Social Work Today E-Zine

The pain that can accompany cancer—both ongoing pain and short but sometimes violent bursts of pain—tends to be worse among nonwhites than among white patients, researchers from the University of Michigan Health System have found. The study appears in The Journal of Pain and Symptom Management.

Researchers prospectively analyzed data from surveying 96 people with advanced cancer over six months. Nonwhite participants reported much more severe consistent pain and “breakthrough” pain-flares of moderate to severe pain than whites. Nonwhite participants also reported a higher incidence of pain interfering with general activity, mood, and walking ability.

“Our findings suggest the burden of cancer pain is unequal with nonwhite patients carrying a larger load,” says lead author Carmen R. Green, MD, director of the Pain Medicine Research, and an associate professor of the department of anesthesiology and health management and policy.

In measures of consistent pain at its least, nonwhites reported scores around 4.75 on a scale of zero to 10, with zero representing no pain and 10 representing pain at its most severe. Those numbers are similar to white respondents’ scores of consistent pain at its worst, suggesting a noteworthy gap between the two groups.

Breakthrough pain also was worse for nonwhites than whites. For instance, nonwhites reported average scores of about 4.5 for breakthrough pain at its least at the three-month time point in the study, compared with an average score of about 2.8 among whites. The gap in pain scores between nonwhites and whites tended to decrease over the course of the six-month study.

Among women in the study, breakthrough pain was found to be higher on average than for men, and women’s most recent pain flares also were stronger on average than men’s flares.

— Source: University of Michigan Health System

The American College of Emergency Physicians (ACEP) said a study from Austin, TX, was incorrectly being used to perpetuate the myth that emergency departments (ED) are overcrowded because of patients with nonurgent medical conditions. Nick Jouriles, MD, president of ACEP, issued the following statement:

“Patients with nonurgent problems represent only 12% of all emergency visits nationally, and they cost the least to treat in both time and resources. It is frankly absurd to blame overcrowding in any emergency department on such a small number of people. Blaming patients deflects attention from the real reasons emergency departments are crowded.

“America’s emergency departments are crowded because we have increasing numbers of patients with serious problems seeking care in a shrinking number of emergency departments. Research clearly shows that most frequent users of the emergency department need emergency care. Every year, the country’s population gets older and sicker; these are the patients who need the most care and take up the most resources. On top of that, many hospitals engage in a practice known as ‘boarding,’ by holding patients in the emergency department even after they have been admitted to the hospital. This prevents doctors and nurses from treating new patients coming for treatment and that is the true source of overcrowding.

“The notion that emergency departments could free up significant treatment space and resources by directing the most vulnerable patients to outside resources is illogical and impractical. In fact, we believe many measures being suggested to provide care elsewhere for nonurgent patients actually increase costs.

“The myth that poor, uninsured, or underinsured patients could just as easily make appointments with a doctor is contradicted by the reality that most care providers will not treat patients without health insurance. Many providers are now also refusing to take patients with Medicare and Medicaid. These patients typically have to wait until their illnesses get severe before seeking emergency care. By that point, they often need to be admitted to the hospital. These are the people society has turned its back on, which is why they turn to emergency departments: They are the only places these people can get help.”

— Source: American College of Emergency Physicians

Women in strained marriages are more likely to feel depressed and suffer high blood pressure, obesity, and other signs of metabolic syndrome, a group of risk factors for heart disease, stroke, and diabetes, University of Utah psychologists found. The same study found men in strained marriages also are more likely to feel depressed, yet do not face an increased risk of metabolic syndrome.

“We hypothesized that negative aspects of marriages like arguing and being angry would be associated with higher levels of metabolic syndrome,” says the study’s first author, Nancy Henry, a doctoral student in psychology. “We further anticipated that this relationship would be at least partly due to depressive symptoms. … We found this was true for wives in this study, but not for husbands.”

For their wider study, the researchers used the Dan Jones & Associates polling firm and newspaper ads during 2001-2005 to recruit 276 couples, who were married an average of 20 years and aged 40 to 70. Each couple filled out several questionnaires for both the encompassing study and for Henry’s study.

The questionnaires included 10 scales: three to assess positive aspects of marriage quality; three scales to measure negative aspects of marital quality; and four scales to gauge symptoms of depression (not necessarily full-blown clinical depression). Each couple also went to a university clinic, where their waists and blood pressure were measured and they were given lab tests for “good” cholesterol, fasting glucose and triglycerides. Together, those data determined if a study participant had metabolic syndrome. They also underwent a screening test designed to exclude any couple that already had cardiovascular disease.

“We know from previous research that women are more sensitive and responsive to relationship problems than men,” Henry says. “The results of this study suggest those problems could harm their health. Understanding the emotional and relationship health of couples can be an important overall factor in understanding physical health.”

— Source: University of Utah

The use of antidepressant medications by patients with fibromyalgia is associated with a reduction in pain, sleep disturbances, and depressed mood and improvement of health-related quality of life, according to an analysis of previous studies, which is published in The Journal of the American Medical Association.

Fibromyalgia, which consists of chronic widespread pain and tenderness, with other symptoms including fatigue and sleep difficulties, has an estimated prevalence of 0.5% to 5.8% in North America and Europe. “Patients with [fibromyalgia] experience disability and reduced health-related quality of life. Fibromyalgia is also associated with high direct and indirect disease-related costs. Effective treatment of [fibromyalgia] is therefore necessary for medical and economic reasons,” the authors wrote.

Winfried Häuser, MD, of Klinikum Saarbrücken in Germany, and colleagues conducted a meta-analysis to evaluate the effects of treatment with antidepressants on fibromyalgia-related symptoms. The researchers identified 18 randomized controlled trials, involving 1,427 participants, for inclusion in the study.

Overall, there was strong evidence for a reduction of pain, fatigue, and depressed mood and improved sleep and health-related quality of life with the use of antidepressants by patients with fibromyalgia.

The researchers found large effect sizes of tricyclic and tetracyclic antidepressants for reducing pain, fatigue, and sleep disturbances; small effect sizes of selective serotonin reuptake inhibitors for reducing pain; small effect sizes of serotonin and noradrenaline reuptake inhibitors for reducing pain, sleep disturbances, and depressed mood; and small effect sizes of monoamine oxidase inhibitors for reducing pain.

— Source: American Medical Association

A new study led by researchers at Albert Einstein College of Medicine of Yeshiva University has clarified how two major variants of HIV differ in their ability to cause neurologic complications. The finding, published in the Journal of Neuroscience, highlights a new target for drugs that could prevent HIV-associated dementia, an incurable and increasingly common complication in people with AIDS. Even with antiretroviral drug therapies, up to one half of people infected with HIV will develop mild to moderate neurological complications, according to some estimates.

Earlier this decade, scientists observed that people with AIDS in India developed dementia at a far lower rate than comparable populations in the United States and western Europe. Most cases of AIDS in India are due to infection with a subtype (clade) of HIV known as clade C, while most cases in the United States and western Europe are due to clade B.

Based on these observations, in 2004, a team of researchers led by Vinayaka R. Prasad, PhD, professor of microbiology and immunology at Einstein, searched for genetic variations between the two clades that could explain the differing rates of HIV-related dementia.

To determine whether this variation makes a practical difference in HIV’s neurotoxicity, the researchers injected either clade B or clade C HIV into the brain of a special strain of immunodeficient mice. After six days—enough time for the viruses to cause neurologic damage—the mice were tested in a complex water maze that challenged their long-term memory as well as their short-term working.

Mice infected with clade B performed significantly worse in the maze than those infected with clade C. Moreover, when the researchers examined the mouse brains, they found more damage to neurons in the brains of mice injected with clade B than with clade C. These results were in line with the
fact that people infected with clade B HIV are at greater risk for dementia than people infected with clade C.

— Source: Albert Einstein College of Medicine of Yeshiva University

Individuals who receive implantable cardiac defibrillators after a sudden heart event appear more likely to die within five years if they experience symptoms of posttraumatic stress disorder (PTSD), regardless of the severity of their disease, according to a report in a recent issue of Archives of General Psychiatry.

Surviving a life-threatening heart condition, such as heart attack or cardiac arrest, causes significant distress, according to the article. Resulting symptoms may qualify an individual for a diagnosis of PTSD. Between 8% and 20% of patients with acute coronary syndromes and 27% to 38% of those who survive a cardiac arrest develop PTSD.

Karl-Heinz Ladwig, PhD, MD, of Technische Universitaet Muenchen, Munich, and Helmholtz Zentrum National Research Center for Environmental Health, Neuherberg, Germany, and colleagues studied 211 patients who had received implantable cardiac defibrillators following a heart event in 1998. Participants were surveyed an average of 27 months after implantation and 38 reported severe PTSD symptoms. All patients were then tracked through medical records, telephone interviews, reports from family members and death certificates through March 2005.

During the average follow-up period of five years, 45 of the patients (30.6%) died. This included 32 of the 109 patients with low or moderate PTSD symptoms and 13 of 38 patients with high levels of such symptoms. “Our findings provide direct evidence for an independent influence of PTSD symptoms on fatal outcome in these patients,” the authors wrote.

Patients with PTSD in the study reported more cardiac symptoms, such as chest pain, than those without PTSD. However, clinical characteristics that typically account for survival differences in such patients did not differ between the two groups. “Therefore, the perceived severity rather than the objective severity of a cardiac condition as determined by cardiac criteria may be associated with PTSD,” the authors wrote.

— Source: American Medical Association

Stimulant medications like those often prescribed for children with attention-deficit/hyperactivity disorder (ADHD) raise blood pressure and heart rate, and some drugs carry warning labels for patients with heart problems. Two professional organizations are at odds over whether routine electrocardiogram (ECG) testing is necessary before a child starts taking a medication for ADHD, reports the Harvard Mental Health Letter.

The controversy is about whether routine ECG testing is necessary before a child starts taking ADHD medication. ECG measures the electrical activity of the heart. In April 2008, the American Heart Association released a statement recommending that it was reasonable—although not mandatory—for clinicians to consider ordering an ECG in children diagnosed with ADHD before beginning treatments with stimulants or other medications.

In August, however, the American Academy of Pediatrics published a statement recommending against routine ECGs—supporting earlier recommendations made by the American Academy of Child and Adolescent Psychiatry—citing data that sudden cardiac deaths, while tragic, are rare. Such deaths occur in about two children for every million taking ADHD medications—fewer than the eight to 62 sudden deaths per million that occur in the general pediatric population.

The discussion about the relationship between heart risk and ADHD medication is likely to continue. For now, Michael Miller, MD, editor in chief of the Harvard Mental Health Letter, says the best advice is for doctors to assess heart disease risk by doing a physical exam and taking a careful medical history and to rely on a mental health professional to evaluate for ADHD.

— Source: Harvard Health Publications