Chronic pain has been identified as a major and underestimated health care problem, with extensive individual, social and economic ramifications. It has been estimated that the annual economic cost of chronic pain in Australia exceeds AU$34 billion. The available epidemiological evidence suggests chronic pain is a relatively common health problem in Australia which is a significant public health issue. Chronic pain is a complex phenomenon which is not easily defined. However, it is important to consider the ways in which chronic pain is conceptualised, as this can have significant implications for the individual in terms of how they think about their pain, and the way they are treated within the health care system and the broader society. In the late nineteenth and early twentieth centuries, pain was predominantly considered a symptom of a biological problem in the body. Absence of physical disease was thought to indicate pain was the result of aberrant psychological processes. However, chronic pain proved resistant to this ‘mind-body’ approach, and the lack of efficacy of many biomedical interventions, combined with an apparently increasing prevalence of chronic pain, pointed to the inadequacy of purely biomedical approaches to pain treatment. The latter part of the twentieth century saw the recognition of pain as a multidimensional experience influenced by the interaction of numerous biological, psychological and social factors. Consequently, the biopsychosocial model of health, which emphasised such a ‘holistic’ perspective, gained substantial recognition in the pain management domain, and was endorsed as the preferred model of pain management. This has contributed to the development of new approaches to chronic pain treatment, particularly in the area of cognitive behavioural therapy and the establishment of multidisciplinary pain centres. There is evidence, however, that the ‘promise’ of the multidimensional conceptualisation and treatment of chronic pain has not been realised in the daily lives of people with chronic pain. Review of the literature indicates a tendency for research and practice to focus on the biological and psychological aspects of chronic pain, while minimising social environmental factors, such as the health care system and cultural belief systems regarding pain, which may also be significant. This thesis proposes that in order to more comprehensively respond to the complex phenomenon of chronic pain, it is necessary to further develop the social domain of the biopsychosocial model. A study was conducted to explore and describe individual experiences of living with chronic pain, as a basis for improving knowledge about the influence of the social environment on the individual. The thesis focuses not only on the individual descriptions of living with chronic pain, but also on the inter-relatedness between the individual and their social environment. Further, this thesis uses a process of critical interpretive analysis to identify aspects of the social environment which can exert a constraining or enabling effect on the individual with chronic pain. The thesis draws on critical realism theory, particularly the morphogenetic approach developed by Archer (1995), to guide the analysis process and to develop potential strategies for addressing identified social disadvantages. The integration of the individual stories of living with chronic pain with an interpretive analysis process, and the underlabouring philosophical perspective of critical realism, provided the framework to investigate the influence of the social environment on individual experience of living with chronic pain. In this thesis, a journey metaphor is used as an overarching framework to tie together the three principal themes identified through the analysis of the interview transcripts. The themes focused on the biomedical, psychological and cultural paths that participants followed in search of understanding and cure for their pain; the social suffering they experienced through lack of understanding and legitimation of their condition; and the identification and development of strategies for living with chronic pain. The thesis highlights the critical importance of focusing not only on the individual with chronic pain but also on the social environment within which the individual lives, and the ways in which these domains intersect and influence each other. The social environment was found to condition the individual and others in society, including health care practitioners, in relation to how they think and behave regarding pain, which in turn can have enabling or constraining consequences for the individual with pain. In particular, cultural beliefs about ‘normal’ pain, and the material structures of the health care system and employment and work places, were found to have a potentially negative impact on the individual with pain. It is concluded that these aspects of society will continue to exert constraining influences on people’s lives until the focus of policy and practice is expanded to include not just the individual with pain, but also the social environment in which they live. To address this, a number of policy and practice improvements are suggested.

<p>Vilka psykologiska processer som gör att vissa individer klarar sig bättre än andra i påfrestande situationer har väckt allt större intresse hos forskarna. Syftet med den här studien var att undersöka vilken betydelse socialt stöd har för anpassningen till kronisk reumatisk sjukdom. Studien utfördes i form av tolv halvstrukturerade intervjuer. Analys av materialet som helhet antydde att intervjupersonerna ansåg att socialt stöd från omgivningen hade hjälpt dem att anpassa sig till sjukdomen. Vården, i form av bland annat läkare, framstod som ett särskilt viktigt socialt stöd. Även stödet från andra individer med liknande sjukdom lyftes fram som betydelsefull. Den största anpassningen till sjukdomen verkar ske de första åren, men tycks också därefter pågå fortlöpande.</p>

<p>Chronic lymphocytic leukemia (CLL) cells are considered to be derived from antigen-exposed B cells. To further explore the antigen-driven selection behind the leukemogenesis of CLL, we performed immunoglobulin (Ig) specificity screening of 7 CLL cell lines and 23 primary CLL clones from patient peripheral blood. We also included a recombinant monovalent monoclonal antibody (mAb) belonging to a subset of CLL cases with identical or semiidentical heavy chain complementarity determining region 3 (HCDR3) of the IGHV3-21 gene rearrangement. We found CLL mAb specificities against vimentin, filamin B, cofilin-1, proline-rich acidic protein 1, cardiolipin, oxidized low density lipoprotein and Streptococcus pneumoniae polysaccarides. These molecules are functionally associated with microbial infection and/or apoptotic cell removal. An antigen-driven selection would therefore imply that CLL B cell precursors are involved in the elimination and scavenging of pathogens and apoptotic cells, which could trigger the development of the disease.</p><p>The limited in vitro survival of CLL cells makes Epstein-Barr virus (EBV) immortalization of CLL cells a useful experimental model for studies on antibody-specificity screening. Considering the intricate procedure of EBV transformation of CLL cells and the many false cell lines used worldwide, we also wanted to characterize and evaluate the authentic origin of several previously established CLL cell lines and their normal lymphoblastoid counterparts. Three of the CLL cell lines tested were truly authentic (I83-E95, CLL-HG3 and CII), two had features of a biclonal Ig expression (232B4 and WaC3CD5+), one was only tentatively verified (PGA-1), whereas one cell line could not be verified (EHEB) due to lack of original patient cells for comparison. Two of the presumed normal lymphoblastoid cell lines tested were shown to be a neoplastic CLL clone. This study emphasizes the importance of proper cell line authentication and we will continue to verify additional cell lines not yet proven authentic.</p><p>In conclusion, we provide evidence for natural Ab production by CLL cells and suggest that these cells might be derived from B cell precursors involved in the innate immunity and, thus, providing a first-line-defence against pathogens and in elimination of apoptotic cells.</p>

<p>Litteraturstudiens syfte var att beskriva vilka copingresurser som individer med långvarig smärta använder sig av samt hur dessa resurser förbättrar eller försämrar individernas möjlighet att acceptera sin smärta. Designen för litteraturstudien var deskriptiv och studien baserades på 17 vetenskapliga artiklar med både kvantitativ och kvalitativ ansats. Litteratursökningarna utfördes i databaserna Medline (via PubMed) samt CINAHL. Huvudresultatet visade att individer med långvarig smärta använde sig av inre copingresurser som fysiska och psykosociala copingresurser samt förmågor vid acceptans av långvarig smärta. Individer använde sig även av yttre copingresurser som socialt stöd och materiella copingresurser. Dessa copingresurser kunde förbättra eller försämra individers möjlighet att acceptera långvarig smärta. Litteraturstudiens slutsats belyste vikten av att sjuksköterskan har kunskap om att fysiska, psykiska, sociala och existentiella aspekter genererade smärtupplevelsen. Sjuksköterskan behövde även ha kännedom om copingresurser för att kunna uppmärksamma individens unika förutsättningar och behov. Detta gjorde det möjligt för sjuksköterskan att erbjuda professionellt stöd anpassat efter individens unika copingresurser och hjälpa denne att uppnå acceptans av långvarig smärta. </p> / <p>The aim of the literature rewiev was to describe which coping skills individuals with chronic pain use and how these skills improve or impair the individuals' ability to accept their pain. The design for the literature study was descriptive and the study was based on 17 scientific articles of both quantitative and qualitative approach. The literature searches were carried out in the databases Medline (via PubMed) and CINAHL. The main result showed that individuals with chronic pain use internal skills such as physical and psychosocial skills and abilities to accept chronic pain. Individuals also use external skills such as social support and material resources. These skills can improve or impair individuals' possibility to accept chronic pain. The conclusion highlighted that a nurse should have knowledge about that physical, psychological, social and existential aspects generated the pain experience. A nurse should also have knowledge about coping skills in order to pay attention to the individual's unique circumstances and needs. This enabled the nurse to offer professional support tailored to the individual's unique coping skills and help the individual to achieve acceptance of chronic pain.</p>

<p>Phenylketonuria (PKU) is an inborn, metabolic disease affecting the enzyme phenylalanine hydroxylase, which converts phenylalanine to tyrosine. Since 1965, all Swedish patients are treated with a diet from the neonatal period, while patients without treatment become severely mentally retarded. This thesis presents a recent survey of intelligence, adjustment, and coping among Swedish patients with PKU aged 8-19 years. In Study I the patients’ blood phenylalanine level was in accordance with treatment norms and they were normal in terms of intelligence and adjustment. The next study was a comparison of adjustment between patients with PKU, patients with neurobehavioral disorders, and patients with obesity. A reference group with matched non-clinical children was included. In this comparison, patients with PKU did not differ from the healthy children. Patients with neurobehavioral disorders were the least adjusted, and patients with obesity differed from the reference group and from patients with PKU in some respects, indicating less work capacity and internalising problems. Study II was undertaken for methodological reasons and showed that the measure of adjustment was reliable and valid. Study III was an investigation of psychological mechanisms associated with adherence to the dietetic therapy in PKU. The results showed that parents’ problem-focused coping was the main factor behind good adherence. A marked transition to self-care was recommended to enhance the patients’ motivation to continue with the diet into adulthood. This thesis concludes that the good outcome among the Swedish patients is due to general improvement of the treatment, but a contributing factor can be the high and fairly equal standards of living in the Swedish society.</p>

This dissertation describes how to apply pharmacokinetic simulations and modeling in a clinical setting to monitor and adjust drug dosing in special patient populations. Pharmacokinetic simulations were used to investigate efficacy and risk of drug toxicity of a new dosing regimen for aminoglycoside antibiotics when administered to renal failure patients. The current method of administering aminoglycosides to renal failure patients is to dose the drug during the last half hour of dialysis sessions. The new proposed method suggests dosing the drug during the first half hour of the dialysis session. Using one-compartment model infusion equations, both methods were simulated to predict drug peaks, troughs and area under the curves. These parameters were used to compare both dosing regimens to find out if the proposed dosing regimen can be suggested in a clinical setting to obtain the same efficacy and lower risk of drug toxicity. The dissertation then describes a prospective clinical study in chronic renal failure patients who received the same tobramycin dose using current and proposed dosing regimens. Results from the clinical study confirm pharmacokinetic simulations and modeling outcomes. Results suggest that both regimens have the same efficacy, but the new proposed method is expected to have lower risk of drug toxicity. The dissertation also describes a retrospective study for vancomycin dosing in renal failure patients. The objective was to confirm that pharmacokinetic modeling could be used to predict and adjust vancomycin dosing for this special population. Vancomycin trough concentrations obtained from patient medical records were compared to predictions obtained using a pharmacokinetic model. It was concluded that there was no statistically significant difference between actual and predicted vancomycin trough concentrations. These results suggest that the pharmacokinetic model can be used to predict and adjust vancomycin dosing to chronic renal failure population. The last part of this dissertation describes evaluation of insulin glargine effect on glycemic control and weight change in a diabetic population. Glycemic control and weight of patients before and after initiation of insulin glargine were evaluated retrospectively. Results showed that initiation of insulin glargine improved glycemic control while weight remained relatively stable. / Graduation date: 2005

Thesis (M. Nurs.)--University of Hong Kong, 2006.

Pain coping is the purposeful effort people use to manage and minimize the negative impacts of pain. The scientific literature on pain coping conceptualizes its role in recovery as a reciprocal interactive process of psychological, social, and biological factors. The objective of this dissertation was to investigate how workers cope with pain and how coping relates to recovery. Paper one-How Do Injured Workers Cope with Pain? A Descriptive Study of Injured Workers with Occupationally Related Long Term Pain, aimed to identify pain coping strategies used by workers and identify characteristics related to each strategy. This study hypothesized that workers coping may be a function of biological, social, and psychological factors. The results indicated that the most frequently used coping strategy was coping self statements, followed by praying and hoping, and catastrophizing. Additionally, coping strategies differed according to gender, marital status, education, part of the body injured, levels of depressed symptomatology, and pain. The objective of paper two, Predicting Recovery for Workers with Chronic Pain: Does Pain Coping Matter?, was to measure the prognostic values of pain coping strategies, using polynomial logistic regression and Cox regression, on two commonly used measures of recovery, self perceived disability and time to suspension of benefits. The adjusted polynomial models showed that coping self statements predicted moderate disability. The Cox regressions showed that increases in diverting attention, pain related behaviours, and perceived control meant small but significant decreased chances of suspended benefits. Paper three, Self Perceived Disability in Workers with Chronic Pain: Does Depression Matter?, sought to identify factors associated with self perceived disability at the beginning of rehabilitation. Depression and pain interacted to affect disability therefore, two multivariable models were built. For depressed workers, every one point increase in pain was associated with a 58% increased odds of moderate disability and a 258% increased odds of severe disability, compared to low disability. Pain control was protective for moderate and severe disability. For non-depressed workers, a one point increase in pain was associated with a 97% increased odds of moderate and a 109% increased odds for severe disability. However, Pain control was non-significant. / Epidemiology

Persons with chronic fatigue syndrome (CFS) often complain of an inability to maintain activity levels and experience a variety of orthostatic symptoms such as dizziness, trembling, nausea, postural hypotension with bradycardia or tachycardia, sweating, palpitations, paleness, and syncope. Orthostatic intolerance (OI) may be defined as an inability to maintain systolic blood pressure (SBP) within 20 mmHg of resting level upon moving from a supine to upright posture. The primary objective of this study is to determine whether men and women with CFS are more susceptible to OI during a 3-stage head-up tilt (HUT) than non CFS, sedentary subjects matched by age, sex, and ethnicity. The secondary objective is to examine whether possible underlying mechanisms may be predictively associated with OI susceptibility in CFS. Possible causes of OI include autonomic nervous system (ANS) dysfunction and altered hematological profile. Thus, specific aims included within this objective are: 1) to determine whether there are differences in resting cardiovascular function {i.e., blood pressure [BP], heart rate [HR], stroke volume [SV], cardiac output [CO], total peripheral resistance [TPR], and contractility [i.e., ejection fraction (EF), fractional shortening (FS), and the velocity of circumferential shortening corrected by HR (VCFc)]}, ANS function {i.e., beta1-, beta2-, and alpha-receptor sensitivities, baroreceptor sensitivity [BRS], and vagal function [i.e., respiratory sinus arrhythmia (RSA), RSA envelope (RSAE), high frequency (HF) spectral component, and HR range]}, and hematological profile [i.e., red blood cell volume (RBCV), plasma volume (PBV), and total blood volume (TBV)] between CFS and non-CFS groups; and 2) to determine whether cardiovascular, ANS, and hematological measures differentially predicted OI during HUT. The results indicate that OI susceptibility does not occur with greater prevalence in persons with CFS than non-CFS sedentary persons. However, power analyses revealed that with a much larger sample size group differences in OI susceptibility would be found. The CFS group was distinguished from the control group only by differences in blood volume measures. There appears to be no substantive group differences in a range of cardiovascular and ANS measures; moreover, none of these measures, including the blood volume measures, accounted for differences in OI susceptibility. Compensatory mechanisms may be present in CFS for the diminished blood volume that could explain the lack of group differences in OI susceptibility. In addition, future research may find some clues relevant to CFS pathophysiology in the assessment of hemodynamic responses during orthostatic challenge in the present subjects.

Psychosocial variables such as attachment style, depression and the working alliance were examined as predictors of treatment outcomes in the context of chronic pain patients receiving physical therapy. Four treatment outcomes were examined: change in pain severity, change in pain interference, patient satisfaction with physical therapy services and patient compliance with treatment recommendations. A model of the interplay between depression and chronic illness presented by Katon (2003) was used as a framework for the current model. Two main hypotheses were suggested. (1) The working alliance is positively related to treatment outcomes. (2) Depression is negatively associated with treatment outcomes. Data were gathered at three outpatient rehabilitation clinics and the physical therapy unit of a multidisciplinary pain clinic in two Midwestern cities. A total of 59 subjects participated and regression analyses found evidence supporting both main hypotheses. The working alliance was found to be positively correlated to the change in pain severity, the change in pain interference, patient satisfaction and patient compliance. Depression was found to be negatively correlated to the change in pain interference, patient satisfaction and patient compliance. Implications for physical therapists working with chronic pain patients include clinical recommendations for developing a good working alliance and screening for depression.