Suffering: the contributions of persistent pain

Examining posttraumatic growth among Turkish family caregivers of cancer patients

Cancer is a deadly disease that affects millions of people worldwide and is a source of great difficulty, stress, and trauma not only for patients but also for their caregivers. The physical and emotional suffering that patients experience by patients can lead their caregivers to cope with constant anxiety, sadness, and uncertainty. Moreover, during the cancer treatment process, caregivers must make a great effort to meet the needs of patients and support them. This situation may negatively affect the quality of life and psychological health of cancer patients' caregivers and may lead them to experience trauma. The aim of this cross-sectional study was to examine posttraumatic growth's relationship with age, the transformative power of suffering, and hope in family caregivers of cancer patients. Participants consisted of 314 Turkish family caregivers of cancer patients (73.2% women; Mage = 39.89 years) selected by using convenience sampling method. Participants answered a data collection tool consisting of a demographic information form, the Posttraumatic Growth Inventory, Trait Hope Scale, and Transformative Power of Suffering Scale. Data were analyzed using descriptive statistics, the Pearson product-moment correlation coefficient analysis, simple mediation analysis, and moderated mediation analysis. The results of this study revealed that hope mediated the association between the transformative power of suffering and posttraumatic growth in family caregivers of cancer patients, whereas age moderated this relationship. Psychosocial support programs for cancer caregivers could benefit from incorporating interventions that explore the transformative potential of suffering and cultivate hope. Tailoring these interventions to address the specific needs of different age groups may enhance their effectiveness. Future researchers should investigate the factors associated with posttraumatic growth in caregivers across diverse cultures, age ranges, and cancer diagnoses.

Qualitative Examination of the Experience of Perceived Injustice Following Disabling Occupational Injury

PURPOSE

The primary objective of this study was to explore individuals' perspectives on the factors, situations or events that contributed to their perceptions of injustice following occupational injury.

MATERIALS AND METHODS

The study sample consisted of 30 participants (18 women, 12 men) who had submitted a time-loss claim for a work-related musculoskeletal injury. Participants with elevated scores on a measure of perceived injustice were interviewed about the factors that contributed to their sense of injustice. A thematic analysis was conducted to identify the broad classes of situations or events that participants experienced as unjust in the weeks following occupational injury.

RESULTS

Three dominant themes emerged from the interviews: (1) Invalidation, (2) Undeserved suffering and (3) Blame. Inductively derived subthemes reflected specific dimensions of post-injury experiences that contributed to participants' sense of injustice.

CONCLUSIONS

Given that suffering and invalidating communication are potentially modifiable factors, there are grounds for optimism that intervention approaches can be developed to prevent or reduce perceptions of injustice in the aftermath of debilitating injury. The development of intervention approaches that are effective in preventing or reducing perceptions of injustice holds promise of contributing to more positive recovery outcomes in individuals who have sustained debilitating work injuries.

Defining suffering in pain: a systematic review on pain-related suffering using natural language processing

ABSTRACT

Understanding, measuring, and mitigating pain-related suffering is a key challenge for both clinical care and pain research. However, there is no consensus on what exactly the concept of pain-related suffering includes, and it is often not precisely operationalized in empirical studies. Here, we (1) systematically review the conceptualization of pain-related suffering in the existing literature, (2) develop a definition and a conceptual framework, and (3) use machine learning to cross-validate the results. We identified 111 articles in a systematic search of Web of Science, PubMed, PsychINFO, and PhilPapers for peer-reviewed articles containing conceptual contributions about the experience of pain-related suffering. We developed a new procedure for extracting and synthesizing study information based on the cross-validation of qualitative analysis with an artificial intelligence-based approach grounded in large language models and topic modeling. We derived a definition from the literature that is representative of current theoretical views and describes pain-related suffering as a severely negative, complex, and dynamic experience in response to a perceived threat to an individual's integrity as a self and identity as a person. We also offer a conceptual framework of pain-related suffering distinguishing 8 dimensions: social, physical, personal, spiritual, existential, cultural, cognitive, and affective. Our data show that pain-related suffering is a multidimensional phenomenon that is closely related to but distinct from pain itself. The present analysis provides a roadmap for further theoretical and empirical development.

Temporomandibular disorders in individuals with Marfan syndrome: an exploratory analysis

BACKGROUND

This study aims to analyze to what extent patients with Marfan syndrome (MFS) are affected by temporomandibular disorders (TMD) and its impact on oral health-related quality of life (OHRQoL). To collect data, an online questionnaire was created to recruit participants from Germany, Austria, and Switzerland through social media and support groups. The questionnaire consists of free-text questions, the German versions of the Oral Health Impact Profile (OHIP-G14), the Depression Anxiety Stress Scale (DASS), and the Graded Chronic Pain Status (GCPS).

RESULTS

A total of 76 participants with diagnosed MFS were included. Of these, 65.8% showed TMD symptoms, the most common being pain or stiffness of the masticatory muscles in the jaw angle (50.0%). Only 14.5% of the participants were already diagnosed with TMD. Of the participants with an increased likelihood of a depression disorder, 76.9% showed TMD symptoms. Of those with a critical score for an anxiety disorder, 90.9% showed TMD symptoms. 73.3% of participants with TMD symptoms reached the critical score for a stress disorder. TMD symptoms were associated with a higher risk for chronic pain. In the median, participants with TMD showed statistically notably higher OHIP-G14 scores than participants without TMD (11.5 [IQR 17] vs. 1 [IQR 3] points, p ≤ 0.001).

CONCLUSION

TMD symptoms had a noticeable impact on OHRQoL in patients with MFS, i.e., chronic pain and psychological impairment. TMD seems underdiagnosed, and more research is needed to prevent the associated chronification of pain and psychological burden to improve the OHRQoL.

When hope is lost

Rehabilitation Medicine and Palliative medicine have much in common as both specialties deal with loss and impending loss related to incurable medical conditions. Significant losses are encountered by patients in both rehabilitation and palliative care settings, and often threaten quality of life, hopefulness, and resiliency. The losses are related to what the patient has identified as self. In this article the author suggests a way of approaching loss and suffering that incorporates, mindfulness, Disidentification and Ego-State work to help preserve a sense of self that is not identified with what is happening to the body.

Existential spectrum of suffering: concepts and moral valuations for assessing intensity and tolerability

This paper has two aims. The first is to defend a recent critique of the leading medical theory of suffering, which alleges too narrow a focus on violent experiences of suffering. Although sympathetic to this critique, I claim that it lacks a counterexample of the kinds of experiences the leading theory is said to neglect. Drawing on recent clinical cases and the longer intellectual history of suffering, my paper provides this missing counterexample. I then answer some possible objections to my defence, before turning to my second aim: an expansion of my counterexample into a spectrum of suffering that varies according to the selves and purposes that suffering affects. Next, I connect this spectrum to the tolerability of suffering, which I distinguish from its affective intensity. I conclude by outlining some applications of this distinction for the psychometric reliability of assessment instruments that measure suffering in clinical contexts.

Breastfeeding at Any Cost? Adverse Effects of Breastfeeding Pain on Mother-Infant Behavior

Breast milk is considered the ideal infant nutrition, and medical organizations encourage breastfeeding worldwide. Moreover, breastfeeding is often perceived as a natural and spontaneous socio-biological process and one of the fundamental roles of new mothers. While breastfeeding is beneficial, little scientific consideration has been given to its potential psychological challenges. Here, we investigate the phenomenon of breastfeeding pain in mothers and its association with maternal and infant behavioral regulation. During the postpartum weeks, the mother-infant dyad can be considered one allostatic unit directed at infant regulation and development. We hypothesize that pain comprises an allostatic challenge for mothers and will thus impair the capacity for dyadic regulation. To test this, we recruited 71 mothers with varying levels of breastfeeding pain and videotaped them with their infants (2-35 weeks old) during spontaneous face-to-face interactions. We quantified the individual differences in dyadic regulation by behaviorally coding the second-by-second affective expressions for each mother and infant throughout their interactions. We tested the extent to which breastfeeding pain alters affect regulation during mother-infant interactions. We discovered that mothers with severe breastfeeding pain express less affective expressions and less infant-directed gaze during interactive moments of engagement and play than mothers with no or moderate pain. Moreover, infants of mothers experiencing pain during breastfeeding express less affective expressions and more mother-directed gaze while interacting with their mothers than infants of mothers who are not in pain. This demonstrates that the allostatic challenge of maternal pain interferes with the behavioral regulation of both mothers and infants. Since the mother-infant dyad is a codependent allostatic unit, the allostatic challenges of one partner can impact the dyad and thus potentially impact child development, bonding, and mother and infant well-being. The challenges of breastfeeding should be considered in addition to the nutritional advances.

Cross-Country Analysis of the Association of Cultural Dimensions with Prescription Opioid Consumption and Implications for Health Education

Background and Purpose: Over 247,000 people died in the U.S. from overdoses related to prescription opioids in 1999-2019, leading the WHO to deem the situation an epidemic. The purpose of this study is to examine whether culture is related to perceptions and behaviors around opioid consumption because culture has been shown, for example, to influence decision-making strategies, risk-taking, and responses to self-congruent communications. Methods: Scores for country-wide dimensions of culture from Hofstede and opioid consumption data from the International Narcotics Control Board were used to study a possible relationship. The relationship was tested by including a set of economic and socio-economic indicators from the World Bank, the United Nations, and PROSPERED. Results: The scores for the cultural dimension of individualism are correlated with opioid consumption on a country level, with higher levels of individualism connected to higher consumption. This correlation is robust to the inclusion of economic and socio-economic variables (GDP per capita, inflation, income inequality, unemployment, education, life expectancy, median age, and sick leave coverage). Conclusions and Importance: Because messages that reinforce a group's cultural value are more meaningful and effective in motivating action, educational health messages about opioid consumption in the U.S. need to be designed with culture in mind to disrupt decisions to take opioid analgesics unless medically justified or to limit their use. More research is needed on how to design self-congruent individualistic versus collectivistic persuasive appeals.

Pain and fatigue in adults with Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome, a questionnaire-based study

The purpose was to study self-reported chronic pain and fatigue symptoms among adults with molecularly verified Loeys-Dietz and vascular Ehlers-Danlos syndrome using a cross-sectional questionnaire design. Seventy adults were invited through a National Resource Centre for Rare Disorders. A study specific questionnaire including Brief Pain Inventory, Standardized Nordic Questionnaire, Fatigue Severity Scale, Hospital Anxiety & Depression Scale, questions on physical activity, and disease burden was used. Fifty-two persons participated, n = 34 with Loeys-Dietz and n = 18 with vascular Ehlers-Danlos syndrome, aged 18-68 years, 58% women. Chronic pain (79%) and fatigue (58%) symptoms were common. Half developed pain during childhood/adolescence. Sleep problems and high multi-organ burden were significantly associated with chronic pain (p = 0.004, p = 0.014) and high fatigue (p < 0.001, p < 0.001). Chronic pain was associated with higher scores of fatigue (p = 0.002). Higher scores of fatigue were associated with lower level of physical activity (p = 0.014), higher cardiovascular burden (p = 0.025), and higher symptoms of anxiety (p = 0.001). In this study, symptoms of chronic pain, fatigue, sleep problems, and disease burden seemed to mutually reinforce each other. Initiatives should consider interventions aimed at postponing the onset and reducing symptoms of pain, fatigue, and sleep problems and thus reduce the total disease burden at an early stage in patients with these complex conditions.

Contributing and Relieving Factors of Suffering in Palliative Care Cancer Patients: A Descriptive Study

To palliate suffering, understanding the circumstances leading to suffering and its amelioration could be helpful. Our study aimed to explore contributing and relieving factors of suffering in palliative care. Adult palliative care stage III or IV cancer in-patients were recruited from University of Malaya Medical Centre. Participants recorded their overall suffering score from 0 to 10 three times daily, followed by descriptions of their contributing and relieving factors. Factors of suffering were thematically analysed with NVIVO. Descriptive data were analysed with SPSS. 108 patients participated. The most common contributing factor of suffering was health factor (96.3%), followed by healthcare factor (78.7%), psychological factor (63.0%) and community factor (20.4%). The most common relieving factor was health factor (88.9%), followed by psychological factor (78.7%), community factor (75.9%) and healthcare factor (70.4%). Self-reported assessment of suffering offers a rapid approach to detect bothering issues that require immediate attention and further in-depth exploration.

What is Pain-Related Suffering? Conceptual Critiques, Key Attributes, and Outstanding Questions

Suffering holds a central place within pain research, theory, and practice. However, the construct of pain-related suffering has yet to be operationalized by the International Association for the Study of Pain and is largely underdeveloped. Eric Cassell's seminal work on suffering serves as a conceptual anchor for the limited pain research that specifically addresses this construct. Yet, important critiques of Cassell's work have not been integrated within the pain literature. This Focus Article aims to take a preliminary step towards an updated operationalization of pain-related suffering by 1) presenting key attributes of pain-related suffering derived from a synthesis of the literature and 2) highlighting key challenges associated with Cassell's conceptualization of suffering. We present 4 key attributes: 1) pain and suffering are inter-related, but distinct experiences, 2) suffering is a subjective experience, 3) the experience of suffering is characterized by a negative affective valence, and 4) disruption to one's sense of self is an integral part of suffering. A key outstanding challenge is that suffering is commonly viewed as a self-reflective and future-oriented process, which fails to validate many forms of suffering and marginalizes certain populations. Future research addressing different modes of suffering - with and without self-reflection - are discussed. PERSPECTIVE: This article offers a preliminary step toward operationalizing the construct of pain-related suffering and proposes priorities for future research. A robust operationalization of this construct is essential to developing clinical strategies that aim to better recognize and alleviate suffering among people living with pain.

Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence-Enabled App (Wysa): Protocol for a Prospective Pilot Study

BACKGROUND

Patients with chronic pain often suffer from coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial Intelligence Supported Cognitive Behavioral Therapy or AI-CBT interventions could offer cost-effective, accessible, and potentially effective resources to tackle this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain.

OBJECTIVE

This prospective cohort study aims to examine the efficacy and usage of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app), using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text-based conversational agent (CA).

METHODS

Participants with self-reported chronic pain (N = 500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is taken from the participants within the app and the Wysa intervention is delivered remotely for 8 weeks. Outcome measures including NPRS (Numeric Pain Rating Scale), PROMIS PI (Patient-Reported Outcomes Measurement Information System Pain Interference), GAD-7 (Generalized Anxiety Disorder), and PHQ-9 (Patient Health Questionnaire) questionnaires will be administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the WAI-SR (Working Alliance Inventory-Short Revised). Retention and usage statistics will be observed for adherence and engagement.

RESULTS

The study will open for recruitment in April 2022 and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late-2022.

CONCLUSIONS

Mental health conversational agents driven by artificial intelligence (AI) could be effective in helping patients with chronic pain learn to self-manage their pain and deal with common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions with a human therapist in loop. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain.

CLINICALTRIAL

The Pain Coping Questionnaire short-form: preliminary reliability and validity

Supplemental Digital Content is Available in the Text. A brief 16-item format of the Pain Coping Questionnaire was developed and found to have acceptable preliminary reliability and validity.

Introduction:

The Pain Coping Questionnaire (PCQ) has support for its validity and reliability as a tool to understand how a child copes with pain of an extended duration. However, measure length may limit feasibility in clinical settings.

Objectives:

The primary goal of this study was to develop a short-form (PCQ-SF) that could be used for screening how children cope with chronic or recurrent pain and examine its reliability and validity.

Methods:

The PCQ-SF was developed in a stepwise manner. First, a confirmatory factor analysis was computed using an amalgamated data set from the validation studies of the PCQ (N = 1225). Next, ratings from researchers and clinicians were obtained on PCQ item content and clarity (n = 12). Finally, the resulting 16-item short-form was tested in a pediatric sample living with chronic and recurrent pain (65 parent–child dyads; n = 128).

Results:

The PCQ-SF has acceptable preliminary reliability and validity. Both statistical and expert analyses support the collective use of the 16 items as an alternative to the full measure.

Conclusions:

The compact format of the PCQ-SF will allow practitioners in high-volume clinical environments to quickly determine a child's areas of strengths and weaknesses when coping with pain. Future research using larger more diverse samples to confirm clinical validity is warranted.

Identifying an Optimal Cut-Off Point for Musculoskeletal Pain in the Upper Extremities to Prevent Lowered Work Performance

OBJECTIVE

This study identified when musculoskeletal pain (MSP) in the upper extremities indicates lowered work performance to gauge when secondary prevention of musculoskeletal disorders is needed.

METHODS

Seven hundred thirty-three subjects from 12 manufacturing or healthcare facilities in Washington state participated. Work performance was measured by the Disabilities of the Arm, Shoulder and Hand work module (DASH-Work). Each DASH-Work score was compared to the mean among U.S. workers to determine if workers had lowered work performance. ROC curve analysis was conducted to find the cut-off in a composite MSP index (summing MSP intensities in shoulders, elbows/forearms, and hands/wrists; range 0 to 24) to detect lowered work performance.

RESULTS

The MSP index score of 2 achieved the best balance between sensitivity (0.79) and specificity (0.69) in detecting lowered work performance.

CONCLUSIONS

To prevent reduced work performance, moderate or multisite pain may require proper management.

Síntomas asociados al sufrimiento en pacientes con enfermedad renal crónica en hemodiálisis

Introducción: Los síntomas insuficientemente controlados pueden constituir un factor determinante o agravante del sufrimiento en los pacientes sometidos a hemodiálisis; sin embargo, escasean las investigaciones que aborden este tema. Objetivos: El presente estudio tiene como objetivo describir el sufrimiento según la severidad de determinados síntomas en pacientes con enfermedad renal crónica en hemodiálisis. Material y Método: El estudio es observacional descriptivo transversal, con algunas tareas de correlación en una muestra de 31 pacientes. Se emplearon la entrevista, el instrumento para detección de bienestar/malestar propuesto por Bayés y colaboradores y una serie de sub-escalas de la Escala de Evaluación de Síntomas de Edmonton/ESAS para identificar la presencia de síntomas (intensidad y frecuencia) que pudieran estar asociados al sufrimiento. Resultados: El 87,1 % del total mostró un bajo predominio de síntomas con severa intensidad asociados al sufrimiento en las últimas 24 horas, el 77,4 % bajo predominio en la semana anterior y el 61,3 % un bajo predominio en un periodo de un mes. No se encontró asociación significativa entre el predominio de los síntomas con intensidad severa asociados al sufrimiento en 24 horas. Conclusiones: En la mayoría de los sujetos predominó el bajo predominio de síntomas con severa intensidad asociados al sufrimiento; la magnitud de la sintomatología no constituyó un factor importante asociado al sufrimiento en estos pacientes.

Mechanistic evaluation of a novel cyclohexenone derivative's functionality against nociception and inflammation: An in-vitro, in-vivo and in-silico approach

The synthesis of a novel cyclohexanone derivative (CHD; Ethyl 6-(4-metohxyphenyl)-2-oxo-4-phenylcyclohexe-3-enecarboxylate) was described and the subsequent aim was to perform an in vitro, in vivo and in silico pharmacological evaluation as a putative anti-nociceptive and anti-inflammatory agent in mice. Initial in vitro studies revealed that CHD inhibited both cyclooxygenase-2 (COX-2) and 5-lipoxygenase (5-LOX) enzymes and it also reduced mRNA expression of COX-2 and the pro-inflammatory cytokines TNF-α and IL-1β. It was then shown that CHD dose dependently inhibited chemically induced tonic nociception in the abdominal constriction assay and also phasic thermal nociception (i.e. anti-nociception) in the hot plate and tail immersion tests in comparison with aspirin and tramadol respectively. The thermal test outcomes indicated a possible moderate centrally mediated anti-nociception which, in the case of the hot plate test, was pentylenetetrazole (PTZ) and naloxone reversible, implicating GABAergic and opioidergic mechanisms. CHD was also effective against both the neurogenic and inflammatory mediator phases induced in the formalin test and it also disclosed anti-inflammatory activity against the phlogistic agents, carrageenan, serotonin, histamine and xylene compared with standard drugs in edema volume tests. In silico studies indicated that CHD possessed preferential affinity for GABAA, opioid and COX-2 target sites and this was supported by molecular dynamic simulations where computation of free energy of binding also favored the formation of stable complexes with these sites. These findings suggest that CHD has prospective anti-nociceptive and anti-inflammatory properties, probably mediated through GABAergic and opioidergic interactions supplemented by COX-2 and 5-LOX enzyme inhibition in addition to reducing pro-inflammatory cytokine expression. CHD may therefore possess potentially beneficial therapeutic effectiveness in the management of inflammation and pain.

The effect of 5-min mindfulness of love on suffering and spiritual quality of life of palliative care patients: A randomized controlled study

OBJECTIVE

Suffering is a common experience in palliative care. In our study, we aimed to determine the effect of 5-min mindfulness of love on suffering and the spiritual quality of life of palliative care patients.

METHODS

We conducted a parallel-group, blinded, randomized controlled study at the University of Malaya Medical Centre (UMMC), Malaysia from February 2019 to April 2019. Sixty adult palliative care patients with an overall suffering score of 4/10 or above based on the Suffering Pictogram were recruited and randomly assigned to either the 5-min mindfulness of love group (N = 30) or the 5-min supportive listening group (N = 30).

RESULTS

There were statistically significant improvements in the overall suffering score (mean difference = -2.9, CI = -3.7 to -2.1, t = -7.268, p = 0.000) and the total FACIT-Sp-12 score (mean difference = 2.9, CI = 1.5 to 4.3, t = 4.124, p = 0.000) in the intervention group compared to the control group.

CONCLUSION

The results provided evidence that 5-min mindfulness of love could affect the actual state of suffering and the spiritual quality of life of palliative care patients.

Anti-inflammatory, hypoglycemic, hypolipidemic, and analgesic activities of Plinia cauliflora (Mart.) Kausel (Brazilian grape) epicarp

ETHNOPHARMACOLOGICAL RELEVANCE

Plinia cauliflora (Mart.) Kausel, known in Brazil as jabuticaba or jaboticaba has been used by Brazilian native populations for medicinal purposes, including those related to inflammatory conditions, such as asthma, diarrhea, disorders in female genitourinary tract, and tonsillitis. Inflammation has emerged as a main factor for the oxidative stress, hyperglycemia, and dyslipidemia present in chronic noncommunicable diseases (NCDs). Such disturbances have been a leading cause of death worldwide for decades, despite significant efforts in developing new therapies. Therefore, strengthening the relevance of ethnobotanic approaches, as P. cauliflora has the potential to become a natural, native, and traditional product to prevent and treat inflammation-associated diseases more effectively for more people.

AIM OF THE STUDY

Evaluate anti-inflammatory, hypoglycemic, hypolipidemic, and analgesic properties of hydroethanolic extract of P. cauliflora epicarps (PcE).

MATERIALS AND METHODS

Phytochemical compound from the PcE were identified through HPLC-DAD-ESI-MSⁿ analysis. Antioxidant activity was determined by measuring 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical scavenging. The anti-inflammatory potential was investigated by carrageenan-induced paw edema and peritonitis in mice. Analgesic effect was assessed, in mice, though hot plate test and acetic acid-induced abdominal writhing. Antidiabetic and hypolipidemic potential were evaluated using alloxan-induced diabetic mice.

RESULTS

Tannins, phenolic acids, and their derivatives were the predominant phytochemicals found. Overall, PcE showed different properties related to the treatment of clinical conditions associated with chronic diseases as a potent antioxidant activity, demonstrating a radical scavenging action similar to gallic acid. PcE oral administration also significantly reduced inflammation induced by paw edema and partially blocked leukocyte migration. Moreover, PcE produced peripheral and central analgesic effects, as evaluated in the writhing model and hot plate tests. Treatment with PcE significantly improved glucose levels and lipid markers in diabetic mice.

CONCLUSIONS

P. cauliflora fruits are rich sources of secondary metabolites, mainly tannins and phenolic acids with high biological potential, which can effectively contribute to the approach of preventing and controlling chronic NCDs.

A neuroimaging biomarker for sustained experimental and clinical pain

Sustained pain is a major characteristic of clinical pain disorders, but it is difficult to assess in isolation from co-occurring cognitive and emotional features in patients. In this study, we developed a functional magnetic resonance imaging signature based on whole-brain functional connectivity that tracks experimentally induced tonic pain intensity and tested its sensitivity, specificity and generalizability to clinical pain across six studies (total n = 334). The signature displayed high sensitivity and specificity to tonic pain across three independent studies of orofacial tonic pain and aversive taste. It also predicted clinical pain severity and classified patients versus controls in two independent studies of clinical low back pain. Tonic and clinical pain showed similar network-level representations, particularly in somatomotor, frontoparietal and dorsal attention networks. These patterns were distinct from representations of experimental phasic pain. This study identified a brain biomarker for sustained pain with high potential for clinical translation.

A Central Amygdala Input to the Parafascicular Nucleus Controls Comorbid Pain in Depression

While comorbid pain in depression (CP) occurs at a high rate worldwide, the neural connections underlying the core symptoms of CP have yet to be elucidated. Here, we define a pathway whereby GABAergic neurons from the central nucleus of the amygdala (GABA^CeA) project to glutamatergic neurons in the parafascicular nucleus (Glu^PF). These Glu^PF neurons relay directly to neurons in the second somatosensory cortex (S2), a well-known area involved in pain signal processing. Enhanced inhibition of the GABA^CeA→Glu^PF→S2 pathway is found in mice exhibiting CP symptoms. Reversing this pathway using chemogenetic or optogenetic approaches alleviates CP symptoms. Together, the current study demonstrates the putative importance of the GABA^CeA→Glu^PF→S2 pathway in controlling at least some aspects of CP.

Chronic Pain After Lung Transplantation and Its Impact on Quality of Life: A 4-Year Follow-up

Aiming to investigate the prevalence of chronic pain and its impact on quality of life of lung transplantation (LTx) recipients, we performed a transversal study collecting data using a standard interview model in 2 different periods: first, in 2016 we studied LTx recipients after 3 to 11 months of the transplantation; and second, in 2019, we studied the same patients after 39 to 55 months of transplantation surgery. The chosen questionnaires were the Brief Pain Inventory and Short-Form Health Survey. Chronic pain was identified in 47.2% of the analyzed recipients at the initial interview and in 40.7% at the second evaluation. In both periods, the domain quality of life was the most affected in contrast to functional capacity, which was the least affected. On the first analysis, a moderate negative correlation was found between pain intensity and functional capacity domains (-0,42/P = .010), pain (-0,46/P = .005), and mental health (-047/P = .004); meanwhile, the second survey showed a moderate/high negative correlation for most of the domains, except for the mental health (-0,036/P = .120). We conclude that the prevalence of chronic pain after LTx is high, and the pain intensity had a moderate negative correlation with domains such functional capacity, mental health, and pain at the first analysis in contrast to the moderate/high negative correlation for almost every domain, except mental health, at the second analysis.

SUFFERING AMONG PATIENTS WITH CANCER UNDERGOING NEUROTOXIC CHEMOTHERAPY: A PHENOMENOLOGICAL APPROACH

ABSTRACT Objective: reveal experiences of cancer patients undergoing neurotoxic chemotherapy. Method: phenomenology-based, qualitative study, carried out with nine adult patients in antineoplastic neurotoxic treatment, interviewed in June and July 2018. The testimonies were analyzed using an empirical comprehensive model. Results: the following categories were delineated: nerves on edge: perception of limitations caused by neuropathic pain induced by chemotherapy; chemotherapy drains me of energy; the suffering of starting again; the suffering of enduring it; alone in a desert, I heard the cry of my silence; chemotherapy: an infusion of hope; and there is no suffering on earth that heaven cannot heal. Conclusion: the study presented various meanings of suffering that emerge from experiences with neurotoxic treatment and found that many dimensions of suffering interpenetrate, making it impossible to disassociate them.

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.

Clinical Management of Pain in Rodents

The use of effective regimens for mitigating pain remain underutilized in research rodents despite the general acceptance of both the ethical imperative and regulatory requirements intended to maximize animal welfare. Factors contributing to this gap between the need for and the actual use of analgesia include lack of sufficient evidence-based data on effective regimens, under-dosing due to labor required to dose analgesics at appropriate intervals, concerns that the use of analgesics may impact study outcomes, and beliefs that rodents recover quickly from invasive procedures and as such do not need analgesics. Fundamentally, any discussion of clinical management of pain in rodents must recognize that nociceptive pathways and pain signaling mechanisms are highly conserved across mammalian species, and that central processing of pain is largely equivalent in rodents and other larger research species such as dogs, cats, or primates. Other obstacles to effective pain management in rodents have been the lack of objective, science-driven data on pain assessment, and the availability of appropriate pharmacological tools for pain mitigation. To address this deficit, we have reviewed and summarized the available publications on pain management in rats, mice and guinea pigs. Different drug classes and specific pharmacokinetic profiles, recommended dosages, and routes of administration are discussed, and updated recommendations are provided. Nonpharmacologic tools for increasing the comfort and wellbeing of research animals are also discussed. The potential adverse effects of analgesics are also reviewed. While gaps still exist in our understanding of clinical pain management in rodents, effective pharmacologic and nonpharmacologic strategies are available that can and should be used to provide analgesia while minimizing adverse effects. The key to effective clinical management of pain is thoughtful planning that incorporates study needs and veterinary guidance, knowledge of the pharmacokinetics and mechanisms of action of drugs being considered, careful attention to individual differences, and establishing an institutional culture that commits to pain management for all species as a central component of animal welfare.

Is pain part of a systemic syndrome in head and neck cancer?

Head and neck cancers (HNC) represent 5% of all malignancies worldwide with about 180,000 cancer deaths per year. Patients with HNC are characterized by a systemic inflammatory state, generally associated with worse outcomes. Treatment-related toxicity is common among HNC patients and causes systemic consequences such as fatigue or cognitive dysfunction. The therapeutic treatments of HNC involve the release in circulation of inflammatory systemic mediators, whose effects trigger a vicious circle that may lead to functional and behavioral alterations. The areas of the head and neck are highly sensitive to pain. Literature data confirm that in HNC patients, pain is one of the most distressing symptoms across all the phases of treatment. Pain is associated with worse general conditions, depression, fatigue, impaired cognitive functions, and lower survival rate. The treatment of advanced HNC cases is multimodal and requires a multidisciplinary psycho-socio-pharmacological approach mediated by a team of experts. The pharmacological approach in management of HNC patients with pain is fundamental and involves the use of opioids, NSAIDs, steroids, or other drugs. Opioids in pain management therapy in patients with HNC could allow the pain level to be adequately monitored, thus improving quality of life. The integration of opioid and non-opioid therapy as well as non-pharmacological interventions is essential for the rehabilitation of physical, social, and psychological functions and to achieve pain control in patients with HNC. Opioid treatment is the mainstay for pain control, being used both for background and breakthrough cancer pain (BTcP) episodes. Fentanyl, easily absorbed and generally well tolerated, appears to be a possible choice due to its versatility. Non-pharmacological interventions, such as tailored yoga, physical exercise, and acupuncture, may have a role in pain management in patients with HNC.

The relation between parental chronic pain, pain-related attention and interpretation biases in pain-free adolescents

BACKGROUND

Children of chronic pain patients run greater risk for developing chronic pain themselves. Exposure to chronic pain of the parent might install cognitive (e.g., pain catastrophizing, interpretation and attentional bias) and affective (e.g., pain anxiety) vulnerability which increase the risk for the development of chronic pain complaints in offspring. This study examines whether pain-free offspring of parents with chronic pain complaints make more health-threatening interpretations and display a stronger pain-related attentional bias compared to the offspring of pain-free parents. We furthermore examined differences between both groups on pain catastrophizing, pain anxiety and somatic symptoms and explored the relations between parental pain catastrophizing and aforementioned pain vulnerability measures in offspring.

METHODS

Offspring of parents with chronic pain complaints (n = 24) and pain-free parents (n = 27) completed measures of attentional bias (i.e., pictorial dot probe), interpretation bias (i.e., ambiguous word association task), pain catastrophizing, pain anxiety and somatic symptoms. Parents completed measures of pain catastrophizing and psychological distress.

RESULTS

No differences between offspring of parents with and without pain complaints were observed on pain catastrophizing, pain anxiety and somatic symptoms. Both groups of healthy adolescents predominantly showed benign, non-health-threatening interpretations. Children of pain-free parents showed an attention bias for pain stimuli, while offspring of parents with pain complaints showed no such bias.

CONCLUSIONS

Future research is needed to further elucidate the precise role of parental pain in the development of pain-related biases and the significance of these biases in the onset and/or maintenance of a chronic pain condition in children and adolescents.

SIGNIFICANCE

Parental chronic pain may install psychological vulnerability for developing chronic pain and associated complaints in offspring. This study did not show differences in pain-directed attentional and interpretation bias between offspring of parents with chronic pain complaints and offspring of pain-free parents. Further (longitudinal) research is needed to elucidate the precise role of parental pain factors in the development of pain-related vulnerability in offspring of chronic pain parents, thereby identifying important targets for the prevention and early intervention of chronic pain.

The sensory and affective components of pain: are they differentially modifiable dimensions or inseparable aspects of a unitary experience? A systematic review

BACKGROUND

Pain is recognised to have both a sensory dimension (intensity) and an affective dimension (unpleasantness). Pain feels like a single unpleasant bodily experience, but investigations of human pain have long considered these two dimensions of pain to be separable and differentially modifiable. The evidence underpinning this separability and differential modifiability is seldom presented. We aimed to fill this gap by evaluating the current evidence base for whether or not the sensory and affective dimensions of pain can be selectively modulated using cognitive manipulations.

METHODS

A rigorous systematic search, based on a priori search terms and consultation with field experts, yielded 4270 articles. A detailed screening process was based on the following recommendations: (i) evaluation of effectiveness; (ii) examination of methodological rigour, including each study having an a priori intention to cognitively modulate one of the two dimensions of pain; and (iii) sound theoretical reasoning. These were used to ensure that included studies definitively answered the research question.

RESULTS

After in-depth critique of all 12 articles that met the inclusion criteria, we found that there is no compelling evidence that the sensory and affective dimensions of pain can be selectively and intentionally modulated using cognitive manipulations in humans.

CONCLUSIONS

We offer potential explanations for this discrepancy between assumptions and evidence and contend that this finding highlights several important questions for the field, from both the research and clinical perspectives.

Pain and Suffering

OBJECTIVE

To review literature on the relationship of pain, spirituality, and suffering as it relates to the patient with cancer who is experiencing pain.

DATA SOURCES

Peer-reviewed articles, textbooks, internet.

CONCLUSION

Pain and suffering are distinct and yet closely related in patients with cancer. Oncology nurses are important in assessing a patient's pain, including dimensions of spirituality and suffering.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are the front line of pain management for patients. This includes recognizing existential distress and suffering and responding to suffering.

Recognising ethnocultural diversity in chronic pain assessment: validation of the Pictorial Representation of Illness and Self Measure (PRISM) for use with culturally diverse communities

BACKGROUND

A comprehensive and accurate assessment of pain is critical for successful pain management. However, there is a lack of reliable and valid assessment tools for exploring multidimensional aspects of the chronic pain experience in culturally and linguistically diverse communities. This study investigates the reliability and validity of the Pictorial Representation of Illness and Self Measure + (PRISM+) for evaluating pain-related suffering and the sociocultural context of chronic pain within culturally and linguistically diverse patient cohorts.

METHOD

Three prospective validation studies are reported for three culturally and linguistically diverse communities. Two hundred and fifty-one patients with chronic pain who self-identified as Assyrian (n = 85), Arabic (n = 83) or Vietnamese (n = 83) completed a PRISM+ assessment, alongside a battery of standardised pain assessments. To evaluate construct validity, the position of the 'pain' disk placement was correlated with the Brief Pain Inventory (BPI), Depression Anxiety and Stress Scale (DASS), and the Short-Form 36 Health Survey (SF-36). For content validity, thematic analysis of patient narratives accompanying each disk placement was conducted. Test-retest reliability of repeated 'pain' and five additional disks (PRISM+) values was analysed using intra-class correlation coefficients.

RESULTS

The PRISM pain assessment demonstrated moderate to good test-retest reliability for Arabic (ICC 0.76; 95% CI 0.65-0.84), Assyrian (ICC 0.65; 95% CI 0.50-0.76) and Vietnamese (ICC 0.82; 95% CI 0.73-0.88) patients. Moderate correlations between the PRISM 'pain' disk and sub-scores for the BPI, DASS and SF-36 were found (p < 0.001). Patient interpretations of the 'pain' disk aligned with accepted definitions of suffering, supporting content validity for PRISM. For the additional disks (PRISM+), moderate to good test-retest reliability (ICC 0.67-0.88) was observed and qualitative analysis highlighted each disk reflected social and cultural values.

CONCLUSION

The PRISM demonstrates acceptable psychometric properties for measuring pain-related suffering for participants with chronic pain across three culturally and linguistically diverse communities. The use of additional disks (PRISM+) presents a reliable and valid option for exploring social and cultural dimensions of chronic pain in clinical encounters.

Palliative Pain Management: When Both Pain and Suffering Hurt

Patients with advanced cancer frequently experience intractable pain without sufficient response to a conventional pharmacological approach. One reason for refractory pain at the end of life can be the bidirectional nature of pain and suffering. Three terminally ill patients were assessed using a multidimensional palliative pain concept, including sensory, affective, cognitive, and existential components. In these patients, resistant pain did not equal insufficient eradication of the nociceptive input, but also suffering. Unrelieved emotions, depressive or anxious symptoms, delirium, difficulties communicating, or chemical coping influenced the expression of pain, illuminating the phenomenon of somatization. Palliative pain treatment integrated analgesic treatments, psychological, rehabilitative, and existential interventions, in consideration of individual expectations and outcomes. With the disciplined assessment and alternative multidisciplinary palliative approach, the quality of life of three terminally ill cancer patients with intractable pain could be enhanced, and unnecessary interventions and escalation of medications avoided.

Cross-Correlation Among Visual Analog, Observational, and Behavioral Pain Scales of Oncological Patients Undergoing Major Abdominal Surgery

PURPOSE

To determine the perception of postoperative pain intensity between nurses and oncology patients undergoing major abdominal surgery.

DESIGN

A prospective cross-correlation study with 173 oncology patients undergoing major abdominal surgery, such as hepatectomy or pancreatectomy.

METHODS

Postoperative pain intensity was evaluated by clinical pain assessment tools such as critical-care pain observation tool (CPOT) and behavioral pain scale (BPS) recorded by the researcher, whereas the visual analog scale was completed by patients. Demographic and clinical data were recorded.

FINDINGS

The Cronbach's α for CPOT and BPS was α = 0.738 for each. There was a significant correlation between CPOT and BPS (ρ = 0.796, P < .001), whereas the visual analog scale was correlated with CPOT and BPS (ρ = 0.351, P < .001 and ρ = 0.352, P < .001, respectively), showing that nurses did not underestimate patients' pain levels.

CONCLUSIONS

The management of postoperative pain intensity after major abdominal surgery requires clinical comprehension by nurses to achieve the reduction or suppression of pain.

Sport-related injury and pain classification

Pain is common in athletes, and pain management in sport has traditionally been equated with injury management. Although both pain and injury interfere with sport performance, they are not synonymous. Acute musculoskeletal injury commonly manifests as nociceptive pain, inflammatory pain, or both. Pain that persists beyond expected injury recovery must account for all potential contributors to pain, including ongoing biomechanical abnormalities, underlying pathophysiology, and psychosocial issues. Pain chronification involves multiple pathophysiologic and neurobehavioral processes that lead from acute injury-related pain to subacute and chronic pain, and must be distinguished from an ongoing biomechanical overuse pattern. The foundation of pain management in athletes is proper pain classification, which involves assessing for any combination of nociceptive/inflammatory pain, neuropathic pain, central sensitization, and autonomic/motor/affective manifestations of pain. Understanding this foundation is critical because there are scant evidence-based guidelines for the management of pain in sport. This chapter will explore the relationship of sport-related injury and pain, and will provide a management framework that is consistent with International Olympic Committee consensus.

Impact of controllability on pain and suffering

Supplemental Digital Content is Available in the Text.

Introduction:

Chronic pain and pain-related suffering are major health problems. The lack of controllability of experienced pain seems to greatly contribute to the extent of suffering. This study examined how controllability affects the perception of pain and pain-related suffering, and the modulation of this effect by beliefs and emotions such as locus of control of reinforcement, pain catastrophizing, and fear of pain.

Methods:

Twenty-six healthy subjects received painful electric stimulation in both controllable and uncontrollable conditions. Visual analogue scales and the “Pictorial Representation of Illness and Self Measure” were used to assess pain intensity, unpleasantness, pain-related suffering, and the level of perceived control. We also investigated nonverbal indicators of pain and suffering such as heart rate, skin conductance, and corrugator electromyogram.

Results:

Controllability selectively reduced the experience of pain-related suffering, but did not affect pain intensity or pain unpleasantness. This effect was modulated by chance locus of control but was unrelated to fear of pain or catastrophizing. Physiological responses were not affected by controllability. In a second sample of 25 participants, we varied the instruction. The effect of controllability on pain-related suffering was only present when instructions focused on the person being able to stop the pain.

Discussion:

Our data suggest that the additional measure of pain-related suffering may be important in the assessment of pain and may be more susceptible to the effects of perceived control than pain intensity and unpleasantness. We also show that this effect depends on personal involvement.

Psychological, cognitive factors and contextual influences in pain and pain-related suffering as revealed by a combined qualitative and quantitative assessment approach

Previous psychophysiological research suggests that pain measurement needs to go beyond the assessment of Pain Intensity and Unpleasantness by adding the evaluation of Pain-Related Suffering. Based on this three-dimensional approach, we attempted to elucidate who is more likely to suffer by identifying reasons that may lead individuals to report Pain and Pain-Related Suffering more than others. A sample of 24 healthy participants (age range 18-33) underwent four different sessions involving the evaluation of experimentally induced phasic and tonic pain. We applied two decision tree models to identify variables (selected from psychological questionnaires regarding pain and descriptors from post-session interviews) that provided a qualitative characterization of the degrees of Pain Intensity, Unpleasantness and Suffering and assessed the respective impact of contextual influences. The overall classification accuracy of the decision trees was 75% for Intensity, 77% for Unpleasantness and 78% for Pain-Related Suffering. The reporting of suffering was predominantly associated with fear of pain and active cognitive coping strategies, pain intensity with bodily competence conveying strength and resistance and unpleasantness with the degree of fear of pain and catastrophizing. These results indicate that the appraisal of the three pain dimensions was largely determined by stable psychological constructs. They also suggest that individuals manifesting higher active coping strategies may suffer less despite enhanced pain and those who fear pain may suffer even under low pain. The second decision tree model revealed that suffering did not depend on pain alone, but that the complex rating-related decision making can be shifted by situational factors (context, emotional and cognitive). The impact of coping and fear of pain on individual Pain-Related Suffering may highlight the importance of improving cognitive coping strategies in clinical settings.

Beyond Abdominal Pain: Pain Beliefs, Pain Affect, and Distress as Determinants of Quality of Life in Patients With Chronic Pancreatitis

GOALS

To assess the relationship between pain, psychological processes, and quality of life (QOL) in chronic pancreatitis (CP).

BACKGROUND

CP is a progressive inflammatory disorder of the pancreas characteristically resulting in abdominal pain and impairing QOL. Pain due to CP is poorly understood and frequently difficult to treat. This pain has historically been understood as a peripheral process originating from the pancreas itself, but a growing body of literature is revealing an important role offered by central influences. Viewed through the perspective of the biopsychosocial model of illness, cognitive variables strongly influence QOL. However, there is little understanding of variables that influence QOL in CP.

STUDY

Patients with CP from the University of Alabama at Birmingham were administered a 165-question test battery which was comprised of questionnaires evaluating pain beliefs, disease-specific QOL, psychological distress, pain sensation, pain affect, and long-term suffering.

RESULTS

Sixty-eight subjects completed the question battery between February 28, 2011 and January 16, 2014. Almost all (91.2%) reported taking pain medication. QOL was significantly associated with reported levels of pain intensity (r=-0.52, P<0.01) as well as perceived self-blame.

CONCLUSIONS

The significant predictors of QOL impairment in CP are pain intensity and perceived self-blame for pain. Further research is needed to elucidate this relationship while also evaluating the effectiveness of systematic modification of these variables in an attempt to improve pain and QOL in CP.

Burden and Quality of Life of Family Caregivers of Stroke Patients

The purpose of this study was to identify the level of burden and quality of life of family caregivers of stroke patients and to investigate the correlation between burden, quality of life (including physical, social, psychological, and environmental domains), age of caregivers, and the care period. A descriptive correlational cross-sectional study was performed, with a convenience sample of family caregivers (n = 30) of stroke patients in São Paulo, Brazil. Data were collected using a questionnaire on participants' characteristics, the Zarit Burden Interview Scale (ZBIS), and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) instrument. A descriptive analysis was performed, and correlations between variables were analyzed using Pearson's product-moment correlation coefficient. The average burden score on the ZBIS was 29.6, representing a moderate burden, and the average overall quality of life score on the WHOQOL-BREF was 62.06%, which indicates moderate quality of life. A significant weak negative correlation was observed between burden and environmental domains (r = -0.470; p =.009), quality of life (r = -0.414; p =.023), and physical domains (r = -0.394; p =.031). No significant correlations were found between burden and quality of life, and variables in the psychological and social domains, age of caregivers, or care period. Caregivers for stroke patients presented with moderate levels of burden and reduction in quality of life. Levels of burden correlated negatively with environmental domains, quality of life levels, and physical domains; however, these correlations were weak, indicating the possible interference of other factors.

A Narrative Approach to Healing Chronic Illness

Many clinicians may feel poorly prepared to manage patient suffering resulting from the travails of chronic illness. This essay explores the thesis that chronically and terminally ill patients can be holistically healed by transcending the suffering occasioned by the degradations of their illnesses. Suffering is conveyed as a story and clinicians can encourage healing by co-constructing patients' illness stories. By addressing the inevitable existential conflicts uncovered in patients' narratives and helping them edit their stories to promote acceptance and meaning, suffering can be transcended. This requires that clinicians be skilled in narrative medicine and open to engaging the patient's existential concerns. By helping patients transcend their suffering, clinicians claim their heritage as healers.

An interpretative phenomenological analysis of the experiences of older people self-managing cancer pain at home

Cancer is predominantly an illness affecting older people, yet there is a higher risk of under-treated pain in this age group. Many older people are required to self-manage their cancer pain at home but this is currently an under-researched and poorly understood area. We explored the experiences of older adults who self-manage cancer pain at home using an Interpretative Phenomenological Analytic approach. Eight older adults (aged 72-85 years) were recruited from a hospital in the United Kingdom and interviewed using a semi-structured questionnaire. Themes which emerged from the analysis suggest the self-management of cancer pain involves a perceived loss of control followed by a temporal process of gaining control over pain. Subordinate themes reflected the physical and social restrictions caused by pain; leading to fears regarding familial burden. Participants utilized inner strengths, past experiences, and social support to cope. Successful self-management of cancer pain in late life is conceptualized utilizing a positive psychology framework.

Chronic pain and fatigue in adults with congenital unilateral upper limb deficiency in Norway. A cross-sectional study

Purpose

To describe Norwegian adults with congenital unilateral upper limb deficiency (CUULD) regarding self-reported chronic pain (intensity, locations, impact on daily life) and fatigue. Analyze associations between chronic pain and demographic/clinical factors and associations between fatigue and demographic/ clinical factors.

Materials and methods

Cross-sectional study. In 2012, a postal questionnaire was sent to 186 persons with congenital limb deficiency, age ≥ 20 years. Seventy seven persons with CUULD responded and are included in this paper. The questionnaire included questions on demographic and clinical factors, chronic pain (Brief Pain Inventory, Standardized Nordic Questionnaire) and fatigue (Fatigue severity scale (FSS)).

Results

Mean age was 42.7 (SD 16.0), 71% were women. Sixty tree % reported chronic pain, many had bilateral pain, most common pain locations were neck (78%) and shoulder/upper arm (78%). However, reported mean pain intensity (3.3 (SD 2.8)) and mean number of pain locations (3.0 (SD 2.5)) were moderate to low. Thirty seven persons reported that pain started in adult age (≥ 19 years). One third reported severe fatigue (FSS ≥ 5). Persons reporting cold sensitivity and severe fatigue were most likely to have chronic pain.

Conclusions

Congenital upper limb deficiency increases the risk of self-reported pain in neck, shoulder/upper arm, cold sensitivity and severe fatigue. Pain, fatigue and cold sensitivity may individually affect function, and may together reinforce functional problems. This should be to taken into account when rehabilitation programs are developed. Further studies of more representative samples should be conducted to confirm our findings.

Effectiveness of bis(phenylimidazoselenazolyl) diselenide on a mouse model of inflammatory nociception

The injection of complete Freund's adjuvant (CFA) in the hindpaw of rodents induces tissue inflammation and nociceptive hypersensitivity. In addition, it has been reported that organoselenium compounds have antinociceptive properties in animal models. The purpose of this study was to investigate the potential antinociceptive effect of bis(phenylimidazoselenazolyl) diselenide (BPIS) in the inflammatory nociception model in mice and its possible mechanism of action. C57BL/6 mice received CFA intraplantar in right hindpaw and the inflammatory response was verified 24h after injection as well as the antinociceptive effect of BPIS. The CFA-induced mechanical allodynia was reversed by BPIS treatment (1mg/kg, p.o.) observed through the von Frey hair test. Additionally, L-arginine (600mg/kg; i.p.), administered before BPIS treatment, blocked its antinociceptive effect. Regarding myeloperoxidase activity, NOx and 3-nitrotyrosine levels, BPIS administration did not reverse alterations observed in the paw of animals injected with CFA. BPIS reversed the increase in spinal NOx content induced by CFA. In the spinal cord, it was also found that CFA induced an increase in malondialdehyde content and a decrease in glutamate uptake, and these alterations were reversed by BPIS. Moreover, BPIS treatment induced an increase in non-protein thiol levels in spinal cord of animals that received CFA injection. No alterations were found in glutathione peroxidase, reductase and S-transferase activities of experimental groups. The obtained data reinforce the relevance of BPIS as an antinociceptive agent as well as highlight the importance of the nitric oxide pathway in the spinal cord and its antioxidant potential for its mechanism of action.

Suffering and dying well: on the proper aim of palliative care

In recent years a large empirical literature has appeared on suffering at the end of life. In this literature it is recognized that suffering has existential and social dimensions in addition to physical and psychological ones. The non-physical aspects of suffering, however, are still understood as pathological symptoms, to be reduced by therapeutical interventions as much as possible. But suffering itself and the negative emotional states it consists of are intentional states of mind which, as such, make cognitive claims: they are more or less appropriate responses to the actual circumstances of the patient. These circumstances often are such that it would rather be a pathological symptom not to be sad and not to suffer. Suffering, therefore, is sometimes and to some extent a condition to be respected. Although I do not dispute that the alleviation of suffering is the main aim of palliative care, in pursuing that aim we should acknowledge a constraint of realism.

A Measure of Suffering in relation to Anxiety and Quality of Life in IBS Patients: Preliminary Results

Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder with a severe impact on quality of life (QoL). We explored the relationship of a visual measure of suffering, the PRISM-RII, with quality of life (QoL) and anxiety measures in IBS patients. Participants were 44 IBS patients who completed several questionnaires and kept a symptom diary for two weeks. The measures used were PRISM-RII (self-illness separation (SIS); illness perception measure (IPM)); IBS-36 (IBS health related QoL); SF-36 (physical and mental health related QoL); State-Trait Anxiety Inventory (STAI-T); Visceral Sensitivity Index (VSI; GI-specific anxiety); and a symptom diary. SIS was negatively correlated to VSI, while IPM was negatively correlated to SIS and the physical component of SF-36 and positively to VSI and symptom severity. We found significant differences between participants who perceive their illness as small and those who perceive it as medium in SIS, symptom severity, VSI, and the mental component of SF-36. Participants, who perceived their illness as small, represented their illness as more distant, showed lower average symptom severity, and had lower GI-specific anxiety and higher QoL. The results indicate that IPM and SIS can be useful in discriminating patients with more prominent psychological difficulties and QoL impairment.

Effects of Yoga in Managing Fatigue in Breast Cancer Patients: A Randomized Controlled Trial

Background:

Cancer-related fatigue is widely prevalent in cancer patients and affects quality of life in advanced cancer patients. Fatigue is caused due to both psychologic distress and physiological sequel following cancer progression and its treatment. In this study, we evaluate the effects of yogic intervention in managing fatigue in metastatic breast cancer patients.

Methods:

Ninety-one patients with metastatic breast cancer were randomized to receive integrated yoga program (n = 46) or supportive therapy and education (n = 45) over a 3-month period. Assessments such as perceived stress, fatigue symptom inventory, diurnal salivary cortisol, and natural killer cell counts were carried out before and after intervention. Analysis was done using an intention-to-treat approach. Postmeasures for the above outcomes were assessed using ANCOVA with respective baseline measure as a covariate.

Results:

The results suggest that yoga reduces perceived stress (P = 0.001), fatigue frequency (P < 0.001), fatigue severity (P < 0.001), interference (P < 0.001), and diurnal variation (P < 0.001) when compared to supportive therapy. There was a positive correlation of change in fatigue severity with 9 a.m. salivary cortisol levels.

Conclusion:

The results suggest that yoga reduces fatigue in advanced breast cancer patients.

Satisfaction with and Perception of Pain Management among Palliative Patients with Breakthrough Pain: A Qualitative Study

Breakthrough pain is a significant contributor to much suffering by patients. The experience of intense pain may interfere with, and affect, daily life functioning and has major consequences on patients' well-being if it is not well managed. The area of breakthrough pain has not been fully understood. This study thus aimed to explore the experiences of breakthrough pain among palliative patients. A qualitative study based on a series of open-ended interviews among 21 palliative patients suffering from pain at an urban tertiary hospital in Malaysia was conducted. Five themes were generated: (i) pain viewed as an unbearable experience causing misery in the lives of patients, (ii) deterioration of body function and no hope of recovery, (iii) receiving of inadequate pain management for pain, (iv) insensitivity of healthcare providers toward patients' pain experience, and (v) pain coping experiences of patients. The findings revealed that nonpharmacologic approaches such as psychosocial support should be introduced to the patients. Proper guidance and information should be given to healthcare providers to improve the quality of patient care. Healthcare providers should adopt a sensitive approach in caring for patients' needs. The aim is to meet the needs of the patients who want to be pain free or to attain adequate relief of their pain for breakthrough pain.