Pain Treatment Unit Research Articles

Application Value of NLR, PLR, LMR, HEART score, and POCT in Early Warning and Accurate Graded Diagnosis of High-Risk Chest Pain in Emergency Medicine

Objective: To evaluate the application value of neutrophils/lymphocytes (NLR), platelets/lymphocytes (PLR), lymphocytes/monocytes (LMR), HEART (history, electrocardiogram, age, risk factors, and troponin) score, and point-of-care testing (POCT) in the early warning and precise diagnosis of high-risk chest pain in emergency medicine. Methods: A total of 157 patients with acute chest pain who were admitted to the emergency department and chest pain treatment unit of our hospital between August 2022 and September 2023 were selected. Rapid testing of bedside myocardial markers (ultrasensitive troponin (hs-cTnI), myoglobin (MYO), creatine kinase isoenzyme (CK-MB), D-dimer (D-Dimer), and N-terminal B-type natriuretic peptide precursor (NT-proBNP)) was performed on the patients using a POCT device (ThermoKing BioMQ60proB). A HEART score was used to classify the patients into low (n = 53), intermediate (n = 59), and high-risk (n = 45) groups, and the NLR, PLR, and LMR were calculated. The NLR, PLR, and LMR values were compared among the three groups of patients, and the optimal cutoff values as well as sensitivity and specificity were determined based on receiver operating characteristic (ROC) analysis. Results: The HEART scores of patients in the low-risk, intermediate-risk, and high-risk groups were (2.72 ± 0.24), (4.75 ± 0.56), and (5.32 ± 0.73) respectively, and the differences were statistically significant (P < 0.05). Compared with the low-risk group, the intermediate-risk group and high-risk group had a significantly higher NLR and PLR, and a significantly lower LMR; the high-risk group had higher NLR and PLR and lower values of LMR as compared to the other two groups, and the difference was statistically significant (P < 0.05). The ROC curves suggested that the area under the curve, sensitivity, and specificity of the combined diagnosis of NLR, PLR, LMR, HEART score, and POCT were greater than those of LR, PLR, and LMR with HEART score and POCT alone. Conclusion: The combined application of NLR, PLR, LMR, HEART score, and POCT has significant application value in the early warning and precise diagnosis of emergency high-risk chest pain. It provides a more simple, easy-to-access, and efficient assessment index for the clinical prediction and treatment of emergency high-risk chest pain.

Practical recommendations for the management of the patient with chronic pain during the pandemic of COVID-19.

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

An Update on Resources, Procedures and Healthcare Provision in Pain Units: A Survey of Spanish Practitioners.

Multidisciplinary pain treatment units are recommended to provide comprehensive diagnosis and treatment of chronic pain, a complex clinical syndrome and one of the leading causes of disability worldwide. The objective of this study was to provide updated results on the situation of pain treatment units in Spain and to determine compliance with recommendations proposed by de Spanish Ministry of Health (SMH). A cross-sectional, prospective, multicenter survey was performed, collecting data on resources, procedures and healthcare provision. Between March and May 2019, the Spanish Pain Society sent an invitation letter to 183 pain units with a link to the questionnaire. Sixty-nine units from 13 regions agreed to participate. According to the International Association for the Study of Pain criteria, only 12 units were classified as multidisciplinary pain centers. Most (95.7%) were in hospitals, 82.6% from the public sector, and 46.4% had protocols to coordinate with primary care. Interviewees rated the adequacy of facilities at 6.3 (from 0 to 10). Moreover, 67% of interviewees found that there were insufficient staff, with no mental health professionals, physical therapists or social workers in 49.3%, 87.0% and 97.1% units, respectively. Only 24 pain units had a day hospital, 44.9% offered psychological interventions, and 79.7% supported teaching and research activities. Results suggest that a small proportion of Spanish pain units meet the national standards for multidisciplinary pain units proposed by the SMH.

Perioperative management of patients with suspected or severe infection with SARS-CoV-2 coronavirus programmed for the implementation of electronic devices for the control of chronic pain

At the end of 2019, a series of patients affected by lung infection of initially unknown aetiology with clinical presentations very similar to viral pneumonia were registered in China. Sequencing analysis of samples from the lower respiratory tract identified a new type of virus from the family Coronaviridae called SARS-CoV-2 as the causative agent of the outbreak; the agent responsible for the disease that was renamed COVID-19.1 Since then, millions of cases have been identified around the world. The World Health Organization (WHO) initially declared the infection to be a Public Health Emergency of International Concern, and later classed it as a pandemic.2, 3 The vast majority of coronaviruses are responsible for mild upper respiratory tract infections in immunocompetent adults, and can cause more serious conditions, such as severe acute respiratory distress syndrome (ARDS) and sepsis in patients with risk factors, namely, cardiovascular disease (10.5%), diabetes (7.3%), chronic respiratory disease (6.3%), high blood pressure (6%) and cancer (5.6%).1, 2 Person-to-person transmission occurs mainly by respiratory droplets and by contact with contaminated material through mucosa (oral, ocular and nasal). It can also be transmitted by aerosols in aerosol-generating therapeutic procedures. The average number of secondary cases produced from 1 case has been estimated at between 2 and 3,2, 4 while the average incubation period is between 5.2 and 12.5 days, although in some cases it can be as long as 24 days.1 The potential repercussions of the disease have led international, regional and local health organizations to adopt a series of measures to deal with COVID-19 and try to reduce its impact5 not only in society as a whole, but also in healthcare. These measures include changing guidelines and promoting strategies such as telemedicine,6 a service that has been introduced in different specialties, including Pain Treatment Units. Telemedicine is basically applicable in routine, elective, non-urgent medical consultations (clinical evolution, start and follow-up of medical treatments, psychological intervention techniques, etc.).6 In certain cases, however, such as patients with chronic pain refractory to medical treatment who need invasive therapeutic procedures, telemedicine services are ineffective because they exclude direct patient-doctor contact, and with it, the risk of virus transmission. In this context, intrathecal drug infusion (IDI) pumps and both spinal cord (SCS) and peripheral nerve (PNS) stimulation device are now frequently used as part of the treatment strategy in patients with chronic pain refractory to other therapies.7 SCSs have now been approved by the US Food and Drug Administration (FDA) for the treatment of chronic neuropathic pain of the spine and limbs, post-surgical spine syndrome, and complex regional pain syndrome. However, they have also been used successfully in many other indications, including chronic intractable angina, peripheral arterial disease, peripheral neuropathic pain, and in the treatment of visceral pain.7, 8, 9 In IDIs, the intrathecal administration of baclofen is approved by the FDA for the treatment of spasticity, and the intrathecal administration of morphine and ziconotide is approved for the treatment of chronic, refractory, nociceptive, neuropathic or mixed cancer or non-cancer-related pain.7, 10 In light of the current situation, we believe it is important to establish guidelines for the management of patients with suspected or serious infection by Coronavirus SARS-CoV-2 scheduled for implantation of electronic systems for the control of chronic pain (IDIs and SCSs). The purpose of these recommendations is to reduce the spread of COVID-19 among both medical personnel and the general population, and they may be updated as the pandemic progresses and new evidence emerges.

Recomendaciones prácticas para el manejo del paciente con dolor crónico durante la pandemia de COVID-19

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Study of the uses of Information and Communication Technologies by Pain Treatment Unit Physicians.

Adequate use of Information and Communication Technologies (ICTs) in health has been shown to save the patient and caregiver time, improve access to the health system, improve diagnosis and control of disease or treatment. All this results in cost savings, and more importantly, they help improve the quality of service and the lives of patients. The purpose of this study is to analyse the differences in the uses of this ICTs between those physicians that belong to Pain Treatment Units (PU) and other physicians that work in pain not linked to these PUs. An online survey, generated by Netquest online survey tool, was sent to both groups of professionals and the data collected was statistical analysed through a logistic regression methodology which is the Logit binomial model. Our results show that those physicians that belong to PUs use ICTs more frequently and consider it more relevant to their clinical practice.

Vulvodynia--An Evidence-Based Literature Review and Proposed Treatment Algorithm.

We searched the medical literature from the last 15years (1998 to 2013) relating to the etiology, diagnosis, and treatment of vulvodynia. The evidence was reviewed supporting the therapeutic proposals currently in use and propose the incorporation of novel, minimally invasive, interventional therapies, within the context of a multidisciplinary approach. This was a systematic review of all relevant studies with no language restrictions. Studies were identified through Medline/PubMed (1998 to March 2013), the Cochrane Library (2001 to 2013), and conference records and book chapters. The keywords used included "chronic pelvic pain," "vulvodynia," "vestibulodynia," and search terms "etiology," "diagnosis," and "treatment" were added. The levels of evidence were assessed using grading system for "Therapy/Prevention/Etiology/Harm" developed by the Centre for Evidence-Based Medicine (CEBM). The grading system assists in clinical decision-making, and we decided to use "The Grading of Recommendations Assessment, Development, and Evaluation (GRADE)." A total of 391 papers were assessed. Of these, 215 were analyzed and 175 were excluded, as they pertained to areas not directly related to the disease under review. The optimal therapy for vulvar pain syndrome remains elusive, with low percentages of therapeutic success, using either local or systemic pharmacological approaches. Surgery involving invasive and often irreversible therapeutic procedures has resulted in success for certain subtypes of vulvodynia. We present a multidisciplinary approach whereby pain treatment units may provide an intermediate level of care between standard medical and surgical treatments.

Clinical experience in opioid switch for noncancer chronic pain treatment

The implementation of opioid switch (OS) as a strategy in non-malignant chronic pain has been scarcely proved. This article aims to evaluate the results of OS in a Pain Treatment Unit. This is an observational retrospective study in which all patients who had been subjeted to OS for a period of 18 months were selected. All of them had been treated with opiods plus adyuvants for more than 6 months and had a visual analog scale (VAS) of at least 5, either with or without adverse effects. Two variables were defined: clinical improvement, as a reduction equal or superior to 3 in VAS or the elimination of two or more adverse effects; equianalgesic dose reduction is the difference between initial and final opioid dose. 7 out of 9 (77%) patients showed clinical improvement. Median equianalgesic dose reduction was 37% (-72% +18%). Five patients (55%) presented adverse effects to opioids before the OS but only one (11%) after OS. OS was beneficial for the management of non-malignant chronic pain patients who have poor response to opioid treatment and/or with adverse effects. A secure OS should include a reduction in equianalgesic opioid dose. Prospective studys would achieve a mayor consensus for the applicance of OS in non-malignant chronic pain treatment.

Utilidad de un cuestionario autoadministrado multidimensional para la gestión de una unidad clínica de tratamiento de dolor

ObjectiveTo study the feasibility of a multidimensional self-administered questionnaire before the patient is seen at the first visit in a clinical Pain Treatment Unit (PTU) of a tertiary hospital, and its impact on the management of patients in the first visit. Patients and methodsCross-sectional study. Self-administered questionnaire that gathered: socio-demographic data, medical history of pain, pain perception (intensity and characteristics), comorbidity of pain and patient expectations of analgesic treatment (“What do you expect from our treatment? If we cannot resolve your pain, what level of pain would you be willing to live with?). A descriptive analysis was performed. ResultsA total of 293 consecutive patients (31% men, 69% women), mean age (SD) 62 (16) years-old, were included in 2011.All patients completed and returned the questionnaire before the first visit to the PTU. The questionnaire was completed fully and correctly by 80% (234, 95% CI: 75-84) of the patients, and the rest completed the questionnaire with some points unanswered.About 24% (70/293, 95% CI: 19-29) of the patients should not have been referred to the PTU [20% were not attended]. A small percentage (9%,26/293, 95% CI: 6-13) were evaluated as «urgent’» and visited over the following 7 days, with 19% (56/293, 95%CI: 15-24) being «preferential» (visited before 15 days) and 52% (152/293, 95% CI: 46-58) as «non-urgent/non-preferential» (visited before 60 days). Almost one third (30%, 87/293, 95% CI: 25-35) did not need a second visit to the PTU. Patient expectations: 21% expected complete pain relief and 64% would accept a lower pain intensity score of 4. ConclusionThe use of a multidimensional self-administered questionnaire before the first visit to a clinical Pain Treatment Unit of a tertiary hospital was a practicable and useful tool for the management of patients on the first visit. Likewise, the questionnaire provided information on the patient's perception of pain and the expectations concerning the analgesic treatment.

Prevención de eventos adversos para la seguridad del paciente en las unidades de tratamiento del dolor crónico

ObjectivesTo identify preventive actions that minimise risk of patients safety in pain treatment units, and to cluster preventive actions into homogeneous groups. The current study is part of a project intended to improve patient safety in pain treatment units, and is aimed at identifying, prioritising and preventing patient safety risk. Material and methodsA group of experts was selected from professionals with a specific clinical background and experience in pain treatment units. This group was provided with information on patient safety and on known adverse events, errors and related causes. Through a brainstorming method the participants were asked: What changes or improvements would need to be undertaken to absolutely prevent the occurrence of each adverse event? The participant's proposals were analysed and grouped according to their homogeneity. ResultsA total of 456 preventive actions were identified. The group that received the highest number of suggestions was the one including changes in the management of healthcare processes, followed by the group that considered improvements in clinical practice, training activities, protocols and policies, and patient communication. ConclusionsAccording to the consensus of the experts, management of healthcare processes and improvements in health care practices are the 2 interventions that are most likely to reduce patient safety risk in pain treatment units.

Identificación y priorización de episodios adversos y fallos relacionados con la seguridad del paciente en las Unidades de Tratamiento del Dolor

ObjectivesAn expert group coordinated by the Andalusian School of Public Health identified the most serious and frequent adverse events in Pain Treatment Units (PTU), as well the failures and underlying causes, as a prior step to preparing preventive actions. The aims of the project were to identify potential adverse events in Pain Treatment Units, identify failures and their underlying causes, and prioritise these failures according to a failure modes and effects analysis (FMEA) tool. Material and methodsThe method employed consisted of a literature search, the selection of an expert group with experience in PTU, creating a catalogue of adverse events using the generation of ideas technique, and putting the FMEA and Risk Priority Index tools into practice. ResultsUp to 66 types of adverse events were identified associated with; medication (30), invasive techniques (15), care process (10), patient information and education (6), and clinical practice (5). It was found that up to 101 failures could be triggered by these adverse events, and that 242 causes could lead to these failures. ConclusionsThe results indicated the need to work principally in two directions, improving the care process in the PTU (the health care organisation), and the professional work, this latter having two aspects, improving the clinical practice, and increase professional skills by means of specific training. Communication, whether inter-professional or inter-department, or with the patient and their family, is identified as a key aspect for improvement.

Dolor pélvico en la embarazada. Disfunción de la sínfisis púbica. Revisión de la literatura

Pubic symphysis diastasis in pregnancy is a frequent and underestimated problem that has important repercussions on maternal morbidity and high prevalence of chronic pelvic pain in women. The functional impotence that it causes and the associated severe pain, entails the use of a number of therapeutic alternatives, ranging from bed rest to complex corrective surgery, reinforcing the importance and necessity of a correct approach to this pathology. Our aim is, after studying many cases referred to the Pain Treatment Unit at our centre, to carry out a review of this pathology, contacting patients, reviewing the therapeutic alternatives available for these types of conditions and their repercussions on the quality of life of the maternal-foetal binomial and chronic pain.

Creencias, actitudes y percepciones de médicos, farmacéuticos y pacientes acerca de la evaluación y el tratamiento del dolor crónico no oncológico

Aim To identify patients’, physicians’ and pharmacists’ attitudes, personal beliefs, experiences and opinions regarding chronic nononcological pain and to determine how these attitudes influence the choice and follow-up of analgesic strategies. Material and methods Design: we performed a descriptive, cross-sectional survey that included three distinct but comparable questionnaires for data collection, adapted to each subgroup: 316 pharmacists and 838 patients were interviewed by telephone, and 697 physicians from different specialties completed a self-administered questionnaire. The variables analyzed included sociodemographic data from each group, descriptive pain variables (prevalence of pain among their patients, pain characteristics [e.g. localization, intensity –visual-analog pain scale, VAS, from 0 “no pain” to 10 “maximum tolerable pain”– frequency, duration, consequences, among others]), and questions related to analgesic treatment (objectives, drug choice and prescription, information provided and received on analgesic drugs, and satisfaction and concerns). Data analysis consisted of a descriptive analysis of the characteristics of each group, followed by analysis of intergroup differences. Results a) physicians: 60% reported that they usually assessed pain intensity in their patients, using VAS (68%) or verbal rating scales (VRS) (36%). Forty-seven percent of the patients attended weekly had pain, which was uncontrolled (VAS score ≥ 4 points) in 63%. The goal of treatment was to improve patients’ quality of life rather than to relieve pain. Strong opioids were only prescribed in 17% of patients, mainly in pain treatment units (PTU), where most patients with chronic nononcologic pain and high-intensity pain were treated and where physicians were most concerned about the effects of pain on patients’ daily lives. Rehabilitation physicians were more reluctant to use opioids because of their adverse effects and the need to use a special prescription form; b) pharmacists: 65% reported no reluctance to use strong opioids, and 63% believed that this attitude was shared by patients. Pharmacists believed that the goals of treatment were to achieve pain relief until pain was tolerable or absent; c) patients: patients’ perceptions of pain intensity assessment differed from that of physicians, since 87% of patients reported that their diferen-physician measured pain at each visit, 6% with VAS and 71% with VRS. For patients, the goal of treatment was to achieve tolerable pain levels. Twenty-three percent were reluctant to use strong opioids due to their adverse effects and their fear of becoming addicts. Conclusion The results of this study highlight the complex and multifactorial nature of pain treatment, requiring the design of improved intervention strategies. Factors to be considered are the high prevalence of uncontrolled pain, the low use of strong opioids, discrepancies in the frequency and methods used for systematic pain assessment, the existence of treatment concerns due to lack of information, and the perception that special regulation of opioids acts a barrier to their prescription.

Eficacia de la acupuntura y sus técnicas relacionadas para el tratamiento del dolor no oncológico en atención primaria: una auditoría médica

Background Pain is one of the principal symptoms for which the general public seeks medical attention, and it is frequently treated by GPs. Although acupuncture is mainly practised in the private field, it enjoys growing acceptance in the public system too, which helps bring down the high cost of its use. The aim of the present study is to evaluate the effectiveness of acupuncture and related techniques in treating non-oncological pain during nine years of activity at the Pain Treatment Unit (PTU) within the Andalusian Public Health System (Spain) in the field of primary healthcare. Methods Retrospective review of 5981 electronically stored case histories of patients who sought treatment for non-oncological pain and were seen at the PTU between June 1997 and July 2006. We excluded from this review those patients who had on any occasion been recruited for clinical trials at the PTU. The primary result measure applied was the success rate, defined as an improvement of least 50% on the Global Assessment Index, which is made up of five variables: pain intensity, as measured on a numerical scale of 0-10, pain frequency, consumption of analgesics, level of incapacity and sleep disorders caused by pain (the latter four variables were measured on a 5-point Likert scale of 0-4). Results The majority (84.5%) of the patients treated were women, with a mean age of 58.8 years (range 8-93), and they attended the healthcare clinic because of pain present for over three months (88.8%) and mainly affecting the lower back (58.8%). In the 5690 patients who completed treatment, the mean success rate was 79.7%, with highest rates (93%) being achieved in patients with cephalalgia. The mean reduction in pain intensity was 5.5 (SD 2.5) points amounting to 67% fall from the baseline. There was a reduction of €7.1 in the mean weekly expenditure on analgesics per patient. From the regression model, we conclude that the patients who suffered acute or subacute pain presented higher success rates than did those with chronic pain (OR, 1.94; 95% CI, 1.53-2.48). Conclusions Acupuncture seems to be effective in treating musculoskeletal pain, and presents no severe adverse events. With acupuncture treatment, the consumption of analgesic and anti-inflammatory drugs is considerably reduced.

Is Impedance a Parameter to be Taken into Account in Spinal Cord Stimulation?

Over the last few decades, spinal cord stimulation (SCS) has become one of the main treatments in the therapeutic arsenal available to pain treatment units. New stimulation systems have been developed and the indications of neurostimulation have been expanded. The premises for a successful technique remain the same; good patient selection, good surgical technique, and good management of electrical parameters when programming. An observational report. The primary objective of the study was to determine the relationship between changes in impedance (R) and energy requirement (E) elicited by changes in patients posture. The postures analyzed were supine (S), sitting (SI), standing (ST), and walking (W). As a second objective, the difference produced in the energy requirement when changing posture was analyzed. A study was carried out in 70 patients with chronic intractable pain implanted with a neurostimulation system between January 2000 and March 2006. We define the perception threshold (Tp); the discomfort threshold (Td); and the therapeutic threshold (Tt). The amplitude of perception was measured in mA. With the resulting data, the therapeutic range (TR) was determined. After performing all measurements with the patient in the ST position, the neurostimulation system was shut off and the patient maintained in the other position for 5 minutes before performing the measurements. The variables R and E were compared by age groups, sex, implant duration, and the time since implant placement. Patients were divided into groups according to whether the location of the implanted electrodes was cervical or thoracic. The full analysis by age, sex, and implant duration was performed in the cervical and thoracic implant groups. No correlation was found between impedance and posture. When the results for R and E were analyzed by sex and age, no statistical differences were found in any of the values in any position. The analysis of time since implant greater than or less than 6 months did not find differences in the energy requirement, although there was a significant difference in the impedance value when patients were in the S position. No significant differences were observed in the analysis by age groups.

Effectiveness of Acupuncture and Related Techniques in Treating Non-Oncological Pain in Primary Healthcare – An Audit

Pain is one of the principal symptoms for which the general public seeks medical attention, and it is frequently treated by GPs. Although acupuncture is mainly practised in the private field, it enjoys growing acceptance in the public system too, which helps bring down the high cost of its use. The aim of the present study is to evaluate the effectiveness of acupuncture and related techniques in treating non-oncological pain during nine years of activity at the Pain Treatment Unit (PTU) within the Andalusian Public Health System (Spain) in the field of primary healthcare. Retrospective review of 5981 electronically stored case histories of patients who sought treatment for non-oncological pain and were seen at the PTU between June 1997 and July 2006. We excluded from this review those patients who had on any occasion been recruited for clinical trials at the PTU. The primary result measure applied was the success rate, defined as an improvement of least 50% on the Global Assessment Index, which is made up of five variables: pain intensity, as measured on a numerical scale of 0-10, pain frequency, consumption of analgesics, level of incapacity and sleep disorders caused by pain (the latter four variables were measured on a 5-point Likert scale of 0-4). The majority (84.5%) of the patients treated were women, with a mean age of 58.8 years (range 8-93), and they attended the healthcare clinic because of pain present for over three months (88.8%) and mainly affecting the lower back (58.8%). In the 5690 patients who completed treatment, the mean success rate was 79.7%, with highest rates (93%) being achieved in patients with cephalalgia. The mean reduction in pain intensity was 5.5 (SD 2.5) points amounting to 67% fall from the baseline. There was a reduction of euro7.1 in the mean weekly expenditure on analgesics per patient. From the regression model, we conclude that the patients who suffered acute or sub-acute pain presented higher success rates than did those with chronic pain (OR, 1.94; 95% CI, 1.53-2.48). Acupuncture seems to be effective in treating musculoskeletal pain, and presents no severe adverse events. With acupuncture treatment, the consumption of analgesic and anti-inflammatory drugs is considerably reduced.

A New Topical Treatment for Acute Herpetic Neuralgia and Post-Herpetic Neuralgia

Pain Research and Treatment Unit, Institute of Neurosurgery, and Institute of Dermatology II, University of Milan, Milan, Italy

Chronic Low Back Pain, Description, and Attributional Styloe

Twenty consecutive, chronic low back pain patients admitted to our pain treatment unit completed the Attributional Style Questionnaire (an instrument that detects a cognitive style that is correlated with, and that predicts, depression) and the Beck Depression Inventory. An age, sex, and education-matched group of normal subjects, a group of patients with asymptomatic essential hypertension, and a group of patients with end-stage renal disease receiving dialysis treatment served as controls. The majority of the chronic-pain and renal-dialysis patients had elevated depression scores, whereas none of the normal subjects or hypertensive patients were outside the nondepressed range. The Attributional Style scores of the pain and renal dialysis patients were significantly deviant from the normal control group, but no more so than those of the patients with hypertension. The results of this study suggest that individuals with a chronic medical condition, either symptomatic (chronic low back pain or renal disease) or asymptomatic (essential hypertension) in nature, develop an attributional style characteristic of depression. These data neither lend support nor refute the thesis that chronic pain syndromes are a variant of, or a masked, depression. Rather, this research implies that a more important question is what identifiable risk factors (for example, attributional style) predispose patients with chronic pain to develop a depressive illness.

Münchausen syndrome presenting with chronic pain: Case report

A factitious disorder is one that has been fabricated or simulated by the patient. Münchausen syndrome is a subtype of factitious disorder. This syndrome has not previously been described in relationship to chronic pain/chronic pain treatment units. Such a patient is presented and the clues to the identification of this syndrome within chronic pain patients are presented.

Pain relief from peripheral conditioning stimulation in patients with chronic facial pain.

In a prospective study, 50 consecutive patients, referred to a pain treatment unit for surgery to alleviate various forms of facial pain, were all given transcutaneous nerve stimulation (TNS) therapy and followed for 2 years. Of the 44 patients remaining at the 2-year follow-up review, 20 (45%) reported satisfactory analgesia from conventional or acupuncture-like TNS. The latter technique markedly improved the overall results. No serious side effects were seen. Atypical facial pain of known etiology responded best to treatment, but satisfactory relief was often produced with tic douloureux. Duration of the pain condition as well as sex of the patient were predictors of treatment results. It is concluded that TNS therapy represents a valid alternative to surgery when pharmacological therapy fails, especially in the elderly and in patients with atypical facial pain.