Special Considerations for the Treatment of Pain from Torture and War

Pain care for survivors of torture and of war shows similarities and marked differences. For both, pain can be complex with unfamiliar presentations and the pains hard to assign to known disorders. For many survivors, pain and associated disability are overshadowed by psychological distress, often by post-traumatic stress symptoms that can be frightening and isolating. Pain medicine in war can exemplify best techniques and organisation, reducing suffering, but many military veterans have persistent pain that undermines their readjustment. By contrast, survivors of torture rarely have any acute health care; their risk for developing chronic pain is high. Even when settled as refugees in a well-resourced country, their access to healthcare may be restricted. Recent evidence is reviewed that informs assessment and treatment of pain in both groups, with the broader context of psychological distress addressed at the end. Clinical and research implications are briefly outlined

Health care providers' judgments in chronic pain: the influence of gender and trustworthiness

Estimates of patients' pain, and judgments of their pain expression, are affected by characteristics of the observer and of the patient. In this study, we investigated the impact of high or low trustworthiness, a rapid and automatic decision made about another, and of gender and depression history on judgments made by pain clinicians and by medical students. Judges viewed a video of a patient in pain presented with a brief history and rated his or her pain, and the likelihood that it was being exaggerated, minimized, or hidden. Judges also recommended various medical and treatment options. Contrary to expectations, trustworthiness had no main effect on pain estimates or judgments, but interacted with gender producing pervasive bias. Women, particularly those rated of low trustworthiness, were estimated to have less pain and to be more likely to exaggerate it. Unexpectedly, judgments of exaggeration and pain estimates were independent. Consistent with those judgments, men were more likely to be recommended analgesics, and women to be recommended psychological treatment. Effects of depression history were inconsistent and hard to interpret. Contrary to expectations, clinicians' pain estimates were higher than medical students', and indicated less scepticism. Empathy was unrelated to these judgments. Trustworthiness merits further exploration in healthcare providers' judgments of pain authenticity and how it interacts with other characteristics of patients. Furthermore, systematic disadvantage to women showing pain is of serious concern in healthcare settings

How do people with chronically painful joint hypermobility syndrome make decisions about activity?

Background:The model of activity avoidance prompted by fear of increased pain and/or harm dominates understanding and research into activity limitation in chronic pain. Yet the accounts of people with chronic pain on decisions about activity limitation are rarely heard beyond the confines of fear and avoidance questionnaires. Methods We used semi-structured interviews to explore the decisions of 11 women attending a pain management clinic with chronically painful Joint Hypermobility Syndrome (JHS). Results Six themes emerged from Interpretative Phenomenological Analysis: the overall aim of keeping pain to a manageable level; considering whether the planned activity was worth it; and running through all judgements, the influence of pain intensity. The decision was tipped towards avoidance by unpredictability of pain and by high emotional cost and towards going ahead with the activity by the wish to exert control and by low emotional cost. Many accounts described a specifiable cost-benefit analysis of individual decisions, weighing the importance of each activity against its potential aversive consequences, which only in a minority of cases was dominated by fear of pain or injury. Conclusions Assumptions of fear as the basis of activity avoidance should not be used uncritically in clinical settings. Decisions about activity should explore beyond pain expectancy, incorporating goals, values, and decision processes

Pain expressiveness and altruistic behavior: an exploration using agent-based modeling

Predictions which invoke evolutionary mechanisms are hard to test. Agent-based modeling in artificial life offers a way to simulate behaviors and interactions in specific physical or social environments over many generations. The outcomes have implications for understanding adaptive value of behaviors in context. Pain-related behavior in animals is communicated to other animals that might protect or help, or might exploit or predate. An agent-based model simulated the effects of displaying or not displaying pain (expresser/nonexpresser strategies) when injured and of helping, ignoring, or exploiting another in pain (altruistic/nonaltruistic/selfish strategies). Agents modeled in MATLAB interacted at random while foraging (gaining energy); random injury interrupted foraging for a fixed time unless help from an altruistic agent, who paid an energy cost, speeded recovery. Environmental and social conditions also varied, and each model ran for 10,000 iterations. Findings were meaningful in that, in general, contingencies that evident from experimental work with a variety of mammals, over a few interactions, were replicated in the agent-based model after selection pressure over many generations. More energy-demanding expression of pain reduced its frequency in successive generations, and increasing injury frequency resulted in fewer expressers and altruists. Allowing exploitation of injured agents decreased expression of pain to near zero, but altruists remained. Decreasing costs or increasing benefits of helping hardly changed its frequency, whereas increasing interaction rate between injured agents and helpers diminished the benefits to both. Agent-based modeling allows simulation of complex behaviors and environmental pressures over evolutionary time

Nursing Education Interventions for Managing Acute Pain in Hospital Settings: A Systematic Review of Clinical Outcomes and Teaching Methods

The objective of this review was to examine the effects of nursing education interventions on clinical outcomes for acute pain management in hospital settings, relating interventions to health care behavior change theory. Three databases were searched for nursing education interventions from 2002 to 2015 in acute hospital settings with clinical outcomes reported. Methodological quality was rated as strong, moderate, or weak using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies. The 12 eligible studies used varied didactic and interactive teaching methods. Several studies had weaknesses attributable to selection biases, uncontrolled confounders, and lack of blinding of outcome assessors. No studies made reference to behavior change theory in their design. Eight of the 12 studies investigated nursing documentation of pain assessment as the main outcome, with the majority reporting positive effects of education interventions on nursing pain assessment. Of the remaining studies, two reported mixed findings on patient self-report of pain scores as the key measure, one reported improvements in patient satisfaction with pain management after a nursing intervention, and one study found an increase in nurses’ delivery of a relaxation treatment following an intervention. Improvements in design and evaluation of nursing education interventions are suggested, drawing on behavior change theory and emphasizing the relational, contextual, and emotionally demanding nature of nursing pain management in hospital setting

How do medical students use and understand pain rating scales?

BACKGROUND AND AIMS: Pain is a multidimensional experience that is difficult to describe and to assess. To scale current pain, assessment refers to a maximum level of pain, but little is known about this process. Further, clinicians tend to underestimate patients’ pain, with or without patients’ own reports, and to underestimate to a greater extent with more clinical experience, possibly due to recalibration of a personal pain scale with increasing exposure to severe pain. We sought to determine how medical students rated pain in early years of clinical exposure, and in relation to experience of their own and others’ worst pains. METHODS: An online survey sampled medical students’ rating and description of their own worst pain and of that witnessed in another; also what would cause the maximum level of pain and what behaviours characterised it. Last, they indicated their preference among pain scales. RESULTS: Thirty-six medical students provided responses, the majority in their first six months of clinical exposure. Students’ own worst pain was rated a mean of 6.7/10 (s.d. 1.6) on a numerical scale; causes were diverse but with many bone fractures. Mean worst pain observed in another was rated 8.6/10 (s.d. 1.4); causes included fractures, gallstones, and sickle cell crises. Another's worst pain was significantly higher (mean 9.4, s.d. 0.8 vs mean 8.0 s.d. 1.4) when rated after the student's own pain than before it (presentation order randomised). We found no effect of clinical exposure on estimation of worst pain in another person, nor was there a personal tendency to rate pain using more or less extreme values. Students expected pain of 10/10 to be presented with many verbal, facial and whole body behaviours, and signs of physiological stress. Collectively, behavioural descriptions were rich and varied, but with many incompatibilities: for instance, between ‘writhing’ and ‘rigidity’ expected in the person with extreme pain. Most students preferred the numerical rating scale over visual analogue and verbal scales. CONCLUSIONS: The study requires replication, particularly for clinical experience, where we found no significant difference in estimation of another's pain over the first three years of medical students’ clinical exposure, but the comparison was underpowered. Despite no systematic individual difference in using pain ratings, there was a marked effect of rating another's worst pain higher when the rater had previously rated his/her own worst pain. This suggests anchoring estimate of another's pain in personal pain experience, and a possible way to mitigate clinicians’ underestimation of patients’ pain. Medical students’ recognition of the importance of facial expression in indicating another's pain severity was encouraging, but most students anticipated only a narrow range of behaviours associated with extreme pain, thereby excluding other authentic behaviours. IMPLICATIONS: Many clinical guidelines mandate regular pain assessment for hospital inpatients, and encourage routine assessment in community and outpatient settings, in order to decide on and monitor treatment. Replication and elaboration of this study could extend our understanding of how clinicians interpret pain scales completed by patients, and how they estimate patients’ pain

Exploring patient experiences of a pain management centre: A qualitative study

BACKGROUND AND AIMS: To improve care and management of patients with chronic pain it is important to understand patients' experiences of treatment, and of the people and the environment involved. As chronic pain patients often have long relationships with medical clinics and pain management centres, the team and team interactions with the patients could impact the treatment outcome. The aim of this study was to elicit as honest as possible an account of chronic pain patients' experiences associated with their care and feed this information back to the clinical team as motivation for improvement. METHODS: The research was conducted at a large hospital-based pain management centre. One hundred consecutive patients aged 18 years and above, who had visited the centre at least once before, were invited to participate. Seventy patients agreed and were asked to write a letter, as if to a friend, describing the centre. On completion of the study, all letters were transcribed into NVivo software and a thematic analysis performed. RESULTS: Six key themes were identified: (i) staff attitude and behaviour; (ii) interactions with the physician; (iii) importance of a dedicated pain management centre; (iv) personalized care; (v) benefits beyond pain control; (vi) recommending the pain management centre. CONCLUSION: The findings suggest that the main reasons that patients recommended the centre were: (i) support and validation provided by the staff; (ii) provision of detailed information about the treatment choices available; (iii) personalized management plan and strategies to improve overall quality of life alongside pain control. None of the letters criticized the care provided, but eight of seventy reported long waiting times for the first appointment as a problem. IMPLICATIONS: Patient views are central to improving care. However, satisfaction questionnaires or checklists can be intimidating, and restrictive in their content, not allowing patients to offer spontaneous feedback. We used a novel approach of writing a letter to a friend, which encouraged reporting of uncensored views. The results of the study have encouraged the clinical team to pursue their patient management strategies and work to reduce the waiting time for a first appointment

Prognostic value of lymph node ratio and extramural vascular invasion on survival for patients undergoing curative colon cancer resection

There was no study funding. We are grateful to Tony Rafferty (Tailored Information for the People of Scotland, TIPs) for providing survival data.Peer reviewedPublisher PD

Endocytosis as a biological response in receptor pharmacology: evaluation by fluorescence microscopy

The activation of G-protein coupled receptors by agonist compounds results in diverse biological responses in cells, such as the endocytosis process consisting in the translocation of receptors from the plasma membrane to the cytoplasm within internalizing vesicles or endosomes. In order to functionally evaluate endocytosis events resulted from pharmacological responses, we have developed an image analysis method -the Q-Endosomes algorithm- that specifically discriminates the fluorescent signal originated at endosomes from that one observed at the plasma membrane in images obtained from living cells by fluorescence microscopy. Mu opioid (MOP) receptor tagged at the carboxy-terminus with yellow fluorescent protein (YFP) and permanently expressed in HEK293 cells was used as experimental model to validate this methodology. Time-course experiments performed with several agonists resulted in different sigmoid curves depending on the drug used to initiate MOP receptor endocytosis. Thus, endocytosis resulting from the simultaneous activation of co-expressed MOP and serotonin 5-HT2C receptors by morphine plus serotonin was significantly different, in kinetics as well as in maximal response parameters, from the one caused by DAMGO, sufentanyl or methadone. Therefore, this analytical tool permits the pharmacological characterization of receptor endocytosis in living cells with functional and temporal resolution

Negative parental responses to coming out and family functioning in a sample of lesbian and gay young adults

Parental responses to youths' coming out (CO) are crucial to the subsequent adjustment of children and family. The present study investigated the negative parental reaction to the disclosure of same-sex attraction and the differences between maternal and paternal responses, as reported by their homosexual daughters and sons. Participants' perceptions of their parents' reactions (evaluated through the Perceived Parental Reactions Scale, PPRS), age at coming out, gender, parental political orientation, and religiosity involvement, the family functioning (assessed through the Family Adaptability and Cohesion Evaluation Scales, FACES IV), were assessed in 164 Italian gay and lesbian young adults. Pearson correlation coefficients were calculated to assess the relation between family functioning and parental reaction to CO. The paired sample t-test was used to compare mothers and fathers' scores on the PPRS. Hierarchical multiple regression was conducted to analyze the relevance of each variable. No differences were found between mothers and fathers in their reaction to the disclosure. The analysis showed that a negative reaction to coming out was predicted by parents' right-wing political conservatism, strong religious beliefs, and higher scores in the scales Rigid and Enmeshed. Findings confirm that a negative parental reaction is the result of poor family resources to face a stressful situation and a strong belief in traditional values. These results have important implications in both clinical and social fields