The classification of patients with chronic pain: age and sex differences.

OBJECTIVE: To further develop an empirically based classification system for chronic pain patients through the examination of age and sex differences, and incorporation of pain duration in the grouping algorithm. SUBJECTS: Three hundred seventy-four chronic pain patients (300 aged 13 to 59 years; 74 aged 60 to 89 years) assessed at an outpatient, multidisciplinary pain management centre. METHODS: Patients completed measures of demographic and descriptive information, pain intensity (box rating scale), perceived disability (modified Pain Disability Index) and affective distress (Symptom Checklist-90 Revised) before multidisciplinary treatment. Standardized scores from the assessment measures were entered into a series of hierarchical, multivariate cluster analyses to identify underlying patient subgroups. RESULTS: Age-based patient groupings from prior research were partially replicated. Significant differences in clinical presentations were observed across age and sex groups. Pain duration was found to make an important contribution to the patient groupings. 'Good control' (low pain, disability, distress) and variants of 'chronic pain syndrome' (elevated pain, disability, distress) groupings were identified across all analyses. Two variants of a 'stoic' profile were identified among older patients, with low levels of distress relative to pain and perceived disability. One of these profiles was associated with long pain duration and was found only among males. Several unique clinical profiles were identified for female patients. CONCLUSIONS: There are important age and sex differences in the clinical presentations of chronic pain patients. Some older patients present with unique clinical profiles that may reflect cohort differences, and/or physiological or psychological adjustment processes. There appears to be a greater number of distinct chronic pain presentations among females. Research on the classification of chronic pain patients within homogeneous diagnostic subgroups is needed.

Coping strategies and psychological distress in cancer patients before autologous bone marrow transplant.

The increased use of bone marrow transplantation (BMT) to treat a variety of cancers has led researchers to study psychological functioning of BMT patients. The majority of studies conducted, however, has focused on adjustment after transplantation. Cancer patients' use of coping strategies before undergoing this procedure may also relate to levels of psychological distress. Our aims were (1) to provide normative coping data, controlling for situation-specific variables with a homogeneous sample, targeted stressor, and fixed time point, using the Ways of Coping Questionnaire; and (2) to identify coping strategies associated with distress before high-dose chemotherapy. Subjects were 49 patients scheduled to receive high-dose chemotherapy and an autologous bone marrow transplant. Consistent with previous coping research, we found that escape-avoidance was related to psychological distress on several measures. Item endorsement analyses of the escape-avoidance subscale suggest that patients may have used more passive than active avoidance strategies. Subsequent participation in a longitudinal study was not affected by initial levels of avoidant coping.

The use of ambulatory EMG monitoring to measure compliance with lumbar strengthening exercise.

This study validates the use of ambulatory EMG monitoring as a measure of exercise compliance. The model rehabilitative exercise used was the Prone Back Extension. Thirty-two undergraduate volunteers were videorecorded as they performed the exercise alone in a closed room. The correlation between a direct observation count of the number of repetitions and an independent EMG-based count was .95. EMG amplitude was examined by repetition and gender with regression and ANOVA. There were significant gender differences in the amplitude of EMG across repetitions. There were no significant differences by gender in the declining slope of amplitude across repetitions. This slope may represent a typical "fatigue" curve. Thus, not only the occurrence but also the intensity of exercise can be quantified.

Staircase assessment of the magnitude and time-course of 50% nitrous-oxide analgesia.

The analgesic effect of 50% nitrous oxide and oxygen on thermal pain sensations was evaluated in a placebo-controlled, double-blind crossover design. In a session immediately before oral surgery, 20 patients used a seven-point verbal scale to rate the intensity of pain sensations evoked by three-second thermal stimuli delivered to 14 sites on the volar forearm at 20-second intervals by a 1-cm-diameter contact thermode. Subjects rated 36 stimuli while breathing room air and then two additional sets of 36 stimuli while inhaling 50% nitrous oxide and oxygen during one set and oxygen placebo during the other. Each of these two stimulus sets was preceded by a two-minute induction of the agent, and the sets were separated by a three-minute washout period. Order of administration was randomized and counterbalanced. Stimulus temperatures were adjusted continuously by an interactive computer program so that response could be maintained at predetermined levels. This method resulted in a continuous measure of analgesia in units of stimulus intensity. Results showed that, in comparison with placebo, nitrous oxide significantly increased the stimulus temperatures (mean = 0.42 degrees C) required to make the same response [F (11,209) = 6.76, p less than 0.0001], indicating analgesia. This increase was one-third to one-half that observed with clinical doses of intravenous fentanyl. Analgesic effects were apparent at three min and wanted 10 min after termination of nitrous-oxide inhalation. These times closely correlated with previous measures of alveolar concentration, further supporting the fast but modest analgesic action of nitrous oxide.

Facultative myiasis by Megaselia sp. (Diptera: Phoridae) in Texas: a case report.

Facultative myiasis caused by larval Megaselia sp. is reported in a human in Texas. On two occasions during 24 h, the youth experienced a "crawling sensation deep in [his] throat" which caused him to cough, expelling a living Megaselia sp. larva. The site of the infestation was presumed to be the sinuses or upper respiratory tract. The symptoms resolved upon expulsion of the larvae, and no additional complications were observed in the patient.

Pediatricians' use of chaperones when performing gynecologic examinations on adolescent females.

This study assesses the influence of the interest and skill in adolescent health care on a pediatrician's use of a chaperone during the pelvic examination. A national sample of 558 pediatricians selected at random and 384 members of the American Academy of Pediatrics' Section on Adolescent Health (SAH) completed questionnaires assessing their perceived skills in and practice of adolescent medicine. Some 90.4% of the non-SAH males and 31.0% non-SAH females always used a chaperone compared to 69.4% of SAH males and 12.5% of SAH females (p less than or equal to 0.05). The actual frequency of chaperone use was less among SAH members than non-SAH pediatricians (p less than or equal to 0.013) and less among females in both groups (p less than or equal to 0.0001). Among male physicians, the variables found to have the strongest association with a less frequent use of chaperones included the frequency that oral contraceptives were prescribed, perceived skill in providing contraceptive counseling, percent of adolescents in the pediatrician's practice, and the frequency with which confidential services were provided. These correlations were stronger among SAH members than non-SAH pediatricians. Among female SAH members, not using a chaperone was associated with a higher perceived skill in managing sexually transmitted diseases, the frequency with which they performed pelvic examinations, and the percent of adolescents in their practice. Among non-SAH female physicians, the perceived skill to perform a pelvic examination and provide contraceptive counseling were associated with increased chaperone use. These data suggest that many factors other than gender and medicolegal influences are associated with the physician's decision concerning the use of a chaperone.

Recommended changes in pediatric education: the impact on pediatrician involvement in health care delivery to adolescents.

In an attempt to examine the extent of implementation of the recommendations issued by the Task Force on Pediatric Education for increased emphasis on adolescent medicine during residency training, pediatricians' perceptions of their skills and abilities to provide health care to adolescents were evaluated. A sample of 558 pediatricians selected at random and 385 members of the American Academy of Pediatrics' Section on Adolescent Health (SAH) completed a 41-item questionnaire. The physicians' perceived levels of skill in ten areas were analyzed while simultaneously assessing the impact of SAH membership, year of graduation from medical school, gender, and percentage of practice time devoted to adolescents on each issue. SAH members, as expected, ranked their levels of skill significantly higher than did the other pediatricians in all areas surveyed. A significant percentage of the SAH pediatricians, however, indicated that their skills were acquired through postresidency fellowship training. There was an increasing trend among all pediatricians in their perceived levels of skill to deliver health care to adolescents during the past several decades, but there has been no appreciable increase in such perceived skill levels since the task force issued its recommendations. In fact, pediatricians graduating from medical school in the decade prior to 1976 who are not SAH members ranked their skills higher than did non-SAH pediatricians who graduated in the past 10 years. These data lead to the conclusion that the recommendations of the Task Force on Pediatric Education have not been adequately implemented.

Vitamin B6-dependent Streptococcus mimicking fungi in a patient with endocarditis.

A patient was referred to our hospital with a tentative diagnosis of fungal endocarditis based upon clinical symptoms, suggestive travel history, and microscopic visualization in blood cultures of gram-negative bulbous filaments that appeared to be fungal elements. Subcultures of the blood culture bottles were unsuccessful on all media with the exception of blood agar plates, which had been cross-streaked with Staphylococcus aureus. These plates grew vitamin B6-dependent streptococci. This nutritionally variant organism was determined by biochemical tests to be Streptococcus mitis (mitior). It had a penicillin MIC and MBC of 0.015 micrograms/mL and 0.03 micrograms/mL, respectively and streptomycin MIC and MBC of 0.78 micrograms/mL and 1.56 micrograms/mL, respectively. The patient was treated with these two agents and recovered. We stress the importance of suspecting vitamin B6-dependent streptococci, even when gram stains may suggest presence of other microorganisms.

Ovarian function, reproduction, and later operations following adnexal surgery.

Among 3102 patients who had major gynecologic operations, only 223 (7.18%) needed adnexal operations during which reproductive potential was preserved. Operations involved ovaries (156), tubes (55), and embryologic cysts (32). After recovery 53.69% of these patients had viable babies (64.46% of patients under age 30). Patients were examined up to 28 years after operations, an average 11.32 years. When last examined. most patients still retained physiologic evidence of ovarian hormonal function; 20 patients had passed through spontaneous menopause, at an average age of 49.4 years. Fifty-two patients needed subsequent pelvic operations, but only 7 for possibly related conditions (4 repeat tubal pregnancies and 3 cyst-adenomas). All but one twisted adnexal mass, with gangrene, originated as a paramesonephric duct cyst. Seventeen adnexal operations were associated with pregnancy: 15 mothers had healthy babies, and 2 aborted. Details concerning numbers and characteristics of specific lesions are included in the paper.