Stress and the medical practitioner

There are stresses peculiar to being a medical practitioner, and superadded stressors applicable to women doctors. Some are extrinsic, some intrinsic. An interacting model is suggested: stresses that are inherent in the practice of medicine precipitate mental disorder in those predisposed to it; practice is particularly stressful to the ambitious, inflexible individual with a family history of mental disturbance and unhappy or unstable childhood.     

Persistent Postmastectomy Pain in Breast Cancer Survivors: Analysis of Clinical,Demographic, and Psychosocial Factors

Persistent postmastectomy pain (PPMP) is increasingly recognized as a major individual and public health problem. Although previous studies have investigated surgical, medical, and demographic risk factors, in this study we aimed to more clearly elucidate the relationship of psychosocial factors to PPMP. Postmastectomy patients (611) were queried about pain location, severity, and burden 38.3 ± 35.4 months postoperatively. Validated questionnaires for depressive symptoms, anxiety, sleep, perceived stress, emotional stability, somatization, and catastrophizing were administered. Detailed surgical, medical, and treatment information was abstracted from patients' medical records. One third (32.5%) of patients reported PPMP, defined as ≥3/10 pain severity in the breast, axilla, side, or arm, which did not vary according to time since surgery. Multiple regression analysis revealed significant and independent associations between PPMP and psychosocial factors, including catastrophizing, somatization, anxiety, and sleep disturbance. Conversely, treatment-related factors including surgical type, axillary node dissection, surgical complication, recurrence, tumor size, radiation, and chemotherapy were not significantly associated with PPMP. These data confirm previous studies suggesting that PPMP is relatively common and provide new evidence of significant associations between psychosocial characteristics such as catastrophizing with PPMP, regardless of the surgical and medical treatment that patients receive, which may lead to novel strategies in PPMP prevention and treatment.     

Influence of psychological factors on risk of temporomandibular disorders

Psychological characteristics potentially may be a cause or consequence of temporomandibular disorder (TMD). We hypothesized that psychological characteristics associated with pain sensitivity would influence risk of first-onset TMD, but the effect could be attributed to variation in the gene encoding catechol-O-methyltransferase (COMT). We undertook a prospective cohort study of healthy female volunteers aged 18-34 yrs. At baseline, participants were genotyped, they completed psychological questionnaires, and underwent quantitative sensory testing to determine pain sensitivity. We followed 171 participants for up to three years, and 8.8% of them were diagnosed with first-onset TMD. Depression, perceived stress, and mood were associated with pain sensitivity and were predictive of 2- to 3-fold increases in risk of TMD (P < 0.05). However, the magnitude of increased TMD risk due to psychological factors remained unchanged after adjustment for the COMT haplotype. Psychological factors linked to pain sensitivity influenced TMD risk independently of the effects of the COMT haplotype on TMD risk.     

Integration of Pain Score and Morphine Consumption in Analgesic Clinical Studies

In pain clinical trials, the rescue analgesic medication such as patient-controlled analgesia morphine is often made available for patients for breakthrough pain. The patient-controlled analgesia morphine usage decreases the study agent's effect on pain relative to placebo and introduces greater variability in attainment of pain scores. For assessment of analgesic efficacy, the isolated statistical analysis of pain score or morphine consumption as a surrogate marker for pain not only loses statistical efficiency but also may incur increased false-positive findings because of multiple testing. The aim of this article is to review the research to date for choices of statistical tests for pain or morphine consumption outcome, with a focus on systematically evaluating a means for collective analgesic assessment of pain and morphine consumption using an integrated outcome. A case example is illustrated for data visualization, statistical comparison, and effect size estimation using the new endpoint. Some implications for clinical practice and further research are discussed.PerspectiveThis article provides statistical evidence to conclude that an integrated outcome of pain score and morphine consumption provides an efficient means for integrated analgesic assessment.     

Pain sensitivity and vasopressin analgesia are mediated by a gene-sex-environment interaction

Quantitative trait locus mapping of chemical/inflammatory pain in the mouse identified the Avpr1a gene, which encodes the vasopressin-1A receptor (V1AR), as being responsible for strain-dependent pain sensitivity to formalin and capsaicin. A genetic association study in humans revealed the influence of a single nucleotide polymorphism (rs10877969) in AVPR1A on capsaicin pain levels, but only in male subjects reporting stress at the time of testing. The analgesic efficacy of the vasopressin analog desmopressin revealed a similar interaction between the drug and acute stress, as desmopressin inhibition of capsaicin pain was only observed in nonstressed subjects. Additional experiments in mice confirmed the male-specific interaction of V1AR and stress, leading to the conclusion that vasopressin activates endogenous analgesia mechanisms unless they have already been activated by stress. These findings represent, to the best of our knowledge, the first explicit demonstration of analgesic efficacy depending on the emotional state of the recipient, and illustrate the heuristic power of a bench-to-bedside-to-bench translational strategy.     

Child and adolescent mental disorders: the magnitude of the problem across the globe

Objective: Describe objectively the global gaps in policy, data gathering capacity, and resources to develop and implement services to support child mental health. Methods: Report on the World health Organization (WHO) child and adolescent mental health resources Atlas project. The Atlas project utilized key informants and was supplemented by studies that focused on policy. This report also draws on current epidemiological studies to provide a context for understanding the magnitude of the clinical problem. Results: Current global epidemiological data consistently reports that up to 20% of children and adolescents suffer from a disabling mental illness; that suicide is the third leading cause of death among adolescents; and that up to 50% of all adult mental disorders have their onset in adolescence. While epidemiological data appears relatively uniform globally, the same is not true for policy and resources for care. The gaps in resources for child mental health can be categorized as follows: economic, manpower, training, services and policy. Key findings from the Atlas project include: lack of program development in low income countries; lack of any policy in low income countries and absent specific comprehensive policy in both low and high income countries; lack of data gathering capacity including that for country‐level epidemiology and services outcomes; failure to provide social services in low income countries; lack of a continuum of care; and universal barriers to access. Further, the Atlas findings underscored the need for a critical analysis of the ‘burden of disease’ as it relates to the context of child and adolescent mental disorders, and the importance of defining the degree of ‘impairment’ of specific disorders in different cultures. Conclusions: The recent finding of substantial gaps in resources for child mental health underscores the need for enhanced data gathering, refinement of the economic argument for care, and need for innovative training approaches.