Relationship between COMT Gene Polymorphism, Anxiety, and Pain Perception during Labour

BACKGROUND

The COMT gene polymorphism is associated with neurological and psychiatric disorders and pain perception. The present study investigates the existence of anxiety and pain perception in relation to the COMT (catechol-O-methyltransferase) gene polymorphism in labouring women (during "natural" childbirth) with or without inhaled analgesia.

METHODS

A total of 181 women who chose vaginal birth were enrolled in this study. To present the difference in pain perception, the parturients were divided into one group (n = 90) that chose labour analgesia with inhaled nitrous oxide (50% nitrous oxide and 50% oxygen) and one group (n = 91) without analgesia. The blood samples were taken during the pregnancy as a part of routine pregnancy controls in the hospital. The COMT gene polymorphism was detected with the PCR technique. The pain perception of parturients was self-evaluated two times according to the VAS (Visual Analogue Scale), and anxiety as a personality trait was determined with the STAI-T (State Trait Anxiety Inventory). Pain perception as well as anxiety were compared according to COMT genotypes.

RESULTS

In the 181 pregnant women, there were 40 women (22%) of wild homozygotes (GG) of COMT, 95 women (53%) of mutant heterozygotes (GA), and 46 women (25%) of mutant homozygotes (AA). A negative association of pain perception with the GA (mutant heterozygote) polymorphism of the COMT gene versus the wild-type (GG polymorphism) was observed. The GA polymorphism of the COMT gene was associated with 0.46 units lower pain perception compared to the wild type (GG). The anxiety trait score in group AA was lower than in groups GA and GG. The difference reached statistical significance only when comparing AA versus GA (p > 0.042). Analgesic efficacy of nitrous oxide was noticed in 22% of labouring women who reported moderate pain (VAS score 4-7).

CONCLUSIONS

The COMT gene polymorphism was associated with pain perception and anxiety among parturients. The COMT gene polymorphism GA was associated with negative pain perception among labouring women. Nitrous oxide showed statistical significance in anxiolytic efficacy during labour in women with mild anxiety as a personality trait. Anxiolytic efficacy of nitrous oxide has shown better efficacy in parturients with the COMT gene polymorphism AA.

Clozapine in Treatment-Resistant Schizophrenia and Its Augmentation with Electroconvulsive Therapy in Ultra-Treatment-Resistant Schizophrenia

Clozapine is considered the gold standard for patients with treatment-resistant schizophrenia (TRS) who have previously tried other antipsychotics at adequate doses (two or more, with at least one being atypical). However, despite optimal treatment, a subgroup of TRS patients with what is known as ultra-treatment-resistant schizophrenia (UTRS) fails to respond to clozapine, which occurs in 40–70% of cases. The most common approach to manage UTRS involves augmenting clozapine with pharmacological or non-pharmacological interventions, with a growing body of evidence that supports the use of electroconvulsive therapy (ECT) as an augmenter. This prospective non-randomized 8-week study, which followed the TRIPP Working Group guidelines and is one of few that separate TRS from UTRS, aimed to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. Patients with TRS were assigned to receive clozapine alone (clozapine group), whereas UTRS patients received bilateral ECT in addition to their current medication regimen (ECT plus clozapine group). The severity of symptoms was evaluated using the Clinical Global Impression Scale (CGI) and Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of the 8-week trial. Both treatment approaches resulted in improved CGI and PANSS scores. The results suggest that both clozapine and ECT are effective treatment options for patients with TRS and UTRS, respectively, and that adherence to guidelines should provide a better frame for future clinical studies.

PALLIATIVE TREATMENT OF INTRACTABLE CANCER PAIN

In 10% to 30% cancer-pain cases standard analgesic therapy fails to provide effective pain relief. Interventional techniques, such as peripheral nerve blocks, neuraxial analgesia along with neurolytic blocks may be used for such refractory pain. Peripheral nerve blocks can be used when pain occurs in the territory of one or more peripheral nerves, but rarely as main therapy. Neuraxial analgesia is a valid option for progressive cancer pain, and healthcare possibilities and costs call into question the utility of intrathecal infusion pumps. Neurolysis is the targeted destruction of a nerve or nerve plexus, using chemicals, radiofrequency ablation (RFA), cryoablation, and neurosurgical procedures; however, it rarely completely eliminates pain because patients frequently experience coexisting somatic and neuropathic pain as well. Complex conditions of palliative patients along with limited high-quality randomized controlled trials limit the use of interventional procedures. Even so, some cancer patients benefit from interventional procedures to achieve pain alleviation and consequently improve quality of life.

PAIN AND ANXIETY EXPERIENCE IN THE CHOICE OF EPIDURAL ANALGESIA IN DELIVERY

The experience of labor pain is a complex process that represents the interaction of the nociceptive stimulus within the physiologic process with a series of psychological factors. The aim of this study was to investigate the relation between the choice of epidural analgesia as a form of pain management and psychological state of woman in labor; moreover, whether the women in labor with a higher level of anxiety have a more intensive experience of pain during labor and therefore decide on epidural analgesia. Pain was evaluated by the visual analog scale, while the sensory and affective pain components were evaluated by the McGill Pain Questionnaire, and anxiety as a trait was measured with the State-Trait Anxiety Inventory-form X. Women in labor with a higher level of anxiety had a significantly increased affective component of pain, but did not significantly more frequently decide on labor with epidural analgesia. The women having chosen epidural analgesia experienced more intense pain during delivery before epidural analgesia, with the sensory component of pain being less pronounced in the women in labor without epidural analgesia, while there was no difference in the affective component of pain.

Self-care of chronic musculoskeletal pain - experiences and attitudes of patients and health care providers

BACKGROUND

Self-care is often the first choice for people with chronic musculoskeletal pain. Self-care includes the use of non-prescription medications with no doctor's supervision, as well as the use of other modern and traditional treatment methods with no consultation of the health care provider. Self-care may have positive effects on the successful outcome of a multidisciplinary approach to treatment. The aim of this study was to investigate the experiences and attitudes of patients and health care providers to the self-care of chronic musculoskeletal pain.

METHODS

Qualitative Phenomenological study, where the data were collected by the method of an audio-taped interview in 15 patients at the outpatient clinic for pain management and in 20 health care providers involved in the treatment of those patients. The interviews were transcribed verbatim and analyzed by principles of Interpretative Thematic Analysis.

RESULTS

Topics identified in patients: a) positive aspects of self-care, b) a need for pain self-care, c) social aspects of pain self-care. Topics identified in health care providers: a) aspects of self-care, b) a need for self-care c) risks of self-care. Most of patients have positive attitude to self-care and this is the first step to pain management and to care for itself. The most frequent factors influencing decision about the self-care are heavy pain, unavailability of the doctor, long awaiting time for the therapy, or ineffectiveness of methods of conventional medicine. The health care providers believe that self-care of chronic musculoskeletal pain may be a patient's contribution to clinical treatment. However, good awareness of methods used is important in this context, to avoid adverse effects of self-care.

CONCLUSION

Patients understand the self-care of musculoskeletal pain as an individually adjusted treatment and believe in its effectiveness. Health care providers support self-care as an adjunction to clinical management only, and think that self-care of musculoskeletal pain acts as a placebo, with a short-lived effect on chronic musculoskeletal pain.