample. These findings indicated that the effects of distraction strategies are influenced by their motivational-affective significance rather than the frequency with which they are used, and provided further evidence that the threat value of pain influences the way in which people cope with their pain. Theoretical and clinical implications are discussed.

Psychological responses to episodic chest pain

Patients with chronic musculo-skeletal pain have been profiled as "dysfunctional", "interpersonally distressed" or "adaptive copers". The relevance of these for episodic visceral pain is unknown. Our aim was to replicate conceptually the taxonomy in patients with episodic visceral pain. Patients with chest pain and gastro-esophageal reflux disease (GERD; n=25), coronary artery (CAD; n=20), or with chest pain but without either reflux or coronary artery disease (non-cardiac chest pain--NCCP; n=23) were assessed using several standard affective and cognitive measures relevant to pain. Differences between the diagnostic groups were explored. K-means cluster analysis broadly replicated the three groups found in previous research but the "interpersonally distressed" group had few members. An additional cluster analysis suggested a more parsimonious solution for the sample was a two-cluster one, which approximated to the "adaptive coper" and "dysfunctional" profiles. Membership of both the three- and two-cluster profiles was not associated with membership of specific diagnostic category.

Sentence completion test for depression (SCD): An idiographic measure of depressive thinking

OBJECTIVES

This study set out to investigate the reliability and validity of the Sentence Completion Test for Depression (SCD) as a clinical measure. In contrast to questionnaire measures of depressive thinking, respondents finish incomplete sentences using their own words. This elicits idiographic information concurrent with measuring depressive thinking.

METHOD

In Study 1, measures of negative thinking were tested between a depressed group and a non-depressed control group. A preliminary item analysis was conducted and replicated on separate samples in Study 2. Psychometric properties of the test were investigated. In Study 3, idiographic validity and sensitivity to change were explored in a sample of clinical cases with reference to cognitive-behavioural case-formulation.

RESULTS

In Study 1, the depressed group produced more negatives and fewer positives, and the SCD demonstrated good content validity, internal consistency and inter-rater reliability. The preliminary short-form had comparable psychometric properties, and these were replicated on new samples in Study 2. Sensitivity and specificity values were above 90% in both studies. In Study 3, idiographic content generated hypotheses about target problems and dysfunctional beliefs within cognitive-behavioural case-formulation, and SCD scores were sensitive to clinical change.

CONCLUSIONS

The SCD demonstrates good construct validity, internal consistency, inter-rater reliability, sensitivity, and specificity. It offers an idiographic assessment of depression that is complementary to questionnaire measures, particularly by generating hypotheses about target problems and dysfunctional beliefs within a cognitive-behavioural case-formulation. This is achieved without loss to reliability and validity at the nomothetic level.

Pancreatic insufficiency in adult celiac disease: do patients require long-term enzyme supplementation?

BACKGROUND

Celiac disease is associated with exocrine pancreatic insufficiency. We previously reported that in 30% (20/66) of adult celiac patients with current or persistent diarrhea the underlying cause was exocrine pancreatic insufficiency. Of these 20 patients, 19 initially improved on pancreatic supplementation. To date, there are no published longitudinal studies.

METHODS

The 20 patients who had initially received therapy for exocrine pancreatic insufficiency were prospectively followed-up for 4 years. Gastrointestinal symptoms, dietary adherence, celiac antibody status, and dose of enzyme supplementation were recorded. Fecal elastase-1 (Fel-1) was repeated to reassess exocrine pancreatic function.

RESULTS

In the study, 19/20 patients were reviewed, as one had died (mean age 59.7 years, 7 males). The mean duration of celiac disease was 13.2 years. Eleven out of nineteen were still taking enzyme supplementation at a mean dose of 45,000 units of lipase per day. Only 1/11 reported no symptomatic benefit and 8/19 patients had discontinued supplementation because their diarrhea had improved. In the whole group there was a significant increase in Fel-1 levels over time, with median values of 90 μg/g at 0 months, 212 μg/g at 6 months, and 365 μg/g at follow-up (45-66 months)(p < 0.0001).

CONCLUSIONS

Fecal elastase-1 is useful in identifying exocrine pancreatic insufficiency in adult celiac patients with diarrhea. Our longitudinal data suggests that pancreatic enzyme supplementation could be discontinued in a substantial proportion of patients as symptoms improve.

Faecal lactoferrin, capsule endoscopy and Crohn's disease. Is there a three way relationship? A pilot study

BACKGROUND & AIMS

Capsule endoscopy has been shown to be useful in diagnosing small bowel Crohn's disease. Faecal lactoferrin has been shown to have a high sensitivity and specificity in discriminating between inflammatory bowel disease and irritable bowel syndrome. There have been no studies on the use of faecal lactoferrin in the setting of suspected Crohn's disease using capsule endoscopy. Our aim was to investigate the clinical utility of lactoferrin in patients with suspected Crohn's disease using capsule endoscopy.

METHODS

Data was collected prospectively on patient symptoms, family history and blood parameters. Patients were requested to return a stool sample and quantitative analysis using sandwich ELISA was performed for faecal lactoferrin.

RESULTS

Seventeen patients were recruited with all patients having had more than one criterion for referral. The diagnostic yield for capsule endoscopy was 41%, of which 71% of patients had an elevated faecal lactoferrin (correlation coefficient 0.56, p=0.01). The sensitivity, specificity, positive predictive value and negative predictive value of faecal lactoferrin were 71%, 100%, 100% and 83%, respectively.

CONCLUSION

Faecal lactoferrin has a high positive and negative predictive value for the diagnosis of small bowel Crohn's disease, detected by capsule endoscopy. Faecal lactoferrin is a useful marker (in conjunction with clinical parameters) to determine which patients should be referred for capsule endoscopy.

Behavioural treatment for chronic low-back pain

BACKGROUND

Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package.

OBJECTIVES

To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach.

SEARCH STRATEGY

The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened.

SELECTION CRITERIA

Randomised trials on behavioural treatments for non-specific CLBP were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.

MAIN RESULTS

We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.

AUTHORS' CONCLUSIONS

For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

Faecal lactoferrin--a novel test to differentiate between the irritable and inflamed bowel?

BACKGROUND

Distinguishing between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) can be challenging.

AIMS

To investigate the utility of faecal lactoferrin as a marker of inflammation in patients with IBD, IBS and controls.

METHODS

Disease activity in IBD patients was assessed using the modified Harvey-Bradshaw Activity Index. Stool samples were analysed using an ELISA assay.

RESULTS

We recruited 137 patients with IBS, 126 with ulcerative colitis (UC) and 104 with Crohn's disease (CD), and 98 healthy volunteers. The median +/- IQ lactoferrin concentration (microg/g faecal weight) was 0 +/- 1.4 for IBS patients, 6.6 +/- 42 for UC patients, 4 +/- 12.7 for CD patients and 0.5 +/- 2 for healthy controls. Lactoferrin levels were significantly higher in IBD patients compared with IBS/healthy controls (P < 0.001). The median lactoferrin concentrations were significantly higher in active UC & CD patients compared with inactive patients (P < 0.001 and P = 0.002 respectively). The sensitivity, specificity, positive and negative predictive values of lactoferrin in distinguishing active IBD from IBS/healthy controls were 67% and 96%, 87% and 86.8% respectively.

CONCLUSIONS

Lactoferrin is useful to differentiate between IBD and IBS, and can be used as an adjunct to blood parameters to determine IBD patients who have ongoing inflammation.

Faecal lactoferrin--a novel test to differentiate between the irritable and inflamed bowel?

BACKGROUND

Distinguishing between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) can be challenging.

AIMS

To investigate the utility of faecal lactoferrin as a marker of inflammation in patients with IBD, IBS and controls.

METHODS

Disease activity in IBD patients was assessed using the modified Harvey-Bradshaw Activity Index. Stool samples were analysed using an ELISA assay.

RESULTS

We recruited 137 patients with IBS, 126 with ulcerative colitis (UC) and 104 with Crohn's disease (CD), and 98 healthy volunteers. The median +/- IQ lactoferrin concentration (microg/g faecal weight) was 0 +/- 1.4 for IBS patients, 6.6 +/- 42 for UC patients, 4 +/- 12.7 for CD patients and 0.5 +/- 2 for healthy controls. Lactoferrin levels were significantly higher in IBD patients compared with IBS/healthy controls (P < 0.001). The median lactoferrin concentrations were significantly higher in active UC & CD patients compared with inactive patients (P < 0.001 and P = 0.002 respectively). The sensitivity, specificity, positive and negative predictive values of lactoferrin in distinguishing active IBD from IBS/healthy controls were 67% and 96%, 87% and 86.8% respectively.

CONCLUSIONS

Lactoferrin is useful to differentiate between IBD and IBS, and can be used as an adjunct to blood parameters to determine IBD patients who have ongoing inflammation.

Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings

In psychological health treatment studies it has been shown that differences between therapists account for some of the non-specific effect of treatment but this phenomenon has not so far systematically been investigated in musculoskeletal disorders. In this study we evaluated and compared the size and potential influence of the 'practitioner effect' (or 'therapist effect') in three randomised treatment trials of low back pain and neck pain patients in primary care. We calculated the proportion of variance in outcomes attributable to differences across practitioners, i.e. the practitioner-variance partition coefficient (p-vpc). As measures of outcome, we focused on self-reported disability as the primary outcome, but we also investigated assessed psychological outcomes. The p-vpc for the disability measures ranged from 2.6% to 7.1% across trials and time points (post treatment and follow up). Estimates differed between treatment subgroups within trials; being highest in treatment subgroups assigned to psychosocial-based interventions. A 'practitioner effect' does exist and is more pronounced in treatments involving greater psychosocial emphasis. This has implications for both practice and research in this clinical area. It highlights the importance of patient-practitioner interactions, and the need to address practitioner effects in designing and analysing outcome studies in low back pain and neck pain in primary care.

Some patients with irritable bowel syndrome may have exocrine pancreatic insufficiency

BACKGROUND & AIMS

Patients with irritable bowel syndrome (IBS) might have other underlying pathologies. Pancreatic disease can be elusive-especially in the early stages, and some symptoms overlap with those of IBS. We evaluated the prevalence of exocrine pancreatic insufficiency in diarrhea-predominant IBS (D-IBS) and assessed the effects of pancreatic enzyme supplementation.

METHODS

The study included patients who met the Rome II criteria for D-IBS, patients with chronic diarrhea, and subjects without diarrhea (controls). Subjects' baseline weight, stool frequency, stool consistency (using the Bristol score), and fecal elastase-1 (Fel-1) levels were determined. Patients were assessed using British Society of Gastroenterology IBS guidelines. Patients with Fel-1 levels less than 100 microg/g stool (indicating pancreatic exocrine insufficiency; group 1) were compared with age- and sex-matched patients with D-IBS and normal levels of Fel-1 (group 2), given pancreatic enzyme therapy, and reassessed at 12 weeks.

RESULTS

Fel-1 levels were less than 100 microg/g in stool from 19 of 314 patients with D-IBS (6.1%; 95% confidence interval [CI], 3.7%-9.3%), none of the 105 patients with chronic diarrhea (95% CI, 0.0%-3.5%), and none of 95 controls (95% CI, 0.0-3.8%) (P < .001). After enzyme supplementation, improvements in stool frequency (P < .001), stool consistency (P < .001), and abdominal pain (P = .003) were observed in patients in group 1, but not in group 2.

CONCLUSIONS

Pancreatic exocrine insufficiency was detected in 6.1% of patients who fulfilled the Rome II criteria for D-IBS. In these patients, pancreatic enzyme therapy might reduce diarrhea and abdominal pain. Pancreatic exocrine insufficiency should be considered in patients with D-IBS.

Abnormal liver function tests in patients with Type 1 diabetes mellitus: prevalence, clinical correlations and underlying pathologies

AIMS

To determine the prevalence of elevated alanine transaminase (ALT) in a large cohort of patients with Type 1 diabetes and to examine the clinical correlations and causes. Methods Patients with Type 1 diabetes mellitus were prospectively recruited and ALT, glycated haemoglobin and lipid profile were measured. Patients with Type 2 diabetes mellitus were recruited as a comparison group.

PATIENTS

with abnormal ALT were investigated for underlying causes. Prevalence of abnormal ALT was analysed at three separate cut-offs and multivariable analysis used to identify independent risk factors.

RESULTS

Nine hundred and eleven with Type 1 diabetes and 963 with Type 2 diabetes were included. The prevalence of elevated ALT was dependent on the cut-off value: > 30 IU/l in males and > 19 IU/l in females, > 50 and > 63 IU/l was 34.5, 4.3 and 1.9%, respectively, in Type 1 diabetes and 51.4, 8.2 and 3.7%, respectively, in Type 2 diabetes. In Type 1 diabetes an elevated ALT was associated with worse glycaemic control, age > 55 years and elevated triglycerides. Investigation of these patients revealed a cause in 43.6% of patients, predominantly non-alcoholic fatty liver disease (NAFLD).

CONCLUSIONS

Elevated ALT is not uncommon in Type 1 diabetes and is associated with NAFLD-related risk factors. Patients with Type 1 diabetes and elevated ALT should be investigated as significant abnormalities may be found which are amenable to interventions.

Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review

The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty-five trials including 1247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive-behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non-pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow-up to better understand maintenance of treatment effects.

Threat of pain influences social context effects on verbal pain report and facial expression

Current theoretical models of pain catastrophizing have diverging predictions regarding the role of social context and perceived threat on pain expression. The communal coping model of catastrophizing predicts that high pain catastrophizers display more pain expression in the presence of another, regardless of the threat value of the pain, while a cognitive appraisal model predicts high pain catastrophizers to express more pain when pain has increased threat value, regardless of social context. A 2 x 2 factorial design was used to test the validity of both predictions. Healthy participants with varying levels of pain catastrophizing were exposed to a cold pressor task, consisting of a 60 s immersion and 60 s recovery period. Interestingly, the immersion results revealed that beyond and independent from the effects of pain catastrophizing, the effect of threat on verbal pain report and facial expression was dependent on social context and vice versa. In a threatening context, perceived threat of pain mediated the inhibitory effect of social presence on pain expression, suggesting that the observer acted as a safety signal. In the recovery period, social presence enhanced facial expression, but only when no threat was induced. The results are discussed in terms of the dynamic interaction between social context and threat appraisals.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. No comprehensive systematic review has been published since 1999.

OBJECTIVES

To evaluate the effectiveness of psychological therapies on pain, disability, and mood.

SEARCH STRATEGY

Randomised controlled trials (RCTs) of psychological therapy were identified by searching MEDLINE, EMBASE and Psychlit and CENTRAL from the beginning of each abstracting service until January 2008. A further search was undertaken from January 2008 to August 2008. Additional studies were identified from the reference lists of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. Studies were excluded if the pain was primarily headache, or was associated with a malignant disease. Studies were also excluded if the number of patients in any treatment arm was less than 10.

DATA COLLECTION AND ANALYSIS

Fifty-two studies were examined with a quality rating scale specifically designed for use with these studies. Data were extracted from 40 studies (4781 participants) by two authors. Two main classes of treatment (Cognitive Behavioural Therapy (CBT) and Behaviour Therapy (BT)), were compared with two control conditions (Treatment as Usual (TAU) and Active control (AC)), at two assessment points (immediately following treatment and six months following treatment), giving eight comparisons. For each comparison, treatment effectiveness was assessed on three outcomes: pain, disability, and mood giving a total of 24 analyses.

MAIN RESULTS

Overall there is an absence of evidence for BT, except for pain immediately following treatment compared with TAU. CBT has some small positive effects for pain, disability and mood. At present there is insufficient data on quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

AUTHORS' CONCLUSIONS

CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months.

Psychological therapies for the management of chronic and recurrent pain in children and adolescents

BACKGROUND

Headache, recurrent abdominal pain, and musculoskeletal pain affect many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This is a substantially updated and expanded version of the Cochrane review published in 2003.

OBJECTIVES

To assess the effectiveness of psychological therapies for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain.

SEARCH STRATEGY

Searches were undertaken of MEDLINE, PsycLIT, EMBASE and CONSORT. RCTs were sought in references of all identified studies, meta-analyses and reviews. Date of most recent search: August 2008.

SELECTION CRITERIA

Randomised Controlled Trials (RCTs) with at least ten participants in each arm post-treatment comparing psychological therapies with placebo, waiting list or standard medical care for children or adolescents with episodic, recurrent or persistent pain, were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood.

MAIN RESULTS

Thirty-four RCT studies were recovered; 29 met the inclusion criteria. The total number of participants completing treatments was 1432. Twenty studies addressed treatments for headache (including migraine); six for abdominal pain; one for both headache and abdominal pain, one study was for fibromyalgia, and one was for pain associated with sickle cell disease. The analysis of headache treatment versus control differences immediately post-treatment for pain gave an odds ratio (OR) of 5.51 (95% CI 3.28 to 9.24; z = 6.46, P < 0.05); NNT = 2.57 (CI 2.2 to 3.13). At follow-up, the OR was 9.91 (95% CI 3.73 to 26.33); z = 9.91, P < 0.05); NNT = 1.99 (CI 1.63 to 2.72). Analysis of non-headache treatment versus control differences immediately post-treatment for pain found a large effect size of -0.94 (95% CI -1.43 to -0.44) Z = 3.71, P < 0.05. At follow-up, a large effect size was found of -1.08 (95%CI -1.84 to -0.33); Z = 2.82, P < 0.05). There were no other significant effects.

AUTHORS' CONCLUSIONS

Psychological treatments are effective in pain control for children with headache and benefits appear to be maintained. Psychological treatments may also improve pain control for children with musculoskeletal and recurrent abdominal pain. There is little evidence available to estimate effects on disability or mood.