Psychological Characteristics of Chronic Pain: a Review of Current Evidence and Assessment Tools to Enhance Treatment

Purpose of Review

The complicated nature of chronic pain involves an interplay between psychological and physical factors, often resulting in increased emotional distress and reduced quality of life. This review is designed to help the medical practitioner who is working with chronic pain patients to be aware of psychological assessment techniques that can add to comprehensive patient understanding and more effectively guide treatment. Enhanced ability to assess and understand the emotional life of the chronic pain patient provides a basis for intervening and treating more successfully.

Recent Findings

There are a broad range of assessment techniques, some of which require a background in psychology and some that do not, that can identify psychological differences in chronic pain patients and serve to guide intervention strategies. Chronic pain is often comorbid with depression, anxiety, catastrophizing, and various ineffective coping strategies. Some patients, however, have demonstrated more adaptive and effective strategies for cognitively and behaviorally coping with pain and normalizing their lives. Proper assessment enables the individualization of treatment to overcome and/or build upon each patient’s psychological frame of mind to maximize the potential for effective functioning.

Summary

The use of standardized and documented psychological assessment techniques can lead to a better understanding of chronic pain patients and contribute in ways that can enhance response to medical treatment and improve quality of life. It is recommended that certain psychological tools be included to supplement the medical assessment of patients who have chronic pain. A basic assessment can include a short psychological-based clinical interview along with brief measures of depression, anxiety, and coping strategies. It is also recommended that the pain physician have access to professional psychological practitioners as a resource for more complicated assessments and psychological intervention services.

     

Irrigation drainage and fibrinolysis for treatment of parapneumonial pleural empyema

We report on our experiences on 336 patients suffering from manifest pleural empyema within a period of 10 years (1985-1995). Considering the pathogenesis, particularly the results of 218 patients with "parapneumonic pleural empyema" were analysed retrospectively. Definite healing could be achieved by chest tube placement and pleural irrigation in 201 patients (= 92.2%). Other 11 patients finally needed surgical interventions (= 5%). Only 6 patients could not be cured: An indwelling tube was palliatively inserted once and 5 patients died in the course of the medical treatment (mortality = 2.3%). Within the first years the irrigation therapy was performed using a single chest tube (n = 38%) but since 1989 a double-lumen drainage was used (n = 158). Since 1987 in most cases (n = 182) intrapleural medicinal fibrinolysis was performed by instillation of streptokinase (Varidase N). If outward invasively pretreated patients (n = 30) are analysed separately, a statistical dependency can be found between the duration and the way of treatment. Without significant difference between the groups (Gr) the average duration of treatment using a single tube without fibrinolysis (Gr1) was 31.8 days, but 26.5 days using a single tube combined with fibrinolysis (Gr2). A clear shortening of the duration is detectable if patients were treated with a combination of double lumen drainage and fibrinolysis: If 2 tubes were used (Gr4) the treatment lasted 20.6 days, using one double-lumen tube (Gr5) it took 19.8 days. There is a proof of significance at comparison of Gr4 with Gr1 (p = 0.005). Gr5 with Gr1 (p < 0.001) and Gr5 with Gr2 (p = 0.014) respectively. A significant longer duration of treatment (40.6 days, p < 0.001) is found for the group of the pretreated patients, if compared with the corresponding groups Gr4 or Gr5. CONCLUSION: Parapneumonic empyemas most often can be cured by irrigation drainage. The mortality is comparatively low. The shortest duration of treatment is needed using the combination of a double-lumen tube with intrapleural instillation of a fibrinolytic agent (Varidase N). Invasively pretreated patients need significantly longer durations at same form of treatment.     

Synergistic interaction of the histone deacetylase inhibitor SAHA with the proteasome inhibitor bortezomib in mantle cell lymphoma

Objectives:  Mantle cell lymphoma (MCL) is an incurable B cell lymphoma, and novel treatment strategies are urgently needed. We evaluated the effects of combined treatment with the proteasome inhibitor bortezomib and the histone deacetylase inhibitor (HDACi) suberoylanilide hydroxamic acid (SAHA) on MCL. Bortezomib acts by targeting the proteasome, and – among other mechanisms – results in a reduced nuclear factor-kappa B (NF-κB) activity. HDACi promote histone acetylation, and also interfere with NF-κB signaling.
Methods:  Human MCL cell lines (JeKo-1, Granta-519 and Hbl-2) were exposed to bortezomib and/or SAHA. Cell viability and apoptosis were quantified by the MTT and annexin-V assay, respectively. Reactive oxygen species (ROS) were analyzed using the fluorophore H₂DCFDA. In addition, activated caspases, proteasome- and NF-κB activity were quantified.
Results:  Combined incubation with bortezomib and SAHA resulted in synergistic cytotoxic effects, as indicated by combination index values <1 using the median effect method of Chou and Talalay. The combination of both inhibitors led to a strong increase in apoptosis as compared to single agents and was accompanied by enhanced ROS generation, while each agent alone only modestly induced ROS. The free radical scavenger N -acetyl- l -cysteine blocked the ROS generation and reduced the apoptosis significantly. In addition, coexposure of bortezomib and SAHA led to increased caspase-3, -8 and -9 activity, marked reduction of proteasome activity and decrease of NF-κB activity.
Conclusions:  This is the first report giving evidence that SAHA and bortezomib synergistically induce apoptosis in MCL cells. These data build the framework for clinical trials using combined proteasome and histone deacetylase inhibition in the treatment of MCL.     

Berolina iubilans: Berlin physicians as Halle doctoral candidates (I): Johann Carl Wilhelm Moehsen (1722-1795), Halle doctoral candidate of 1742

The celebration of the 750th anniversary of the city of Berlin gave rise to remember life and work of several physicians who after their graduation at Halle university set up their practice in Berlin and here performed remarkable accomplishments in various fields. One of these representatives of an ars medica Berolinensis is Johann Carl Wilhelm Moehsen (1722-1795), graduated at Halle university in 1742, a polyhistor, who dealt with several subjects and with his regional-historical studies initiated a historiography of science including history of medicine.     

Impotence and aging: clinical and hormonal factors

A cross-sectional study of 216 impotent men aged 40 to 79 years (mean age 60.9 years) was conducted to determine if there are age-related changes in clinical and hormonal parameters in an impotent population. There was a slight increase in the degree of sexual dysfunction with age, with complete erectile failure occurring in a larger percent of the 60- and 70-year-olds than in the younger patients (41% vs 27% for the 40 year olds, P less than .05). No patient above the age of 70 years reported any full erections, even of short duration. In contrast, reported levels of libido did not vary significantly with age. Abnormal penile Doppler studies diagnostic of vasculogenic impotence were found in 17.8% of the patients tested, and an additional 17.8% were found to have evidence suggestive of a vascular etiology. These abnormal vascular findings were associated with an extremely high prevalence of clinically apparent atherosclerosis in this population. In 22.9% of the subjects, an abnormal vascular response was found only on exercise, ie, a "pelvic steal", which only occurred above the age of 50 years. There was a marked age-related alteration in the concentration of testosterone (T) and bioavailable testosterone (BT), but no statistically significant change in the levels of gonadotropins with age. An increase in the prevalence of eugonadotropic hypogonadism with age was found, which suggested an increasing prevalence of hypothalamic pituitary dysfunction in this patient group. For both vascular and hormonal changes (such as low T and BT), the greatest changes appear to occur after the age of 50.(ABSTRACT TRUNCATED AT 250 WORDS)     

Georg Ernst Stahl (1659-1734)--on the 250th anniversary of his death 14 May 1984

The 250th anniversary of Georg Ernst Stahl's death (1659-1734) is the occasion for remembering the remarkable work of this Halle professor in ordinary. In the history of medicine and natural sciences Georg Ernst Stahl is imbedded on the one hand by his psychodynamistic system and on the other hand by the foundation of the phlogiston chemistry. The enactment of the Prussian Medicinal Edict of 1725, which created new criteria for the organised public health of his time, took place during the time of his function as archiater in Berlin.     

275 years of Halle's drug exporting establishment

The forwarding of medicaments in Halle stands in the first place in the early history of the pharmaceutic industry. The enterprise established in the years 1708/1709 worked according to economic points of view seeming modern and occupied temporarily a central position in the export business of drugs. It reached its culmination point in the second half of the 18th century. In the 19th century the export business was fused with the still nowadays existing Waisenhaus druggist 's shop in Halle.