Barriers and facilitators to self-management of asthma in adolescents: An interview study to inform development of a novel intervention.

BACKGROUND AND OBJECTIVE: Despite literature that spans twenty years describing the barriers to asthma self-management in adolescents, successful, clinically based interventions to address this important issue are lacking. Given the limitations of some of the previous studies, we conducted a study that aimed to gain a broader insight into barriers and facilitators to self-management of asthma by adolescents, not just adherence to treatment, and triangulated their views with those of their parents and healthcare professionals. METHODS: Focus groups and interviews were conducted separately for 28 adolescents with asthma aged 12-18 years, 14 healthcare professionals and 12 parents. Focus groups and interviews were audio-recorded, and transcripts from each participant group were analysed separately using inductive thematic analysis. We triangulated the three perspectives by comparing themes that had emerged from each analysis. RESULTS: Adolescents', parents' and healthcare professionals' views were summarized into ten related themes that included forgetting and routines, knowledge, embarrassment and confidence, communication with healthcare professionals, triggers, support at school, apathy and taking responsibility. We found that adolescents, parents and healthcare professionals raised similar barriers and facilitators to self-management and our results provide further validation for previous studies. CONCLUSION AND CLINICAL RELEVANCE: Our study highlights that healthcare professionals may need to consider a range of psychological and contextual issues influencing adolescents' ability to effectively self-manage their asthma, in particular, how they implement treatment routines and the understanding that adolescents have of their condition and treatments. Crucially, healthcare professionals need to consider how this information is communicated and ensure they facilitate open, inclusive, two-way consultations. From this more comprehensive understanding, we have developed interventional strategies that healthcare professionals can utilize to empower adolescents to improve their asthma self-management.

Lessons learned on recruitment and retention in hard-to-reach families in a phase III randomised controlled trial of preparatory information for children undergoing general anaesthesia.

BACKGROUND: Recruitment and retention are documented as two of the most difficult elements of conducting clinical trials. These issues are even more challenging in paediatric trials, particularly when the families being recruited and retained are deemed 'hard to reach'. METHODS: Through the authors' own reflection on the conduct of the trial this paper examines recruitment and retention with hard to reach families from the perspective of a recently completed clinical trial on preparatory information for children undergoing general anaesthesia for tooth extractions in which approximately 83% of those approached and eligible agreed to participate. RESULTS: The lessons learned for recruitment include: the importance of children's assent; maximising limited resources when screening and approaching potential participants; valuing families' time; and developing effective professional relationships. The retention rate was 83-85.5% at follow up time points up to 3.5 weeks following recruitment, insights into how this was accomplished include: ensuring continuity of care; determination to connect via telephone; valuing families' time; and close monitoring of appointment date changes. CONCLUSIONS: Implications for future paediatric trials with hard to reach families are discussed. TRIAL REGISTRATION: ISRCTN18265148 ; NIHR Portfolio 10,006. Date of Registration: 29 November 2013. The trial was registered after commencement but before completion of data collection.

Attentional bias for pain- and period-related symptom words in healthy women who experienced a recent painful period.

BACKGROUND: Attentional biases for pain-related information have been commonly reported in patients with chronic pain. Biases may also exist in individuals who recently experienced an episode of acute clinical pain, although limited investigation has been conducted. The present study is the first to explore attentional biases in women who experienced recent menstrual pain. METHODS: Seventy healthy women were recruited who experienced a regular menstrual cycle and a recent painful period. All participants completed a visual-probe task with pain-related and period-related symptom words, which were presented at subliminal (14 ms, followed by nonsensical consonant letter string for 286 ms) and supraliminal (300 ms, 1250 ms) exposure durations. Participants then completed a series of self-report measures, including a measure of cyclical perimenstrual symptoms. RESULTS: Recent menstrual pain severity was found to be significantly predictive of attentional bias towards pain-related words presented for 1250 ms. However, no significant evidence of bias was found towards period-related symptom words. CONCLUSIONS: Pain-related attentional biases are associated with recent menstrual pain severity. The experience and severity of pain, rather than its duration (i.e., whether pain is chronic or acute), may be the primary determinants of pain-related attentional bias. Future research could explore attentional biases in acute clinical pain samples to confirm this notion.

Eye movements during visual search for emotional faces in individuals with chronic headache.

BACKGROUND: Attentional biases for pain-related information have been frequently reported in individuals with chronic pain. Recording of participants' eye movements provides a continuous measure of attention, although to date this methodology has received little use in research exploring attentional biases in chronic pain. The aim of the current investigation was to explore the specificity of attentional orienting bias using a novel visual search task while recording participant eye movement behaviours. This also allowed for the investigation of whether attentional biases for pain-related information exist in the presence of multiple stimuli competing for attention. METHODS: Twenty-three participants with chronic headache and 24 pain-free, healthy control participants were engaged in a visual search task where pain, angry, happy and neutral faces were used as both target and distractor stimuli. While completing this task, participants' eye movements were recorded. RESULTS: Supporting the adopted hypothesis, participants with chronic headache, relative to healthy controls, demonstrated a significantly higher proportion of initial fixations to target pain expressions when the pain expressions were presented in displays containing neutral-distractor faces. No significant differences were found between groups in the time taken to fixate target pain expressions (localization time). CONCLUSIONS: Individuals with chronic headache show facilitated initial orienting towards pain expressions specifically when used as targets in a visual search task. This study adds to a growing body of research supporting the presence of pain-related attentional biases in chronic pain as assessed via different experimental paradigms, and shows biases to exist when multiple stimuli competing for attention are presented simultaneously.

How parents make sense of their young children's expressions of everyday pain: a qualitative analysis.

BACKGROUND: Little is known about the communication of everyday pain between young children and their parents, i.e. when children experience pain resulting from minor injury or illness that occur in everyday life. This study aimed to gain an in-depth understanding of how parents make sense of their young children's expression of everyday pains and how they respond. METHODS: Parents (n = 48) of children (1-5 years inclusive) participated in focus group discussions at seven children's centres across England where they were asked to describe their children's communication of everyday pain. Thematic analysis was used to analyse the data. RESULTS: Six main themes were identified in the parents' discourse. Parents described children's pain communication as (1) sharing common elements, but unique to each child; (2) having multifaceted pain and non-pain-related purposes; (3) challenging to interpret; (4) influenced by their own pain-related communication; (5) requiring a variety of pharmacological, psychological and physical strategies to manage. The sixth theme that emerged from the data related to parents' dissatisfaction with health care providers, particularly general practitioners' sometimes quick dismissal of parental concerns about their children's pain and illness complaints. CONCLUSIONS: These findings suggest that parents have well developed, although personal, ways of recognizing and responding to their children's communication of pain, but also experience uncertainty in their judgments. Parents would benefit from information about the developmental aspects of pain and should be included as active partners in their children's pain assessment and management.

Translating the tears: parents' use of behavioural cues to detect pain in normally developing young children with everyday minor illnesses or injuries.

OBJECTIVES: The objectives of this paper were to (i) identify the behavioural cues used by parents to detect young children's transient pain from minor illnesses or injuries ('everyday pain'); and (ii) perform an initial psychometric evaluation of the Parents' Post-operative Pain Measure (PPPM) in the context of children's everyday pain. METHOD: Cross-sectional Internet survey. RESULTS: One thousand seven hundred sixteen parents of children (1-6 years) completed the survey. The parents reported more behaviours when children had pain from minor illnesses than from minor injuries (9.6 ± 3.9 vs. 2.5 ± 2.3, P < 0.001). Principal component analysis of the PPPM revealed a two-factor solution for illness-related pain and a three-factor solution for injury-related pain. Behavioural cues varied with characteristics of children (age, gender and prior hospital experience) and parents (gender, age and parenting experience). CONCLUSIONS: The PPPM is a promising tool for parental assessment of children's pain in everyday situations. Further research is needed to determine its utility in facilitating communication between parents and healthcare professionals, and in improving the management of young children's pain.

From tears to words: the development of language to express pain in young children with everyday minor illnesses and injuries.

BACKGROUND: Little is known about the development of language to express pain in the young or how children and parents verbally communicate when young children have everyday minor illnesses and injuries. METHODS: UK parents of children between the ages of 1 and 6 were invited to complete an Internet survey on children's pain language during everyday situations of minor illness or injury. RESULTS: Of the 1716 parents completing the survey, 45% reported their child had at least one word to express pain by 17 months of age, increasing to 81% by 23 months of age. Children used different words based on their age and in the contexts of minor illnesses and injuries, with words for expressing pain related to illness emerging slightly later. Children's language was purposeful in describing causes of pain and requesting specific forms of assistance from parents even in the very youngest age groups. Parents' communicated with their children primarily to gain further information about the source and nature of pain and to direct children's behaviour. CONCLUSIONS: Children rapidly develop an extensive vocabulary to describe pain between 12 and 30 months of age, with words for pain from injury emerging first and reflecting the development of normal speech acquisition. The differences in verbal expressions in the context of minor illnesses and injuries suggest that children make a cognitive distinction between the origins and sensory aspects of pain. These findings can help parents, childcare and healthcare professionals to appreciate the early communication capabilities of young children and to engage in more effective pain assessment and management for young children.

The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings.

BACKGROUND: Existing evidence suggests that neurobehavioural disability is a frequent legacy of serious head trauma and has a major impact on the psychological well-being of relatives and friends of people with brain injuries. OBJECTIVE: To explore which neurobehavioural legacies of serious head trauma have the greatest impact on personal relationships and increase the risk of relationship breakdown. METHOD: Forty-eight partners of people who had suffered serious head trauma were asked to complete a 12-item measure to rate how different neurobehavioural characteristics had adversely affected their relationship with the brain injured person. Twenty-three couples who had divorced or separated from their injured partner in the years following injury comprised the 'separated' group, 25 still in the relationship at the time data were collected comprised the 'together' group. RESULTS: Even though many neurobehavioural characteristics of brain injury were reported by partners of both the separated and the together group as placing a strain on the relationship only mood swings accounted for a significant between groups difference [t(40.13) = 3.33, p = 0.002]. The magnitude of the difference in the means was large (712 = 0.19). CONCLUSIONS: Unpredictable patterns of behaviour, as perceived by partners of brain injured individuals, impose the greatest burden on personal relationships and may contribute to relationship breakdown.

Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations.

A randomized controlled trial was conducted to compare the efficacy of clinical hypnosis versus cognitive behavioral (CB) coping skills training in alleviating the pain and distress of 30 pediatric cancer patients (age 5 to 15 years) undergoing bone marrow aspirations. Patients were randomized to one of three groups: hypnosis, a package of CB coping skills, and no intervention. Patients who received either hypnosis or CB reported less pain and pain-related anxiety than did control patients and less pain and anxiety than at their own baseline. Hypnosis and CB were similarly effective in the relief of pain. Results also indicated that children reported more anxiety and exhibited more behavioral distress in the CB group than in the hypnosis group. It is concluded that hypnosis and CB coping skills are effective in preparing pediatric oncology patients for bone marrow aspiration.

Comparison of the efficacy and safety of tropisetron, metoclopramide, and chlorpromazine in the treatment of emesis associated with far advanced cancer.

BACKGROUND: A single institution, prospective, randomized trial was performed in terminal cancer patients to compare tropisetron (TRO), metoclopramide (MET), and chlorpromazine (CHL) in the management of nausea and emesis. Patients had far advanced cancer, were far removed from chemotherapy or radiotherapy, and their nausea and emesis was not due to bowel obstruction, drug intake, or cranial, electrolytic, or metabolic causes. The effects of antiemetic treatments were evaluated from Days 1-15. METHODS: Two hundred and eighty patients were randomized to receive 1) MET+ dexamethasone (DEX) (10 mg*4 and 2 mg*1, respectively, orally), 2) TRO (5 mg*1, orally), 3) TRO + MET (5 mg*1 and 10 mg*2, respectively, orally), 4) TRO + MET + DEX (5 mg*1, 10 mg*2, and 2 mg*1, respectively, orally), 5) CHL + DEX (25 mg*2 and 2 mg*1, respectively, orally), 6) TRO + CHL (5 mg*1 and 12.5 mg*2, respectively, orally), or 7) TRO + CHL + DEX (5 mg*1, 12.5 mg*2, and 2 mg*1, respectively, orally). Total control was defined as no nausea or emesis. RESULTS: By the end of the 15th day, total control of emesis was obtained in 23.6% (9 of 38) of MET + DEX patients, 78.9% (30 of 38) of TRO patients, 84.2% (32 of 38) of TRO + MET patients, 92.3% (36 of 39) of TRO + MET + DEX patients, 33.3 (13 of 39) of CHL + DEX patients, 84.6% (33 of 39) of TRO + CHL patients, and 92.5% (37 of 40) of TRO + CHL + DEX patients. Total control of nausea was achieved in 18.4% (7 of 38) of MET + DEX patients, 65.7% (25 of 38) of TRO patients, 73.6% (28 of 38) of TRO + MET patients, 87.1% (34 of 39) of TRO + MET + DEX patients, 17.9% (7 of 39) of CHL + DEX patients, 74.3% (29 of 39) of TRO + CHL patients, and 85% (34 of 40) of TRO + CHL + DEX patients. When comparing MET + DEX versus TRO; MET + DEX versus TRO + MET; MET + DEX versus TRO + MET + DEX; MET + DEX versus TRO + CHL; MET + DEX versus TRO + CHL + DEX; CHL + DEX versus TRO; CHL + DEX versus TRO + MET; CHL + DEX versus TRO + MET + DEX; CHL + DEX versus TRO + CHL; and CHL + DEX versus TRO + CHL + DEX, significant differences were noted. All antiemetic drugs were well tolerated with no severe side effects observed in any treatment arm. CONCLUSIONS: These data suggest that 5-HT3 receptor antagonists such as tropisetron clinically are more effective in the control of emesis of patients with far advanced cancer than previously used agents. This study raises important issues when attempting to decide which antiemetic therapy to choose for an individual patient with far advanced disease.

What do Greek physicians know about managing cancer pain?

BACKGROUND: Pain is prevalent in cancer patients. Although the World Health Organization has issued guidelines for treating pain in cancer patients, pain is often not treated optimally. Numerous barriers have been identified that prevent health care professionals from providing effective treatment for pain. The knowledge and attitudes of health care professionals with regard to pain and its impact on the patient are among them. The purpose of the present study was to evaluate knowledge about and attitudes toward cancer pain and its management among Greek oncologists, surgeons, anesthesiologists, and general practitioners. METHOD: Knowledge of the principles and methods of cancer pain treatment was assessed by a questionnaire distributed to a representative sample of 1,200 Greek physicians. RESULTS: The study results highlight very substantial knowledge deficits in the treatment of cancer pain by the evaluated physicians. CONCLUSIONS: Cancer pain management in Greece is still developing, and the latest knowledge is spreading slowly but steadily.

Comparison of tropisetron and chlorpromazine combinations in the control of nausea and vomiting of patients with advanced cancer.

The single-institution, prospective, randomized trial was performed to evaluate the efficacy of tropisetron and chlorpromazine in the management of nausea and vomiting of terminal cancer patients. Patients had no recent chemotherapy or radiotherapy, and emesis was not due to bowel obstruction, electrolytic or metabolic disturbances, drug intake, or intracranial disease. One hundred and sixty patients randomly received either (a) chlorpromazine (CLO) (50 mg/day) plus dexamethasone (DEX) (2 mg/day), (b) chlorpromazine (25 mg/day) plus tropisetron (TRO) (5 mg/day), (c) chlorpromazine (25 mg/day plus tropisetron (5 mg/day) plus dexamethasone (2 mg/day), or (d) tropisetron (TRO) (5 mg/day). Patients were monitored from day 1 to day 15. No nausea or vomiting was defined as "total" control. On day 15, total vomiting control was achieved in 33.3% of the patients receiving CLO + DEX, 84.6% of the patients receiving CLO + TRO, 92.5% of the patients receiving CLO + TRO + DEX, and 78.9% of the patients receiving TRO. Total control of nausea was achieved in 18.0% of the patients receiving CLO + DEX, 74.4% of the patients receiving (CLO + TRO), 85.0% of the patients receiving CLO + TRO + DEX, and 65.8% of the patients receiving TRO. Tropisetron-containing combinations produced significant control of nausea and vomiting from the third day onward. All antiemetic drugs were well tolerated. These data suggest that tropisetron-containing combinations or tropisetron as a single agent are much more effective in the control of emesis in patients with advanced cancer than the conventional antiemetic combination of chlorpromazine plus dexamethasone. Tropisetron is well tolerated and may be the best choice for controlling persistent nausea and vomiting in terminal cancer patients.

Tropisetron versus Metoclopramide in the Control of Emesis in Far-Advanced Cancer.

The present study was conducted to assess the optimum treatment for nausea and vomiting in patients with far advanced cancer. More specifically, we studied patients with cancers that were too far advanced to benefit from chemotherapy or radiotherapy and whose nausea and vomiting were not due to drug intake, cranial, electrolytic, or metabolic causes. One hundred twenty patients who were under antiemetic medication with metoclopramide (MET) and suddenly presented with uncontrolled nausea and vomiting were randomized to three different therapeutic regimens: MET plus dexamethasone (DEX), MET plus tropisetron (TRO), and MET plus TRO plus DEX. Patient diary cards were used to assess nausea and vomiting. By the end of day 15, total control of vomiting was achieved in 24% of MET plus DEX patients, in 84% of MET plus TRO patients, and in 92% of MET plus TRO plus DEX patients. Total control of nausea was achieved in 18% of MET plus DEX patients, in 74% of MET plus TRO patients, and in 87% of MET plus TRO plus DEX patients. All antiemetic treatments were similarly well tolerated. TRO in combination with either MET or MET and DEX produced the best control of both nausea and vomiting.

The use of the genogram in palliative care.

A genogram is a format for drawing a family tree that records information about family members and their relationships over at least three generations. The genogram has been widely promoted as a useful tool for gathering, recording and displaying family information in order to practice family-oriented health care. We present a format for constructing the genogram and to outline the principles underlying its interpretation and application in clinical practice, so as to facilitate its use by physicians, nurses, psychologists, family therapists, and other professionals working with families in palliative care. Finally, the future potential of the genogram as a research and clinical tool in palliative care is discussed.

Disclosure of diagnostic information to cancer patients in Greece.

Truth-telling to cancer patients is controversial. The aim of the present study was to investigate oncologists', radiotherapists', and palliative care specialists' attitudes and truth-telling practices in Greece. A postal survey of a representative sample of 300 oncologists, radiotherapists, and palliative care specialists was made in February 1993. A total of 228 doctors completed and returned the questionnaires. It appears that withholding the truth from cancer patients remains very common in Greece.