Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache

A computer and a hand search of the literature recovered 33 papers from which 25 trials suitable for meta-analysis were identified. We compared the effectiveness of cognitive-behavioural treatments with the waiting list control and alternative treatment control conditions. There was a great diversity of measurements which we grouped into domains representing major facets of pain. Effect sizes, corrected for measurement unreliability, were estimated for each domain. When compared with the waiting list control conditions cognitive-behavioural treatments were associated with significant effect sizes on all domains of measurement (median effect size across domains = 0.5). Comparison with alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning. We conclude that active psychological treatments based on the principle of cognitive behavioural therapy are effective. We discuss the results with reference to the complexity and quality of the trials.

Coping with epilepsy: do illness representations play a role?

OBJECTIVES

To determine the relative contributions of neuroepilepsy, coping and illness representation variables to psychological adjustment in epilepsy.

DESIGN

The study was a cross-sectional design, contrasting the adjustment of recently diagnosed and chronic patients. Neuroepilepsy, illness representation, coping and adjustment variable were all measured.

METHOD

A total of 94 patients were studied comprising three groups: recently diagnosed patients, chronic patients cared for in hospital clinics, and chronic patients cared for by their GP. A measure was developed to assess each patient's illness representations of epilepsy.

RESULTS

Overall, the epilepsy patients showed significant adjustment problems relative to a normative group. There were, however, significant differences between epilepsy subgroups: recently diagnosed and chronic (clinic) patients exhibited problems, but chronic (GP) patients were relatively well adjusted. After controlling for the effects of group membership and neuroepilepsy variables, coping and illness representations, each explained significant additional variance on measures of psychological adjustment. Patients presenting with adjustment difficulties were characterized by high seizure frequency, avoidance father than problem-focused coping, doubt about their diagnostic label and belief in poor containment.

CONCLUSIONS

We conclude that the illness representations paradigm has value in understanding psychosocial adjustment to epilepsy. This approach offers the potential to identify the critical factors in patients' adaptation to illness. Such insights into the coping process may contribute to the development of effective clinical interventions.

The role of SF-1/Ad4BP in the control of the bovine gene for the steroidogenic acute regulatory (StAR) protein

The bovine gene for the steroidogenic acute regulatory protein (StAR) was cloned and sequenced, including 2 kb of the upstream control region of the gene. The gene comprises seven exons arranged similarly to those of the human and mouse gene sequences. The sequence analysis identified three cis elements corresponding to the binding motif for the transcription factor SF-1/Ad4BP, at - 100, - 240 and - 1190 from the transcription start site. Electrophoretic mobility shift analysis (EMSA) using nuclear proteins from bovine corpus luteum and bovine adrenal as well as in vitro transcribed/translated SF-1/Ad4BP consistently showed that only the site at -1190 bound the transcription factor significantly. Very weak binding was detectable also at the - 240 site, but none at the -100 site. Heterologous transfection of StAR promoter deletion-reporter constructs into Hela cells cotransfected with an expression vector for bovine SF-1/Ad4BP, showed that this transcription factor can specifically act on the bovine StAR gene promoter, but preferentially in regions corresponding to the two proximal SF-1/Ad4BP elements at - 100 and - 240, though with only low relative effect. Furthermore, additional cotransfection of a construct expressing a constitutive protein kinase A catalytic subunit to mimic the effects of cAMP stimulation, led to a small SF-1/Ad4BP-dependent increase in reporter activity mediated only by the same proximal sites. Since the bovine StAR gene promoter does not appear to have a functional cAMP responsive element (CRE), either this effect is mediated in this system directly by SF-1/Ad4BP, or by other factors interacting with this transcription factor, but which do not involve CRE-mediated gene activation. Taken together, the results show that there is a discrepancy between the results of the EMSA experiments and those using transfection of promoter-reporter constructs, which needs to be resolved before a clear understanding of SF-1/Ad4BP-mediated regulation of the StAR gene is attained.

Systematic review of outpatient services for chronic pain control

AIM OF REPORT. This report reviews the evidence about the effectiveness of treatments for chronic pain. While treatment of chronic pain is usually seen as an integrated service, this report concentrates on the individual interventions that constitute the service. HOW THE RESEARCH WAS CONDUCTED. Searches of databases and journals identified over 15,000 randomised studies with pain as an outcome, and many more which were not randomised. Over 150 systematic reviews relevant to chronic pain treatment were identified and their quality assessed using a simple scoring system. Systematic reviews conducted for this report were based mainly on randomised trials. The number needed to treat (NNT) was chosen as the output for the report. NNTs of 2-4 indicate effective treatments. Because NNT is treatment-specific it overcomes problems associated with highly variable placebo or control event rates in pain trials. Such variability is predominantly due to the limited numbers of patients in the clinical trials. Dichotomous outcome measures are important in synthesising information from many studies, and in deriving NNTs. Methods have been developed which allow mean information on pain relief and intensity to be converted reliably into the simple dichotomous outcome of at least 50% pain relief. RESEARCH FINDINGS. PHYSICAL INTERVENTIONS. Transcutaneous electrical nerve stimulation (TENS) has been shown not to be effective in postoperative and labour pain. In chronic pain, there is evidence that TENS effectiveness increases slowly, and that large doses need to be used. There is lack of evidence for the effectiveness of TENS in chronic pain. There is a lack of evidence for the effectiveness of relaxation. Intravenous systemic regional blockade with guanethidine has been shown to be without effect. Epidural corticosteroids are effective in the short term for back pain and sciatica. Injections of corticosteroids in or around shoulder joints for shoulder pain have been shown not to be effective. There is a lack of evidence supporting spinal cord stimulators. Case series are of poor quality and do not provide evidence of effectiveness, although at least 50% pain relief at 5 years is reported in over 50% of patients. PHARMACOLOGICAL INTERVENTIONS. Minor analgesics are important in chronic pain. NNTs were calculated for analgesics given orally for moderate or severe acute postoperative pain. The NNTs found ranged from 17 (poor) for codeine, 60 mg, to 2.5 (good) for ibuprofen, 400 mg. Anticonvulsant and antidepressant drugs are prescribed for neuropathic pains like diabetic neuropathy. NNTs are of the order of 2.5, showing them to be effective treatments. However, there are too few studies with too few patients to determine which is the best drug. Minor adverse events are common, and major adverse events occur in about 1 in 20 patients. There are no studies comparing antidepressants and anticonvulsants directly. Systemic local anaesthetic-type drugs have been shown to be effective in nerve injury pain but there is little or no evidence to support their use in migraine or cancer-related pain. Topical NSAIDs (for example, gels, creams) are effective in rheumatological conditions with an overall NNT of 3. There are too few studies to determine which is the best agent. Topical NSAIDs have few adverse events; most importantly they are without the major gastrointestinal adverse events found with oral NSAIDs, which might make them an important choice for some patients with peripheral arthritis. (ABSTRACT TRUNCATED)

Frequency of patients' consulting in general practice and workload generated by frequent attenders: comparisons between practices

BACKGROUND

Patients who attend frequently may present a problem for general practitioners (GPs) in several ways. The frequency of patients' consulting, comparisons between practices, and the effect of frequent consulting on the clinical workload have not been quantified previously.

AIMS

To examine the distribution of the number of consultations per patient in four general practices. To estimate the clinical workload generated by frequent attenders. To model the data to demonstrate the contribution of age, sex, and practice on the likelihood of attending frequently.

METHOD

Analysis and modelling of a validated data set of date records of consultations collected routinely over a 41-month period from four practices in and around Leeds, representing 44,146 patients and 470,712 consultations.

RESULTS

A minority of patients consulted with extreme frequency. All practices had similar distributions but varied with respect to the numbers of frequent attenders, and the frequencies of their consulting. The most frequent 1% of attenders accounted for 6% of all consultations, and the most frequent 3% for 15% of all consultations. Females and older people were more likely to be frequent attenders.

CONCLUSION

Frequent attenders have an important effect on GPs clinical workload. Between one in six and one in seven consultations are with the top 3% of attenders. Further research is needed to explain the behaviour underpinning frequent attendance in order to identify appropriate management strategies; such strategies could have an important effect on clinical workload.

Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey

OBJECTIVE

To study the time course and prediction of responses to reassurance after gastroscopy showing no serious illness.

DESIGN

Selection of consecutive patients were assessed before gastroscopy, immediately after reassurance, and at follow up at 24 hours, 1 week, 1 month, and 1 year. Responses of subgroups of patients identified as high, medium, and low health anxiety by the health anxiety questionnaire were analysed.

SETTING

Endoscopy clinic in a general hospital.

INTERVENTION

Oral reassurance that there was "nothing seriously wrong."

SUBJECTS

One consultant physician and 60 patients aged 18-74 referred for gastroscopy.

MAIN OUTCOME MEASURES

Physician's and patients' ratings of the extent of the reassurance and patients' ratings of their anxiety about their health and of their illness belief.

RESULTS

There was good agreement between the patients and the physician about whether reassurance had been given. Health anxiety and illness belief decreased markedly after reassurance. Patients with high health anxiety showed a significant resurgence in their worry and illness belief at 24 hours and 1 week, and these levels were maintained at 1 months and 1 year later. Patients with medium levels of health anxiety showed a reduction in worry and illness belief after reassurance, and this was generally maintained during follow up. Patients with low health anxiety maintained low levels of health worry and illness belief throughout the study. Partial correlation analyses showed that the levels of worry and illness belief after reassurance were predicted by the health anxiety questionnaire. This measure also had predictive value beyond that of a measure of general anxiety.

CONCLUSIONS

Medical reassurance results in a reduction of worry about health and of illness belief, but this may be very short term. Measurable individual differences in health anxiety can be used to predict the response to reassurance.

The relationship between laparoscopic disease, pelvic pain and infertility; an unbiased assessment

OBJECTIVES

To measure the relationship between laparoscopically detected pelvic pathology and pelvic pain or infertility.

METHODS

Women undergoing diagnostic laparoscopy either for the investigation of pelvic pain, for sterilisation or for the investigation of infertility were studied. The indication for surgery was recorded before laparoscopy. At operation a series of 35-mm slide photographs were taken of the pelvis and later scored by two independent assessors without knowledge of the indication for surgery.

RESULTS

Satisfactory photographs were obtained in 298 women. Minimal endometriosis was not associated with pain (adjusted OR 1.3; 0.5-2.8), although moderate disease was non-significantly so (2.5; 0.4-7.1). Severe disease was significantly more common and never occurred in patients being sterilised (P = 0.02). The odds of pain were not increased in the presence of dilated veins > 9 mm diameter (OR 1.1; 0.4-3.2) or adhesions (OR 0.6; 0.2-4.7). The odds of infertility were non-significantly increased in the presence of minimal and moderate endometriosis (OR 2.0; 0.8-5.3, and OR 4.2; 0.6-25 respectively) and again significantly more common in the presence of advanced disease (P = 0.002). The odds of infertility tended to be lower in the presence of severely dilated veins (OR 0.2; 0.032-1.2). There was no clear effect of adhesions (OR 0.9; 0.1-5.9).

CONCLUSIONS

The long established associations between severe endometriosis and pelvic pain, and between endometriosis in general and infertility are confirmed. However there is little or no association between minimal endometriosis, pelvic adhesions or dilated pelvic veins and pain. Previously reported associations may have been an artefact of the surgeon's knowledge of the indication for operation when assessing the pelvis.

Vascular damage without hypertension in transgenic rats expressing prorenin exclusively in the liver

We have developed a transgenic animal model to investigate the effects of overexpression of rat prorenin on the cardiovascular system. Two transgenic rat lines were generated in which rat prorenin expression was directed to the liver by a human alpha1-antitrypsin promoter. Liver-specific expression was confirmed by RNase protection assay. Plasma prorenin concentrations in transgenic rats were increased 400-fold in the males of both lines but were increased only two- to threefold in the females. Thus, transgene expression exhibited sexual dimorphism. Blood pressures were not significantly higher in transgenic rats than in nontransgenic controls. The ratio of heart weight to body weight was greater in male transgenic rats than in the nontransgenic controls. Histological analysis revealed severe renal lesions and hypertrophic cardiomyocytes in transgenic males only. This transgenic model demonstrates a likely role of prorenin in the development of cardiac and renal pathology independent of hypertension. These animals will facilitate studies of the effects of blockade of the renin-angiotensin system and other pharmacological interventions on the development and treatment of cardiac, vascular, and renal lesions induced by changes in this system in the absence of chronic hypertension.

Real world data--retrieval and validation of consultation data from four general practices

OBJECTIVE

We aimed to retrieve data on consultations from general practice databases and to develop and use appropriate methods of validation for these data.

METHOD

MIQUEST software was used to retrieve the data from four practices. The data were validated by comparing them with figures generated by practice-based searches, measuring the uptake of recording of consultations over time, and comparing records of consultations in the case notes with those on the practice computers.

RESULTS

The required data were retrieved from general practice databases, but the path to success was difficult, and typified by uncertainty and unpredictability. The recording of consultations on the computers of four practices was more complete than the recording in the paper case records. There was a time period in the early months of computer use when the recording of consultations was less complete. There were differences in the completeness of recording consultations between practices, doctors, and patients.

CONCLUSIONS

This study confirms the potential of general practice databases for research, demonstrates how MIQUEST software can be a useful tool in retrieving data from general practice databases, and indicates how the completeness of data recording permitted further analysis for the purposes of our study.

Structure and expression of the bovine oxytocin receptor gene

The gene for the bovine oxytocin receptor has been sequenced using a combination of clones derived from a bovine endometrial cDNA library from estrus and a bovine genomic DNA library, with confirmation of structure using reverse transcription PCR programmed by term myometrial RNA. The receptor belongs to the seven transmembrane domain family and predicts a protein of 391 amino acids. A comparison of the genomic sequence with the cDNA structure, as well as reverse transcription polymerase chain reaction (RT-PCR) analysis, shows there are two introns, one in the 5'noncoding region that appears to be differentially spliced in the bovine uterus and a conserved intron within the open reading frame between the regions encoding the transmembrane domains VI and VII. Northern blot analysis indicated three major transcripts in myometrium and endometrium in vivo at approximately 6.5 kb, 3.5 kb, and 2.0 kb. In situ hybridization analysis of uterine tissue at term showed highest mRNA concentrations in the endometrial epithelium, particularly in the deep glands, a pattern confirmed also at the immunohistochemical level by monoclonal antibodies raised against a human amino-terminal peptide. Further confirmation of the identity of the receptor was obtained by transient transfection of a reconstituted receptor construct into COS-7 cells. The expressed receptor was shown to have identical pharmacological properties in respect to various oxytocin analogs to the natural bovine endometrial receptor.

Carbonic anhydrase is present in human oesophageal epithelium and submucosal glands

Carbonic anhydrase (EC 4.2.1.1) activity was investigated in normal human oesophageal mucosa using the Hansson and Ridderstråle catalytic cobalt methods. The enzyme was detected in the cell membranes and nuclei and, to a lesser extent, in the cytoplasm of the epithelial cells of the mucosa giving a 'chicken wire' appearance. Activity decreased towards the lumen. Other stratified squamous epithelia--buccal mucosa, ectocervix and skin--gave a similar pattern. Acinar cells of oesophageal submucosal glands also exhibited activity for the enzyme, but the ducts did not. The formation of reaction product was prevented by acetazolamide and ethoxzolamide and by the omission of bicarbonate frm the substrate medium. Carbonic anhydrase in oesophageal squamous epithelium may be involved in the control of intra- and extracellular pH, while that in the glands is more likely to be concerned with bicarbonate secretion.

A scale for the assessment of hedonic tone the Snaith-Hamilton Pleasure Scale

BACKGROUND

Hedonic tone and its absence, anhedonia, are important in psychopathological research, but instruments for their assessment are lengthy and probably culturally biased.

METHOD

A new scale was constructed from the responses of a large sample of the general population to a request to list six situations which afforded pleasure. The most frequent items were reviewed and those likely to be affected by cultural setting, age, or sex were removed. A pilot study led to an abbreviated scale of 14 items, covering four domains of pleasure response. This questionnaire was subjected to psychometric evaluation in new samples from the general population and psychiatric patients.

RESULTS

The scale was found to have a score range that would distinguish a 'normal' from an 'abnormal' response. Validity and reliability were found to be satisfactory.

CONCLUSIONS

The new scale, the Snaith-Hamilton Pleasure Scale (SHAPS), is an instrument which may be recommended for psychopathological research.

Scaling the affective domain of pain: a study of the dimensionality of verbal descriptors

This study evaluated the multidimensional structure of affective verbal descriptors and investigated individual differences in the scaling of the descriptors. Patients with chronic low back pain, chronic headache and rheumatoid arthritis (25 per group) and 25 control subjects, matched for age and sex, made similarity judgements of a set of 12 verbal descriptors, e.g., awful, miserable. They also completed the Coping Strategies Questionnaire, the Hospital Anxiety and Depression Scale, McGill Pain Questionnaire Short Form, and a measure of verbal intelligence. The similarity data were subjected to individual differences multidimensional scaling (ALSCAL) and the resulting subject weights were related to group membership and the questionnaire data. The multidimensional nature of affective descriptors was confirmed. A 4-dimensional solution was identified: the first 3 dimensions were comparable with previous findings and labeled Tolerability, Focus of Attention and Minor Emotional Reaction. The 4th dimension was enigmatic and attributable to the back pain group. There were significant differences between the groups in their weighting of the dimensions and in their self-reported coping strategies. The results are discussed with reference to an earlier study and the degree of consistency across the studies is noted. Implications of the results for the conceptualisation and measurement of the affective domain of pain report are outlined.

The Pain Beliefs and Perceptions Inventory: a British replication

The factorial structure, reliability, and validity of the Pain Beliefs and Perceptions Inventory (PBPI) was investigated in a sample of 84 pain patients drawn from a pain clinic in the United Kingdom. The recovered factorial structure replicated that of a previous study. The 4 derived subscales, Mysteriousness, Self-Blame, Pain Constancy and Pain Permanence, had excellent reliability (internal consistency); Chronbach's alpha was greater than 0.80. However, the construct validity of the PBPI, assessed by examining the association between the subscales and the Coping Strategies Questionnaire (CSQ), was not supported. The results are discussed with particular reference to the interpretative issues concerning 2 of the subscales and their relation to the concept of the 'time line' component of illness representation.

Autobiographical memory and chronic pain

The influence of chronic pain on the recall of autobiographical memories of pain and non-pain events was examined. Eleven chronic pain patients and 11 age- and sex-matched control subjects retrieved autobiographical memories to neutral and pain-related cue words. Patients and controls retrieved equal numbers of memories, but pain subjects retrieved more memories incorporating elements of physical pain. Analysis of the content of these memories revealed that patients and controls recalled equal numbers of memories of themselves and other people in acute pain and that the difference observed was attributable to the pain patients recalling memories of themselves in chronic pain. Memories of pain were recalled significantly faster than non-pain memories. The results are discussed with reference to the possible biasing effects of pain state on memory and the schematic processing of pain memories.

Vivid memory for 'everyday' pains

A 2-part study in which memory for everyday pains was investigated is reported. The first part compared ratings of vivid, 'flashbulb' memories of pain and non-pain events. Memories of pain events were rated as having been more surprising, having induced more negative emotional change, and having provoked greater change in ongoing activity than their non-pain event counterparts. In the second part of the study the relationship between remembering the pain event, experiencing the pain and re-experiencing the sensory qualities was examined. No subject reported sensory re-experiencing and 41% of subjects were unable to recall the sensory quality of the pain experience memory. Elements of pain experience (recalled intensity, distress and sensory quality) were differentially associated with components of pain event memory. Distress was associated with the reported frequency with which the pain event was rehearsed and with ratings of emotional and activity change induced by the pain event. In contrast, ratings of the intensity and sensory quality of the pain were associated with the reported vividness of the pain event memory. It is concluded that memories of painful events are readily retrievable and that the memory for a pain event, the sensory and affective qualities of pain experience and somatosensory component of pain are separated in their encoding and/or retrieval. The possible mechanisms whereby pain memories are encoded and retrieved are discussed. The clinical implications of the data concerning how judgements of past pain are made and the possible role of memory in coping are also noted.

Memory for acute pain experience is specifically inaccurate but generally reliable

Sixty patients having their wisdom teeth removed under general anaesthetic were tested immediately after surgery and 2 weeks later. Subjects completed versions of the McGill Pain Questionnaire (MPQ) and the UWIST Mood Adjective Checklist (UMACL). At the second test they were randomly assigned to 1 of 3 groups and either cued for their mood experience, cued for their pain experience or asked to recognise those words which they had chosen on the first occasion. Forty-nine patients completed the study. Accuracy of remembering was measured using Cohen's kappa (kappa) as a measure of agreement over the 2 tests. In general, accuracy of remembering was only 'fair' for both mood and pain (kappa = 0.5). Contrary to expectation cueing did not improve specific recognition, e.g., cueing for pain did not improve memory for pain words. However, there was evidence that memory of mood was more accurate when patients were cued to remember their pain. There was also evidence of a shift in the hedonic tone of the remembered mood; patients remembered their mood as being more negative than it actually was.

Implicit memory in multiple sclerosis

A number of neuropsychological studies have revealed that memory problems are relatively common in patients with multiple sclerosis (MS). It may be useful to compare MS with conditions such as Huntington's disease (HD), which have been referred to as subcortical dementia. A characteristic of these conditions may be an impairment in implicit (unconscious) memory, but not in explicit (conscious) memory. The present study examined the functioning of explicit and implicit memory in MS. Results showed that implicit memory was not significantly impaired in the MS subjects, and that they were impaired on recall but not recognition. A correlation was found between implicit memory performance and disability status in MS patients. Findings also suggest the possibility of long-term priming of implicit memory in the control subjects. The implications of these results are discussed.

Paranoia and the defensive attributional style: deluded and depressed patients' attributions about their own attributions

A data set of Attributional Style Questionnaire responses collected by Kaney & Bentall (1989) from persecutory deluded, normal and depressed subjects was added to a similar data set collected by the first author. The attributions made for hypothetical positive and negative events by the combined pool of subjects were then blind rated for internality by five independent judges. Whereas the internality ratings made by the subjects for their own attributions showed evidence of an exaggerated self-serving bias in the case of the deluded subjects, and an absence of such a bias in the case of the depressed subjects, the independent ratings showed no such group differences. These findings suggest that the differences in internality for positive and negative events observed on the ASQ between deluded, normal and depressed subjects may not reflect differences in the types of causal statements made by these subjects but differences in their attributions about their attributions. The relevance of this observation for attribution theory in general and attributional accounts of psychopathology in particular are discussed.

Graphical analysis of single-case time series data

This article outlines the major principles for constructing good graphs and visual displays. Several methods for exploring time series data with graphical techniques are given: these include procedures for summarizing the central tendency of data, plotting linear and non-linear trend, and displaying variability and change in variability over time. We emphasize the need to explore single-case data thoroughly in order to highlight various components. Graphical analysis should be conducted in tandem with statistical analysis.

Memory for pain: a review

This paper reports a qualitative review of the literature on memory for pain. Most research has focused on the accuracy of memory for pain intensity. There is some evidence that recall is moderately accurate but this conclusion is tentative because of significant methodological problems. There is also some evidence that recall of acute pain is more accurate than recall of chronic pain and we make some suggestions as to why this difference might occur. We conclude that further research on memory for pain should be informed by reference to methodological practices developed in cognitive psychology and embedded within an appropriate theoretical framework.

The effect of melatonin on the formation of gastric stress lesions in rats

Prior melatonin administration (1,5 and 10 mg/kg b. wt) causes a significant reduction in gastric ulceration induced in male rats by restraint immobilization in the presence of low temperatures.

An experimental investigation of the construct validity of the McGill Pain Questionnaire

In order to circumvent problems with self-report measures of pain we conducted an experimental analysis of MPQ pain descriptors using a Stroop task. In this task subjects are asked to name the colours in which stimulus words are written. Previous research has demonstrated that words with emotional significance interfere (indexed by increased latencies to respond) with a person's ability to name the colour. We predicted that: (1) chronic pain patients, compared with normal controls, would show more interference to words drawn from the MPQ, and (2) affective/evaluative descriptors would produce greater interference than sensory descriptors. There was support for the first hypothesis but not the second. Possible reasons for these findings are discussed.

Relationship between radiological classification and the serological and haematological features of untreated pulmonary tuberculosis in Indonesia

Immunological and metabolic responses were studied in 110 patients with newly diagnosed pulmonary tuberculosis and 32 healthy controls from similar socioeconomic backgrounds. The severity of lung involvement was assessed radiologically, but this was not related to the current features of cell mediated immunity or to those of many aspects of the serological response to Mycobacterium tuberculosis. However, the patients with more extensive pulmonary tuberculosis showed higher titres of IgG2 antibody to whole killed M. tuberculosis and to the ML34 epitope shared by many species of mycobacteria. The patients with more extensive pulmonary tuberculosis showed a more marked metabolic response to infection as manifested by changes in serum levels of acute phase reactant proteins. Accordingly, the metabolic responses are considered to be more likely to prove of value in clinical monitoring of patients for severity of infection, or of reactivation of infection with M. tuberculosis, than immunological responses.

The development of a self-administered psychophysical scaling method: internal consistency and temporal stability in chronic pain patients

Twenty chronic pain patients carried out a self-administered cross-modal matching task to scale pain intensity and unpleasantness descriptors on 2 occasions separated by 2-3 weeks. Measures of psychological distress (HAD and GHQ) and verbal intelligence (Mill Hill Synonym Test) were also taken. On the 2 occasions 65% and 70% of patients were able to scale intensity words with an internal consistency of r greater than or equal to 0.90. Eleven (55%) patients met this criterion on both occasions. The percentage of patients meeting the internal consistency criterion for unpleasantness descriptors was much lower, 25% and 40% on the 2 occasions. For patients who met the internal consistency criterion for intensity words there was very high test-retest stability for the group scale values of the intensity words. There was no evidence that the level of psychological distress was associated with ability to scale unpleasantness words. Intelligence was positively related to the ability to scale intensity descriptors.

The dimensionality of verbal descriptors in Tursky's pain perception profile

In the first part of the study 20 subjects (11 headache, 9 normals) free-sorted descriptors from the intensity and affect scales of the Tursky pain perception profile (PPP) into groups on the basis of similar meaning. In part 2 they made similarity ratings of all pairs of words within the intensity and affect scales. In the third part of the study subjects completed a cross-modal matching task to scale the intensity and affect words. Data from the first 2 parts of the study were examined with multidimensional scaling (MDS) and hierarchical cluster analyses. Free-sorting the descriptors did not produce 2 groups corresponding to the intensity and affect descriptors described in the Tursky PPP. The descriptors were arranged in 6 groups described by subjects as reflecting increasing painfulness. An MDS analysis showed that the groups could be located in 2-dimensional space in which the dimensions of intensity and affective distress could be easily discerned. When the descriptors from the intensity and affect scales were rated within each scale, a second MDS analysis showed that, whereas the intensity descriptors could be fitted by a 1-dimensional representation, the affect descriptors required a 3-dimensional model. There was evidence that subjects with extensive pain experience placed greater weight on the second and third affective dimensions compared with relatively pain-free subjects.

Some simple statistical tests for exploring single-case time-series data

Statistical analysis of single-case time-series data has received considerable attention. Many of the techniques discussed in the literature require long series of data or sophisticated statistical techniques. The present paper describes a number of 'quick and dirty' non-parametric tests which can be applied to relatively short time series. These tests require minimal calculations and can be carried out by inspecting graphical plots of the data. Each test is illustrated and tables for significance testing have been worked out. The importance of these tests lies in their potential to facilitate the accurate description of time series data. They are recommended as techniques for exploratory data analysis, the philosophy of which parallels Sidman's (1960) 'data led' approach to experimentation.

The development of a self-administered psychophysical scaling method: range effects

101 subjects engaged in a self-administered cross-modal matching task to scale descriptors of pain intensity and unpleasantness. The correlation between the two responses was used to determine reliability (internal consistency). When r greater than or equal to 0.90 was set as a criterion about 3% of the subjects were unable to calibrate standard stimuli reliability, 6% were unable to calibrate intensity descriptors and 60% were unable to calibrate unpleasantness descriptors reliably. When the criterion reliability was set at r greater than or equal to 0.85 all subjects successfully scaled the intensity descriptors. Further relaxation of the criterion to r greater than or equal to 0.80 reduced the 'failure' rate for unpleasantness descriptors to 24%. These data compare favourably with other published results from non-chronic and chronic pain patients. The provision of a fixed reference value produced range effects in the resulting scale but do not severely attenuate the range of the scale as has been previously suggested. It is concluded that a self-administered version of the task is feasible. Reasons for the poor performance with the unpleasantness descriptors are discussed.

Receptors for neuropeptides are induced by exogenous poly(A)+ RNA in oocytes from Xenopus laevis

Receptors for the hormones vasopressin, angiotensin II, and thyrotropin-releasing hormone have been studied electrophysiologically in Xenopus laevis oocytes previously injected with poly(A)+ RNA from the respective receptor-containing tissues. The injected oocytes responded to the hormones by demonstrating oscillations in membrane currents as recorded by the voltage-clamp method. The response was dependent on the hormone concentrations and detectable between 5 and 1000 nM concentrations. Size fractionation of poly(A)+ RNA from the respective tissues showed that the mRNAs encoding the three hormone receptors were larger than 18S rRNA, suggesting a length of at least 2 kilobases. When vasopressin was added to the oocyte bath, an inward membrane current was generated in oocytes injected with rat poly(A)+ RNA from liver but not from kidney. This suggests that the V1-type (liver), not the V2-type (kidney), vasopressin receptor can be expressed and electrophysiologically identified in the oocyte. A V1-specific, but not a V2-specific, antagonist suppressed the vasopressin-dependent effect. Application of angiotensin II to liver poly(A)+ RNA-injected oocytes elicited oscillations in membrane current, indicating that these oocytes also expressed receptors for angiotension II; the antagonist [Sar1, O-methionyl-Tyr4]angiotensin II blocked this effect. Poly(A)+ RNA from tumor-derived GH3B6 cells, known to contain receptors for thyrotropin-releasing hormone, injected into oocytes induced receptors responding to thyrotropin-releasing hormone; the drug chlordiazepoxide suppressed the thyrotropin-releasing hormone response.

Measurement of the dichotic listening ear advantage for intersubject and interstimulus comparisons

Conventional dichotic listening techniques can unquestionably be used for nominal (left vs. right) categorization of ear or hemispheric differences. These techniques cannot, however, be used for ordinal comparisons of the size of ear advantages among different subjects or different tasks if the measure of the size of the lateral asymmetry is confounded with effects of varying overall performance, attentional bias, or choice of laterality index. A psychophysical procedure is described which is designed to avoid these confounds by measuring discrimination ability, in decibels, as the interaural intensity difference (IID) required for a specific accuracy. Results from two experiments with right-handed subjects showed an average right-ear advantage of about 3 db for phoneme discrimination and an average left-ear advantage of the same size for intonation discrimination.

The neurohypophyseal hormones vasopressin and oxytocin. Precursor structure, synthesis and regulation

Complete cDNA sequences for the vasopressin and oxytocin precursor polyproteins have been determined for the rat, calf, human and pig (vasopressin only), indicating the essential conservation of the precursor structures throughout mammals. DNA probes specific for vasopressin or oxytocin mRNAs have been used to identify both classic (hypothalamic) and novel (thymus, corpus luteum, phaeochromocytoma) sites of hormone expression. Semiquantitative DNA/RNA hybridization suggests that in rats expression of the vasopressin and oxytocin genes is positively effected by osmotic stress, negatively by a systemically applied excess of vasopressin; in the latter experiment a reduction in the hypothalamic levels of vasopressin and oxytocin mRNAs in normal and Brattleboro rats have been observed. This suggests a feedback regulation by the hormone as a possible element in controlling the transcription of the vasopressin gene.

'Demand characteristics' in body-size estimation in anorexia nervosa

We asked 24 patients with anorexia nervosa and 30 normal controls to estimate their body-size several times, each time using different instructions. The degree of over-estimation was found to vary predictably with the wording of the instructions. Informing the subject that she had made an error without specifying the direction of the error resulted in reduced over-estimation on a subsequent trial, for both anorexics and controls. 'Internally directed' instructions were associated with a greater degree of over-estimation than 'external' instructions in both groups, but particularly in anorexic subjects. Our results indicate the necessity of controlling the 'demand characteristics' of such experiments.