A preliminary examination of the relationship between employment, pain and disability in an amputee population.

PURPOSE: To examine amputees' use of health, social and voluntary services and to assess the perceived benefit of such use. Additionally, to examine the degree and type of changes made in occupational status in relation to both pain and prosthetic limb use following amputation. METHOD: A survey methodology was employed to examine the services used by amputees and their experiences of occupational change. A response rate of 62% resulted in 315 amputees completing the study. The study sample was drawn from patient records at three artificial limb and appliance centres in the central belt of Scotland. RESULTS: Overall the data suggest that few amputees make use of the available services for general amputation-related problems. Even fewer services were utilized for phantom limb pain or for other pain problems. Moreover, of those services that were used, very few were reported as being helpful. Amputation had severe consequences in terms of employment with 75% of the sample in employment prior to the amputation and only 43.5% remaining following amputation. Additionally, of those who did remain in employment there were a number of changes from pre- to post-amputation occupational classification. Employment status was related to the intensity of phantom limb pain, and daily prosthetic limb use with unemployed amputees reporting higher levels of pain and lower levels of prosthesis use. CONCLUSIONS: The study demonstrates the need for further research to determine whether the results obtained regarding occupational changes following amputation result pain, disability, amputees' attitudes towards themselves in relation to work, or to employers' attitudes and beliefs about their capabilities. Further research is also required to determine why so few amputees make use of available services and why, even when they are used, such services are not perceived as being helpful. Finally, there is a need to clarify the relationship between the extent of daily prostheses use, the experience of phantom limb pain and employment status.

Psychological distress in amputees with phantom limb pain.

Research suggesting that psychological factors play a role in phantom limb pain abounds in the literature. Despite recent research suggesting that these factors exacerbate rather than cause phantom limb pain, clinicians still frequently use personality as a rationale to explain amputees' phantom limb pain. The present study aimed to examine psychological distress in a working-age population of amputees not specifically seeking help for their pain. The study was conducted in two phases. Phase 1 included 315 amputees who completed the General Health Questionnaire (GHQ). Phase 2 included a subset of the original sample who completed the Beck Depression Inventory (BDI). In Phase 1, although over 50% of the sample reported GHQ scores over the threshold used to detect "caseness," this was not related to phantom limb pain. In Phase 2 of the study, only 15% of the sample reported moderate to severe symptoms of depression. Only 4% of the variance in phantom limb pain was accounted for using the overall BDI score. When BDI items were examined individually within regression models, a number significantly predicted phantom limb pain. However, the items most related to phantom limb pain were those involved in "performance difficulties" rather than "negative affect." The present study suggests that negative affect in amputees may be related to disability rather than pain.

Variation in phantom limb pain: results of a diary study.

Amputees experience multiple, complex problems in addition to phantom limb pain. Although studies have yielded useful data on the relationship between phantom limb pain and other variables, this research generally has evaluated only one aspect of phantom limb pain and measured it at only one time point. The present study examined ongoing phantom limb pain and associated factors prospectively through the use of hourly pain diaries that are completed over a 7-day period. The sample comprised a subset of 89 lower limb amputees taking part in a longitudinal research study. Subjects had a mean age of 46.1 years. Forty-seven per cent were female, 53% male. Subjects completed a Pain/Coping Diary that measured phantom limb pain intensity, activity levels, medication use, and alcohol use on an hourly basis over a 7-day period. It also asked subjects to list the coping strategies used on the same hourly basis over a 7-day period. The diaries highlighted the following: Phantom limb pain appears to be episodic in nature and there is great variation in its intensity. Amputees use a limited repertoire of coping strategies to deal with episodes of phantom limb pain, and of those strategies that are used, few reduce the level of pain. This variability in phantom limb pain has important implications for those involved in the care of amputees as a report of phantom limb pain at a given point in time may not reflect the amputee's overall pain experience.

Lancefield grouping and smell of caramel for presumptive identification and assessment of pathogenicity in the Streptococcus milleri group.

AIM: To evaluate Lancefield grouping and caramel smell for presumptive identification of the Streptococcus milleri group, and to find whether Lancefield group, species, or protein profile correlated with virulence or infection site. METHODS: Prospective studies were made of 100 consecutive streptococcal isolates in blood cultures or pus from 100 patients in whom the severity of infection was categorised as serious, moderate, or not significant. The usefulness of Lancefield group and the caramel smell for presumptive identification was examined, and the relation of the S milleri species, Lancefield group, and SDS-PAGE protein analysis to severity of infection and infection site was investigated. Lower respiratory tract and genital tract specimens, strict anaerobes, group D streptococci, and strains identified as Streptococcus pneumoniae, Streptococcus pyogenes, or Streptococcus agalactiae were excluded. RESULTS: Most streptococci occurring in pure or significant growth density were S milleri group (87/100; 87%, 95% confidence interval 0.81-0.93). Of these, 89.7% (78/87; 0.84-0.96) were associated with infection. Lancefield group F antigen predominated (41/87; 47.1%, 0.38-0.56). Lancefield group F alone or accompanied by the caramel smell had a specificity of 100%, but a sensitivity of only 47.3% for group F alone, and 19.5% for group F accompanied by the caramel smell. There was no significant association between species, Lancefield group, and severity of infection, site of infection, or pathogenicity. SDS-PAGE analysis failed to discriminate between strains. CONCLUSIONS: Neither species nor Lancefield antigen was related to the site of infection. The presence of Lancefield group F antigen alone or accompanied by a caramel smell was a useful indicator for the S milleri group when present, but was too insensitive to use as a screening test. Most streptococci occurring in pure culture or in significant growth density were of clinical importance. Such organisms should be identified to species level to detect the S milleri group.

Structural deterioration in Celestin tubes.

Two cases are described where, after 2 years, a nylon-latex Celestin tube which was left in situ to bypass a benign stricture underwent structural deterioration and produced complications requiring tube replacement. It is recommended that an alternative endo-oesophageal tube should be considered where a lifespan of this order is contemplated.

A prospective study of acute pancreatitis.

All 78 patients with acute pancreatitis admitted to one hospital in a 2-year period were included in a prospective survey of conservative management. The overall mortality rate was 11.5 per cent, being 46 per cent for 11 patients subjected to early laparotomy and only 6 per cent for patients managed without operation. Twenty-six patients were considered to have severe acute pancreatitis and all 9 deaths occurred in this group. Biliary disease was present in 51 per cent of patients, and the majority of those with biliary disease were over 60 years old. Alcohol-related acute pancreatitis occurred in 26 per cent of the total patients, and none of this group was over 60 years old. Acute pancreatitis was considered idiopathic in origin in only 13 per cent of the patients. Elective biliary surgery in 30 patients resulted in freedom from recurrent attacks of acute pancreatitis for the follow-up period (12-30 months). The results compare favourably with those in which glucagon and high dosage aprotinin (Trasylol) have been utilized in the management of acute pancreatitis.