Evidence-based pain medicine for primary care physicians.

The last several decades have seen a marked increase in both the recognition and treatment of chronic pain. Unfortunately, patients frequently misunderstand both the nature of pain and the best practices for its treatment. Because primary care physicians treat the majority of chronic pain, they are ideally situated to provide evidence-based pain care. The majority of the medical evidence supports a biopsychosocial model of pain that integrates physical, emotional, social, and cultural variables. The goal of this primer is to assist primary care physicians in their understanding of pain, evaluation of the chronic pain patient, and ability to direct evidence-based care. This article will discuss the role of physical rehabilitation, pain psychology, pharmacotherapy, and procedural interventions in the treatment of chronic pain. Given the current epidemic of drug-related deaths, particular emphasis is placed on the alternatives to opioid therapy. Unfortunately, death is not the only significant complication from opioid therapy, and this article discusses many of the most common side effects. This article provides general guidelines on the most appropriate utilization of opioids with emphasis on the recent Centers for Disease Control and Prevention guidelines, risk stratification, and patient monitoring. Finally, the article concludes with the critical role that a pain medicine specialist can play in the management of patients with chronic pain.

The story of the Texas Pain Society: formation and function of a regional pain society.

The idea of forming a Texas Pain Society came to the Founders in 1987 due to disparity and deficiencies in the practice of pain management in the United States and, in particular, the State of Texas. The Founders considered very carefully the implication of forming such a society. They diligently mapped out the mission and goals of the Texas Pain Society in those early formative years. This report is the history of Texas Pain Society as the activities unfolded from 1989 to 2011. The reader may question why there is a need to tell such a story. We believe strongly that, with disparities of standards of practice in pain medicine and poor recognition of advances in pain management, this scenario is quite common in many states and countries. The practitioners of pain management in these regions certainly must have considered getting together and forming a consensus on the standards of practice in their communities. This historical report of the Texas Pain Society provides the relevant information necessary and the efforts to be made for a society's mission to achieve its goals and have an ongoing impact in its own region. We hope that we have shed some light on a process for the formation of a regional pain society such as ours.

[The importance of a developmental approach in psychiatric assessment and treatment of adults with intellectual disability]. / Die Bedeutung des emotionalen Entwicklungsniveaus bei der psychiatrischen Behandlung von Menschen mit geistiger Behinderung.

INTRODUCTION: Mental disorders are 3-4 times more frequent in individuals with intellectual disabilities than in those without. From a developmental perspective the reason for this high prevalence could be, besides biological aberrations, a personality development with a difference between cognitive and emotional developmental levels. This discrepancy renders the person being highly vulnerable for the onset of problem behaviour and psychiatric disorders. For a proper insight into processes which have led to the disorder, it is necessary to evaluate the level of emotional development. This can be determined by the "schema of emotional development (SEO)" developed by A. Dosen. METHODS: By means of a case description the authors demonstrate the application of SEO in the assessment and utilization of the concept of the level of emotional development in clinical practice. RESULTS: The knowledge of the level of emotional development contributes to the explaining and understanding of the disorder, and also facilitates the establishment of an integrated diagnosis and the creation of appropriate integrated treatment strategies. Hence, temper tantrums, sleep patterns and mood improved in the case described. CONCLUSION: Besides biopsychosocial aspects, the developmental aspect, and in particular the level of emotional development should be taken into consideration in the diagnostic work-up and treatment of individuals with intellectual disabilities and mental health problems. The data generated by the SEO may help in understanding the disorder and developing a treatment approach for these individuals.

[Psychotherapy in intellectual disability. Theoretical background and implementation]. / Psychotherapie bei Menschen mit Intelligenzminderung. Theoretischer Hintergrund und praktische Umsetzung.

BACKGROUND: Every third person with intellectual disability suffers from additional mental health problems, among others phobic disorders. Yet we do not know whether psychotherapeutic methods that are effective in the normal population are applicable to people with intellectual disabilities. PATIENTS AND METHODS: We give a survey of the development and the present state of the art of psychotherapy, particularly with regard to phobic disorders in intellectual disability. Therapeutic recommendations described in the literature will be evaluated in a case study of one patient. RESULTS: The confrontation with the phobic stimulus is the basis of behavior therapy for people with intellectual disability as well. However, with respect to the special needs of these people, some modifications need to be considered in the treatment strategy. In addition to some general rules like simple language or the use of visual materials, some techniques of intervention turned out to be particularly effective, e.g., graduated in vivo exposure, involving significant others, contingency management, and coping strategies. CONCLUSION: Specific phobias in intellectual disability can be treated with behavior therapy as well. However, the special needs of these people need to be considered.

Prevention of mechanical failures in implanted spinal cord stimulation systems.

Introduction. Spinal cord stimulation (SCS) is an effective procedure for the treatment of neuropathic extremity pain, with success rates approaching 70%. However, mechanical failures, including breakage and migration, can significantly limit the long-term effectiveness of SCS. A systematic analysis of surgical techniques was undertaken by a consensus group, coupled with extensive in vivo and in vitro biomechanical testing of system components. Methods. A computer model based on morphometric data was used to predict movement in a standard SCS system between an anchored lead and pulse generator placed in various locations. These displacements were then used to determine a realistic range of forces exerted on components of the SCS system. Laboratory fixtures were constructed to subject leads and anchors to repetitive stresses until failure occurred. An in vivo sheep model also was used to determine system compliances and failure thresholds in a biologically realistic setting. A panel of experienced implanters then interpreted the results and related them to clinical observations. Results. Use of a soft silastic anchor pushed through the fascia to provide a larger bend radius for the lead was associated with a time to failure 65 times longer than an anchored but unsupported lead. In addition, failures of surgical paddle leads occurred when used with an anchor, whereas without an anchor, no failures occurred to 1 million cycles. Based on these findings, the panel recommended a paramedian approach, abdominal pulse generator placement, maximizing bend radius by pushing the anchor through the fascia, and anchoring of the extension connector near the lead anchor. Discussion. Several factors are important in longevity of SCS systems. We discovered that technical factors can make a large difference in SCS reliability and that strict attention to these "best practices" will provide the best chance for maintaining the integrity of SCS systems over the long term.

Improving medical care for West Virginia seniors.

Using data published by the Health Care Financing Administration (HCFA), supplemented with information obtained from West Virginia Medicare claims data and Medicare hospital records, we compared the performance of West Virginia physicians and hospitals on 22 quality of care indicators for six common conditions. The conditions are myocardial infarction, congestive heart failure, atrial fibrillation, stroke, breast cancer screening and pneumonia. Quality indicator performance for most indicators in West Virginia from 1997-98 was lower than the average of the 19 states with data collected at the same time. For some indicators, such as early use of beta blockers following myocardial infarction (52.7%), administration of influenza vaccine (58.2%), and warfarin prescription to atrial fibrillation patients (45.1%), the state's care ranked near the bottom. However, quality scores varied widely among West Virginia health care providers, suggesting that statewide improvement in care is feasible. Ongoing efforts among physicians, hospitals and the peer review organization are aimed at achieving such improvement.

Influenza immunization and mortality among diabetic Medicare beneficiaries in West Virginia.

This study estimated the increased risk of death among Medicare beneficiaries with diabetes in West Virginia who do not receive influenza beneficiaries with diabetes. Medicare beneficiaries with diabetes who did not have claims for influenza vaccination had approximately a 1.7-fold risk of death during a subsequent influenza season, compared with those with a vaccination. This risk was observed in all age and sex subgroups, and was changed very little by adjustment for comorbidity. The adjusted odds ratio for death in the vaccinated group (compared with the unvaccinated group) during the 1996-97 influenza season was 0.639 (95% confidence interval 0.565-0.722); in 1997-98 it was 0.601 (95% confidence interval 0.527-0.687). West Virginia Medicare beneficiaries with diabetes are at a significantly increased risk of death during an influenza season if they do not have prior claims for influenza vaccination.

A ten-year review of the validity and clinical utility of depression screening.

OBJECTIVE: Use of depression screening instruments in primary care is controversial. The authors reviewed research studies published since the development of national practice guidelines to determine whether new evidence might favor screening. The review focused on evidence-related validity and clinical utility of depression screening instruments. METHODS: Silver Platter MEDLINE was searched for English-language studies of depression screening instruments published between 1986 and 1995. Studies were classified by type--reviews of studies, outcome studies, validation studies. RESULTS AND CONCLUSIONS: Fifty-nine studies met criteria for review. Validation studies were the most frequent type (39 studies) and were subclassified according to population, type of comparison, and analytical method. These studies documented the validity of screening instruments compared with formal criteria and demonstrated consistently better performance for systematic approaches compared with clinical impressions. Thirteen studies were reviews; those reviewing evidence for effectiveness disagreed in their conclusions. Only seven outcome studies related to depression screening instruments were found, and none showed measurable benefit in a screened population. Several studies showed that very brief instruments performed about as well as longer, well-validated questionnaires for screening in general populations.

A preliminary comparison between local public health units in the Canadian Province of Ontario and in the United States.

This comparison between public health departments in the United States and in the Canadian Province of Ontario addresses the funding and staffing and the size and program content of local health departments after Canada's national health reform provided universal access to personal health services. Ontario's local health departments are required to provide a uniform set of public health services. In the United States, there is substantial variation among jurisdictions in kinds and amounts of services delivered. Ontario health units have staff sizes and budget levels that increase in proportion to population served, like those in the United States. But in Ontario, per capita expenditures increase with decreasing population, while the reverse is true in the United States. This anomaly may be attributed to lack of critical staff or elimination of key programs in small U.S. departments. Medical care of indigents probably accounts for the increased per capita costs seen in very large U.S. health departments. An estimated price for uniform public health services meeting the Ontario requirements in all U.S. jurisdictions as they were organized in 1989 is $5.8 billion per annum (not adjusted for inflation). If smaller health departments were consolidated, a savings of more than $1 billion could be realized. Even with this reorganization, average expenditures in smaller U.S. health departments would need to be doubled, and staff sizes increased by about 50 percent to meet Ontario's uniform public health program standards.

Project Wildfish: rewarding through innovation.

The appropriateness of a reward system depends, in part, on the developmental level of the staff. Based on a model developed at Shadyside Hospital, Pittsburgh, PA, called the Transformational Model for the Practice of Professional Nursing, we have determined that the potential for innovation becomes a highly valued reward for a healthy, well-developed nursing unit. Project Wildfish illustrates the energy, commitment, and enthusiasm that innovation can inspire.

Hydrogen ion concentration in the mucus layer on top of acid-stimulated and -inhibited rat gastric mucosa.

BACKGROUND/AIMS: The gastric mucosa is covered by a continuous layer of bicarbonate-containing mucus gel; the question arises how acid, formed in the gastric glands, moves into the lumen. METHODS: The pH in the gastric mucus gel and gel thickness were measured in anesthetized rats with pH-sensitive microelectrodes (tip diameter, 1-5 microns). RESULTS: During pentagastrin (40 micrograms.kg-1.h-1) stimulation of acid secretion, the pH was higher in the gel than in the lumen (pH 2) up to a distance of 115 +/- 18 microns from the epithelial surface and maximal (pH 7.2 +/- 0.1) at the surface. A similar pH gradient was recorded at luminal pH 3. After omeprazole (10 mumol/kg) inhibition of endogenous acid secretion and with exogenous acid in the lumen, the pH profile was broader: 204 +/- 26 microns at luminal pH 2 and 231 +/- 63 microns at luminal pH 3. In contrast, the pH at the epithelial surface was lower (pH 6.8-6.9). The gel thickness (200-300 microns) was similar in all groups. CONCLUSIONS: The significantly higher surface pH in acid-secreting stomachs probably reflects better availability of interstitial mucosal bicarbonate. Bulk transport of secreted acid in channels created by the gland luminal hydrostatic pressure may additionally act to limit acidification of the mucus gel.

Continuing outbreak of hepatitis A linked with intravenous drug abuse in Multnomah County.

A communitywide outbreak of hepatitis A occurred in Portland, OR, from 1983 through 1986. At the peak of the outbreak, the age- and sex-specific annual incidence rate approached 400 cases per 100,000 population among men ages 25 to 34, the highest risk group. The community incidence rate was nearly 10 times the relevant national incidence rate. A review of the records concerning cases of hepatitis A reported in the last 6 months of 1985 revealed that about half the number of young adults whose cases were investigated during that time reported a history of intravenous (IV) drug use--a proportion about 50 times greater than expected among persons in that age range. A simultaneous epidemic of overdose deaths from heroin and a concomitant increase in hepatitis B incidence rates led to the suspicion that this was a drug-abuse-associated epidemic of hepatitis among new IV drug users. Control of this outbreak was difficult because the population most at risk was distrustful of public health officials. Increased surveillance in food service establishments and schools might have prevented outbreaks from a common source in the general population; however, an increase of sporadic cases in the nondrug-using population clearly occurred.

Women's G tolerance.

G tolerances of 102 women and 139 men subjected to Standard Medical Evaluation (Medeval) G Profiles were compared. Unpaired t-tests revealed no significant difference between the women and men in either relaxed or straining G tolerance. Covariance analysis controlling for differences in tolerance due to age, height, weight, and activity status revealed the women to have marginally lower tolerance; the analysis also identified height as a factor having a strong negative influence on G tolerance, and weight as having a positive influence. When the women were matched only by height to the men in the comparison group, the women's mean G tolerances were significantly lower than the men's. On Standard Training G Profiles 88% of 24 women and 80% of 213 men completed the runs, but this difference was not significant. G tolerances of 47 women were measured on the Medeval Profiles both during and between menses, but no significant differences related to menstruation were found. No important differences between women and men in signs or symptoms of G stress were observed, except for two instances of urinary stress incontinence in women during the Training Profiles. We conclude that women should not categorically be excluded from aircrew duties for reasons of G intolerance.