An exercise cum cognitive-behavioral intervention for older adults with chronic pain: A cluster-randomized controlled trial.

OBJECTIVE: To examine the medium-term effects of a group intervention combining exercise and cognitive-behavioral strategies (EC) on older adults with chronic pain. METHOD: One hundred and fifty-two Hong Kong Chinese older adults with chronic pain affecting bones, muscles, and joints were randomized by clinic/social center to receive 10 weekly sessions of EC or pain education (control). The primary (pain intensity) and secondary outcomes (pain disability, pain self-efficacy, pain catastrophizing, pain coping, depressive symptoms, health-related quality of life, and hip and knee strength) were collected at baseline (T1), postintervention (T2), and 3- (T3) and 6-month follow-ups (T4). The trajectories of intervention effects were modeled by EC × time and EC × time2 interaction terms in mixed-effects regression. RESULTS: Significant EC × time and/or EC × time2 interactions were found for pain intensity, pain disability, self-efficacy, and catastrophizing, such that the treatment effect leveled off (pain disability) or diminished (pain intensity and catastrophizing) over time, or continued to increase in a linear fashion (self-efficacy). There was also a treatment main effect on hip/knee muscle strength. Group differences in favor of EC were observed up to 3-month follow-up for pain intensity (d = -0.51) and hip/knee muscle strength (d = 0.38), and up to 6-month follow-up for pain disability (d = -0.60) and self-efficacy (d = 0.52). No group difference was found for catastrophizing at any time point. No treatment effects were found for the other outcomes. CONCLUSION: Older people suffering from chronic pain can benefit from a program incorporating both cognitive-behavioral techniques and physical exercise. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Typology of pain coping and associations with physical health, mental health, and pain profiles in Hong Kong Chinese older adults.

OBJECTIVES: To identify typology of pain coping in older adults and to see whether the coping types or patterns were associated with pain, physical health, and mental health outcomes. METHODS: Six hundred and fifty six Chinese older adults were recruited on a convenience basis from social centers in Hong Kong. A 14-item Brief Pain Coping Scale (BPCS) was constructed on the basis of the Chronic Pain Coping Inventory. Outcome measures included pain intensity, pain disability, pain-related cognitions, depressive symptoms, health-related quality of life, and health and physical functioning (in terms of chronic illnesses, basic and instrumental activities of daily living, and self-rated health). Coping typology was identified using latent class analysis. RESULTS: A 3-class solution based on BPCS provided the best fit to data. Class 1 used almost all coping strategies on a daily basis, Class 2 used the strategies less frequently, whereas Class 3 adopted few strategies. Yet, Class 3 was basically indistinguishable from Class 1 across the outcome variables, even though the participants had more chronic illnesses and poorer instrumental activities of daily living than those in Class 1. Class 2, however, had the poorest outcome profiles, reporting more pain, disability, depression, and health-related quality of life than the other two classes. The differences in coping could not be explained by the differential effectiveness of coping strategies across groups. CONCLUSION: The way coping was used, and the way it was related to pain, mood, health and functioning outcomes, varied substantially across individuals. Implications for coping skills interventions are discussed.

Developing a Short Multidimensional Measure of Pain Self-efficacy: The Chronic Pain Self-efficacy Scale-Short Form.

BACKGROUND AND OBJECTIVES: The 22-item Chronic Pain Self-efficacy Scale (CPSS) measures three domains of pain self-efficacy: pain management, physical functioning, and coping with symptoms. This study aims to develop a short form (CPSS-SF) that retains the multidimensional structure of the instrument. RESEARCH DESIGN AND METHODS: Six hundred sixty-four community-dwelling Chinese older adults aged 60-95 years with chronic pain completed a survey. Confirmatory factor analysis (CFA) was conducted on the 22-item CPSS. Regression analyses were performed to examine the items' correlations with criterion variables. After CPSS-SF items were selected, the performance of CPSS-SF subscales in terms of accounting for pain-related outcomes was compared with the full version. RESULTS: CFA supported a modified 3-factor model of the CPSS. On the basis of factor loadings on the 3 dimensions and the items' correlations with pain intensity and pain disability, 11 items were selected for the CPSS-SF, which correlated at .97 with the full version. Regression analyses showed that the associations of the CPSS-SF subscales with pain intensity, pain disability, depressive symptoms, instrumental activities of daily living, and physical and mental health-related quality of life, were indistinguishable from their full-version counterparts. DISCUSSION AND IMPLICATIONS: The CPSS-SF is a valid instrument that can be used in lieu of the full scale. Its availability will facilitate the assessment of pain self-efficacy in research and clinical settings due to its brevity but strong psychometric properties. However, the current evidence is limited to Chinese older adults; more research is needed to ascertain its validity in other age and cultural groups.

The Pain Catastrophizing Scale-short form: psychometric properties and threshold for identifying high-risk individuals.

OBJECTIVE: The Pain Catastrophizing Scale (PCS) measures three aspects of catastrophic cognitions about pain-rumination, magnification, and helplessness. To facilitate assessment and clinical application, we aimed to (a) develop a short version on the basis of its factorial structure and the items' correlations with key pain-related outcomes, and (b) identify the threshold on the short form indicative of risk for depression. DESIGN: Cross-sectional survey. SETTING: Social centers for older people. PARTICIPANTS: 664 Chinese older adults with chronic pain. MEASUREMENTS: Besides the PCS, pain intensity, pain disability, and depressive symptoms were assessed. RESULTS: For the full scale, confirmatory factor analysis showed that the hypothesized 3-factor model fit the data moderately well. On the basis of the factor loadings, two items were selected from each of the three dimensions. An additional item significantly associated with pain disability and depressive symptoms, over and above these six items, was identified through regression analyses. A short-PCS composed of seven items was formed, which correlated at r=0.97 with the full scale. Subsequently, receiver operating characteristic (ROC) curves were plotted against clinically significant depressive symptoms, defined as a score of ≥12 on a 10-item version of the Center for Epidemiologic Studies-Depression Scale. This analysis showed a score of ≥7 to be the optimal cutoff for the short-PCS, with sensitivity = 81.6% and specificity = 78.3% when predicting clinically significant depressive symptoms. CONCLUSIONS: The short-PCS may be used in lieu of the full scale and as a brief screen to identify individuals with serious catastrophizing.

The relationship of self-efficacy to catastrophizing and depressive symptoms in community-dwelling older adults with chronic pain: A moderated mediation model.

Self-efficacy has been consistently found to be a protective factor against psychological distress and disorders in the literature. However, little research is done on the moderating effect of self-efficacy on depressive symptoms in the context of chronic pain. This cross-sectional study aimed to examine if pain self-efficacy attenuated the direct relationship between pain intensity and depressive symptoms, as well as their indirect relationship through reducing the extent of catastrophizing when feeling pain (moderated mediation). 664 community-dwelling Chinese older adults aged 60-95 years who reported chronic pain for at least three months were recruited from social centers. They completed a battery of questionnaires on chronic pain, pain self-efficacy, catastrophizing, and depressive symptoms in individual face-to-face interviews. Controlling for age, gender, education, self-rated health, number of chronic diseases, pain disability, and pain self-efficacy, pain catastrophizing was found to partially mediate the connection between pain intensity and depressive symptoms. Furthermore, the relationship between pain intensity and depressive symptoms was moderated by pain self-efficacy. Self-efficacy was also found to moderate the relationship between pain intensity and catastrophizing and the moderated mediation effect was confirmed using bootstrap analysis. The results suggested that with increasing levels of self-efficacy, pain intensity's direct effect on depressive symptoms and its indirect effect on depressive symptoms via catastrophizing were both reduced in a dose-dependent manner. Our findings suggest that pain self-efficacy is a significant protective factor that contributes to psychological resilience in chronic pain patients by attenuating the relationship of pain intensity to both catastrophizing and depressive symptoms.

A multicomponent intervention for the management of chronic pain in older adults: study protocol for a randomized controlled trial.

BACKGROUND: Studies have shown that physical interventions and psychological methods based on the cognitive behavioral approach are efficacious in alleviating pain and that combining both tends to yield more benefits than either intervention alone. In view of the aging population with chronic pain and the lack of evidence-based pain management programs locally, we developed a multicomponent intervention incorporating physical exercise and cognitive behavioral techniques and examined its long-term effects against treatment as usual (i.e., pain education) in older adults with chronic musculoskeletal pain in Hong Kong. METHODS/DESIGN: We are conducting a double-blind, cluster-randomized controlled trial. A sample of 160 participants aged ≥ 60 years will be recruited from social centers or outpatient clinics and will be randomized on the basis of center/clinic to either the multicomponent intervention or the pain education program. Both interventions consist of ten weekly sessions of 90 minutes each. The primary outcome is pain intensity, and the secondary outcomes include pain interference, pain persistence, pain self-efficacy, pain coping, pain catastrophizing cognitions, health-related quality of life, depressive symptoms, and hip and knee muscle strength. All outcome measures will be collected at baseline, postintervention, and at 3 and 6 months follow-up. Intention-to-treat analysis will be performed using mixed-effects regression to see whether the multicomponent intervention alleviates pain intensity and associated outcomes over and above the effects of pain education (i.e., a treatment × time intervention effect). DISCUSSION: Because the activities included in the multicomponent intervention were carefully selected for ready implementation by allied health professionals in general, the results of this study, if positive, will make available an efficacious, nonpharmacological pain management program that can be widely adopted in clinical and social service settings and will hence improve older people's access to pain management services. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR-IIR-16008387. Registered on 28 April 2016.

The effects of exposure to scenarios about dementia on stigma and attitudes toward dementia care in a Chinese community.

BACKGROUND: This study investigated whether brief exposure to information has any effect on stigmatizing attitudes towards older people with dementia, and how people responded to this medical diagnosis. METHODS: 494 adults were randomly assigned to three groups differentiated by experimental conditions. Group A (control) responded to questions on stigma directly. Group B (symptom) read two vignettes that described the symptoms of two fictitious individuals with dementia, before answering questions on stigma. Group C (label) read the same vignettes which ended with a statement that the person was recently diagnosed with dementia by a physician. Data were analyzed with ANOVA, together with other pre-existing between-subjects factors. RESULTS: Brief exposure to information about dementia led to a statistically significant reduction in stigma (Groups B, C < A), regardless of whether the diagnostic label of "dementia" was included or not. Moreover, lower stigma was reported by persons who knew a relative or friend with dementia, who were younger and more educated, and who thought dementia was treatable. CONCLUSIONS: As stigmatizing attitudes toward dementia are still a hindrance to early help-seeking in Asian communities, the findings suggest that community education may play a useful role in alleviating this barrier to early detection and intervention.

Trends in pathology graduate medical education.

Comprehensive data show trends in graduate medical education in pathology with regard to the numbers of accredited programs, persons certified from those programs, and demographics of the population of first year-trainees in pathology. Experience with US seniors and foreign-trained physicians in the PGY match process for pathology from 1991 through 2000 is presented, along with data on the types of medical schools generating pathology trainees for the PGY-1 year and the top medical schools of origin of US medical graduates who completed the program and became certified in pathology between 1995 and 1999. The impact of reimbursement of the credentialing year is also addressed through data collected from the PRODS Survey 2000, and those results are reviewed. Finally, turnover rates among pathology program directors of combined AP/CP programs and subspecialty programs since 1994 are presented. An analysis of these trends is provided, along with suggestions to improve both the perception of careers in pathology and the actual choice of a career in pathology.

Association of reactive nitrogen species metabolites, myeloperoxidase, and airway inflammation in lung transplants.

BACKGROUND: We have previously reported that patients who had single or double lung transplants had higher concentrations than controls of nitrite and nitrate, which are metabolites of reactive nitrogen species (RNS), in bronchoalveolar lavage fluid (BALF) and serum. METHODS: This study investigates implications of RNS metabolites as markers of airway inflammation in a distinct group of lung transplant patients (n = 40). All patients underwent spirometry, routine surveillance transbronchial lung biopsies, and bronchoalveolar lavage as required by clinical protocol. Four normal controls also had bronchoscopy for measurement of BALF nitrite (NO2-) and nitrate (NO3-). BALF NO2- and NO3-, myeloperoxidase (MPO), protein, and urea were assayed. Total nitrite (NO2- plus enzymatically reduced NO3-) and urea were measured in serum. RESULTS: BALF RNS metabolites were mainly NO3-. Forced expiratory volume in 1 s (FEV1) obtained near bronchoscopy was compared with best postoperative FEV1. Total nitrite in transplant patients' BALF and serum were 3.8 +/- 0.2 and 49 +/- 5 microM, respectively. Total nitrite in controls' BALF and serum were 2.2 +/- 0.7 and 19 +/- 2 microM, respectively (P < 0.05 compared with transplant values). Serum total nitrite correlated (Pearson product moment) with percentage of neutrophils in BALF (R = 0.650, P < 0.0001), MPO (R = 0.431, P = 0.0055), change in FEV1 from baseline (deltaFEV1) (R = -0348, P = 0.0298), and days after transplantation (R = 0.345, P = 0.0294). None of the associated variables, airway inflanmmation (quantified as a score, "B"), deltaFEV1, serum, or BALF total nitrite, were explained by infection. Univariate analysis of airway inflammation in patients showed that it was associated with BALF neutrophils, deltaFEV1, and serum total nitrite. CONCLUSIONS: Serum nitrite appears to reflect the degree of airway inflammation in this lung-transplant study group.

The utility of open lung biopsy following lung transplantation.

BACKGROUND: Most pulmonary complications associated with lung transplantation have non-specific clinical characteristics. Furthermore, common diagnostic modalities, including bronchoscopy with transbronchial biopsy (TBB), often do not render a definitive diagnosis. In this study, we reviewed our experience with open lung biopsy (OLB) following lung transplantation, specifically regarding its ability to safely provide clinically relevant information that affects therapeutic decisions. METHODS: From October 1989 to March 2000, 202 patients underwent lung transplantation at our institution. We reviewed the clinical course of the 42 patients who received 48 OLBs. Of these patients, we determined the pre-operative clinical condition, preceding TBB histologic information, OLB histology, treatment changes, and procedural complications as a result of the OLB. RESULTS: A new, clinically unsuspected diagnosis was made in 14 biopsies (29% of all OLB), and all of these resulted in therapy changes. Thirty-two biopsies (67% of all OLB) confirmed our clinical suspicions, and new therapy was initiated in 30 of these patients. Two patients (4% of all OLB) had non-diagnostic OLB. Four biopsies (8% of all OLB), including the 2 non-diagnostic OLBs, did not result in any therapy changes or initiation of new therapy. Complications occurred in 3 patients, all of whom had an air leak for >7 days. CONCLUSION: Open lung biopsy in lung transplant patients renders a new, unsuspected diagnosis in nearly one third of patients and leads to specific, directed therapy in the vast majority of patients. Open-lung biopsy can be performed safely and should be considered when diagnosis is uncertain in clinically deteriorating patients.

Cost-based (Part A) pathology physician services. Origin, current spectrum, and future.

The authors review pathology cost-based services, how they developed, their current status, and future applications in a managed care environment. Special emphasis is given to the utility of outcomes analysis for pathology cost-based services.

A review of carisoprodol deaths in Jefferson County, Alabama.

BACKGROUND: Carisoprodol is a skeletal muscle relaxant with the potential for abuse. A carisoprodol overdose is rarely considered fatal. Nevertheless, we encountered carisoprodol in several cases, prompting review of our experience. METHODS: We did a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office from January 1, 1986, to October 31, 1997, reviewing investigative reports and autopsy findings. RESULTS: Carisoprodol was present in 24 cases. Seventeen decedents died of acute drug intoxication. Carisoprodol was never the sole drug detected at autopsy, nor was it ever the sole cause of death. Propoxyphene was a co-intoxicant in 8 of the 24 cases. CONCLUSIONS: Carisoprodol causes respiratory depression. Since the mechanism of death was respiratory depression in 82% of the decedents who died of acute intoxication, we consider that carisoprodol was probably responsible, in part, for those deaths. The simultaneous use of propoxyphene and carisoprodol seems to be especially dangerous.

Further studies on anti- and proconvulsant effects of inhibitors of nitric oxide synthase in rodents.

We confirmed that the effects of inhibitors of nitric oxide (NO) synthase, such as Nomega-nitro-L-arginine methyl ester and Nomega-nitro-L-arginine, differ depending on several experimental factors. Both compounds but not their less active enantiomers delayed picrotoxin-induced clonus in mice yet increased the incidence of clonus following low-dose picrotoxin. Nomega-nitro-L-arginine methyl ester significantly reduced the latencies of both myoclonus and clonus in older but not younger Sprague-Dawley rats receiving pentylenetetrazol s.c. By contrast, there was no significant change in the latencies for myoclonus and clonus in Wistar rats (older and younger). However, when pentylenetetrazol was administered i.p. rather than s.c., Nomega-nitro-L-arginine methyl ester dramatically increased latencies of convulsive indicators, including tonus, in both Sprague-Dawley and Wistar rats. Nomega-nitro-L-arginine methyl ester also delayed tonus but not myoclonus or clonus in mice, regardless of the systemic route of administration of pentylenetetrazol. Both Nomega-nitro-L-arginine methyl ester and NG-nitro-L-arginine increased the tonic CD50 of pentylenetetrazol in mice and Nomega-nitro-L-arginine methyl ester delayed 4-aminopyridine-induced tonus. However, Nomega-nitro-L-arginine methyl ester reduced the tonic CD50 of both picrotoxin and 4-aminopyridine in mice and failed to suppress tonus following maximal electroshock. Evidently, inhibitors of NO synthase are not universally effective antitonic drugs.

A 15-year review of railway-related deaths in Jefferson County, Alabama.

A retrospective computer search of the records of the Jefferson County Coroner/Medical Examiner Office covering the 15-year period from 1981 to 1995 revealed 86 cases in which either a train caused death or in which a body was found dead by the tracks. The average age of the decedents was 39 years (range, 3 weeks-87 years). Men accounted for 88% of the deaths. The manners of death were as follows: three natural, 64 accident, seven suicide, six homicide, and six undetermined. Six decedents were found dead by the tracks, but death was not caused by a train. Six decedents were railroad employees who died on the job. In 47 cases, the decedents were trespassing on railroad property. Five trespassers were riding the rails, and 42 were pedestrians struck by a train. Motor vehicle collisions with trains claimed 27 lives--19 drivers and eight passengers. All together, 45% of the decedents were intoxicated. Intoxication was greatest by far in individuals witnessed to have been lying on the tracks before being hit by a train. The nature of individuals riding the rails has changed in the past few decades. Freight trains today are being used by illegal immigrants as transportation within the United States. The majority of traffic fatalities occurred because the driver intentionally tried to beat the train to the crossing. These drivers were seldom intoxicated, and only two were teenagers. Lives of such impatient drivers might be spared by the installation of a crossing guard-rail that cannot be circumvented.

Rabbit DQ52 and DH gene expression in early B-cell development.

Rabbits predominantly rearrange the most 3'VH gene (VH1); thus combinatorial diversity is very limited. In man and mouse, the most 3'DH gene, DQ52, is preferentially rearranged early in B-cell development. To test whether this preference for rearranging a DH gene segment based on 3' end proximity exists in rabbit, we cloned and sequenced the rabbit DQ52 gene. The 11 base pair coding region sequence is identical to a published mouse DQ52, and 81.8% similar to the human sequence. It is localized approximately 805 bp upstream of the JH1 gene. However, the 3' recombination signal sequence has an atypical nonamer. We prepared mRNA from 15- to 28-day fetal rabbits and amplified expressed VDJ sequences of mu mRNA by RT-PCR. The PCR products with VDJ rearrangements were cloned and sequenced. As expected, 44 of 45 VDJ sequences reflected use of the 3' VH1a2 gene, but the DQ52 gene was utilized very infrequently, if at all. We found only one VDJ sequence from 28-day fetal liver B-cells with 8 bp that matched the germline DQ52 sequence. Instead of expressing DQ52, another DH gene, Df was frequently expressed. We cloned the genomic Df gene and localized it about 32 kb upstream of the JH region. Thus, in contrast to man and mouse, rabbits preferentially express a DH gene located in the middle of the DH region early in B cell ontogeny. This may correlate with more frequent initial rearrangement of VH to DH in rabbit B cells.

Characterization of a rabbit germ-line VH gene that is a candidate donor for VH gene conversion in mutant Alicia rabbits.

Normal rabbits preferentially rearrange the 3'-most VH gene, VH1, to encode Igs with VHa allotypes, which constitute the majority of rabbit serum Igs. A gene conversion-like mechanism is employed to diversify the primary Ab repertoire. In mutant Alicia rabbits that derived from a rabbit with VHa2 allotype, the VH1 gene was deleted. Our previous studies showed that the first functional gene (VH4) or VH4-like genes were rearranged in 2- to 8-wk-old homozygous Alicia. The VH1a2-like sequences that were found in splenic mRNA from 6-wk and older Alicia rabbits still had some residues that were typical of VH4. The appearances of sequences resembling that of VH1a2 may have been caused by gene conversions that altered the sequences of the rearranged VH or there may have been rearrangement of upstream VH1a2-like genes later in development. To investigate this further, we constructed a cosmid library and isolated a VH1a2-like gene, VH12-1-6, with a sequence almost identical to VH1a2. This gene had a deleted base in the heptamer of its recombination signal sequence. However, even if this defect diminished or eliminated its ability to rearrange, the a2-like gene could have acted as a donor for gene-conversion-like alteration of rearranged VH genes. Sequence comparisons suggested that this gene or a gene like it could have acted as a donor for gene conversion in mutant Alicia and in normal rabbits.