published_or_final_version / Anaesthesiology / Master / Master of Philosophy

Live kidney donors are healthy volunteers who are exposed to major surgical procedure and physical harms with no direct therapeutic benefits. Efforts to minimize their risks and morbidity are therefore of utmost importance. The current thesis describes studies on donor evaluation, surgical procedure and postoperative management of live kidney donors. The overall purpose is to evaluate and possibly improve routines and treatments in order to reduce risks and the overall morbidity of live kidney donors. In Study I, we evaluated the assessment of kidney function during donor evaluation and found that the accuracy of iohexol glomerular filtration rate (GFR) is compromised by large variations in repeated measurements in presumably healthy donors. We proposed that there is a need for improvement of GFR measurements and that the assessment of predonation kidney function should be more comprehensive, involving GFR, laboratory investigations, functional and morphological examinations and sound clinical judgment. In Study II, we addressed the risk of perioperative venous thromboembolism (VTE) and concluded that expanding the standard screening protocol for VTE to include perioperative venous duplex can potentially decrease the VTE-related morbidity. In studies III and IV, we investigated the impact of hand-assisted retroperitoneoscopic (HARS) nephrectomy on donor safety and perioperative morbidity. The HARS nephrectomy uses the hand-assisted approach, which enables immediate manual compression for hemostasis in case of sudden and severe bleeding. Additionally, the pure retroperitoneal access further increases the safety margin of laparoscopic donor nephrectomy by 1) minimizing the risk of intestinal injury, and 2) exposure of the retroperitoneal nerves, making HARS suitable for continuous infusion of local anesthetics (CILA). CILA effectively reduces the need for opioid consumption and has the potential to totally obviate opiate analgesics postoperatively. Consequently, CILA in combination with HARS reduces morphine-related morbidity and promotes postoperative recovery. In accordance with these data, we recommend improvement and modification of the donor evaluation process as well as a broad introduction of HARS nephrectomy in combination with CILA to increase the safety margin for live kidney donors.

Despite the increasing acceptance of biopsychosocial models of pain and multidisciplinary treatments for pain, relatively little is known about the specific psychological variables and social processes related to postoperative pain in children, especially in an outpatient setting. The present study examined demographic, medical, and psychological predictors of children's pain and parents' administration of pain medication. Two hundred and thirty-six families with children aged 2 to 12 undergoing day surgery participated in the study. This included a subset of 100 children aged 6 to 12, who were asked to complete self-report measures of anxiety, expected pain, coping style, and pain. Parents of all children completed measures of expected pain, expected benefit from medication, perspective taking, and negative attitudes towards analgesics. Parents and school-aged children completed pain diaries on the day of surgery and two days following surgery. The prevalence of clinically significant pain was somewhat lower than in previous studies, but both pain and undertreatment (parents who gave less than the recommended amount of pain medication) remained common. Predictors of pain were examined by multiple regression, using data from the subset of 100 children aged 6 to 12. More intense pain was related to more invasive surgery, a constellation of analgesic-related variables (more doses of analgesia given, the use of a regional block, the use of local infiltration), high anxiety, high expectations of pain, and a tendency to cope with pain by acting out and catastrophizing. Predictors of dosing were examined by multiple regression, using data from the entire sample of 236 children. Parents gave more medication when their children had invasive surgery and high levels of pain, when they expected a lot of pain, and when they were relatively unconcerned about the negative effects of pain medication. In each case, the psychological variables, entered as a block, were significant predictors of pain even after controlling for demographic and medical variables. Health care providers should be aware of psychological factors predicting pain, as they may help to identify families that are at "high risk" for pain and undermedication. In addition, the variables identified in this study are appropriate targets for further research on psychological factors that cause, mediate or contribute to pain processes, and as such may contribute to the development of theoretical models of pain and pain management.

The purposes of this study is to determine: (a) the relationship between the dependant variables, (b) the relationship between the Borg pain scale and the performance tests, (c) the difference in performance between involved and uninvolved extremities, and (d) the effects of the three different therapeutic exercise treatments on selected performance tests and pain free isometric strength testing. Fifty subjects with physician diagnosed anterior knee pain (AKP), completed initial performance testing and 14 subjects completed initial testing, therapy and six weeks later final performance testing. The 14 subjects were randomly assigned to one of three therapeutic exercise treatment groups. The performance tests included; pain free isometric strength tests (90, 60, 45, and 15 degrees knee flexion), stair test, timed hop, triple hop, crossover hop, Figure 8 and Borg pain scale rating for each performance test. The results indicated a significant correlation between performance tests and pain free isometric strength tests. There was no relationship indicated between the performance tests, Borg pain scale ratings. The contrast between the injured and uninjured extremities performance test values of the fifty subjects that completed the initial testing indicated no significant (p< 0.05) difference. The results of this study indicated that there was no significant difference between the therapeutic exercise treatment groups. In conclusion, the three anterior knee pain treatments had no effect on strength and performance. / School of Physical Education

Doctor of Philosophy / Despite the demonstrated efficacy of cognitive-behavioural therapy for chronic pain, recent research has attempted to identify predictors of treatment outcome in order to improve the effectiveness of such treatments. This research has indicated that variables such as the nature of the onset of the pain and psychopathology are associated with poor adjustment to chronic pain. Accordingly, these variables might also be predictive of poor response to treatment. Individuals who experience a sudden onset of pain following an injury or accident, particularly when the instigating event is experienced as psychologically traumatic, may present for treatment with high levels of distress, including symptoms consistent with a posttraumatic stress response. The impact of this type of onset of pain and posttraumatic stress symptoms on adjustment to chronic pain and treatment outcome is the focus of this thesis. Three studies were conducted to clarify and extend earlier research findings in this area. Using 536 patients referred for treatment in a tertiary referral pain management centre, the first study examined the psychometric properties of a widely used self-report measure of posttraumatic stress symptoms (the PTSD Checklist, or PCL), modified for use in a chronic pain sample. This study provided preliminary support for the suitability of the PCL as a self-report measure of Posttraumatic Stress Disorder (PTSD) symptoms in chronic pain patients. However, the study also highlighted a number of issues with the use of self-report measures of posttraumatic stress symptoms in chronic pain patient samples. In particular, PCL items enquiring about symptoms which are a common aspect of the chronic pain experience (e.g. irritability, sleep problems) appeared to contribute to high mean scores on the PCL Avoidance and Arousal subscales. Furthermore, application of diagnostic cut-off scores and an algorithm recommended for the PCL in other trauma groups suggested that a much larger proportion of the sample was identified as potentially meeting diagnostic criteria for PTSD than would have been expected from previous research. The second study utilised the modified PCL to investigate the impact of different types of onset of pain (e.g. traumatic onset) and posttraumatic stress symptoms on adjustment to chronic pain in a sample of 196 chronic pain patients referred to the same centre. For patients who experienced the onset of pain related to a specific event, two independent experts in the field of PTSD determined whether these events satisfied the definition of a traumatic event according to DSM-IV diagnostic criteria. Adjustment was assessed through a number of validated measures of mood, disability, pain experience, and pain-related cognitions. Contrary to expectations, comparisons between patients who had experienced different types of onset of pain revealed few significant differences between them. That is, analyses comparing patients presenting with accident-related pain, or pain related to other specific events, to patients who had experienced spontaneous or insidious onset of pain revealed no significant differences between the groups on measures of pain severity, pain-related disability, and symptoms of affective distress after adjustment for age, pain duration, and compensation status. Similarly, comparisons between patients who had experienced a potentially traumatic onset of pain with those who had experienced a non-traumatic or spontaneous or insidious onset of pain also revealed no significant differences on the aforementioned variables. In contrast, compensation status, age, and a number of cognitive variables were significant predictors of pain severity, pain-related disability, and depression. The final study investigated the impact of type of pain onset and posttraumatic stress symptoms on response to a multidisciplinary cognitive-behavioural pain management program. Unlike the previous study, this treatment outcome study revealed a number of differences between onset groups. Most notably, patients who had experienced an insidious or spontaneous onset of pain reported greater improvements in pain severity and maintained these improvements more effectively over a one month period than patients who had experienced pain in the context of an accident or other specific incident. There was also limited evidence that improvements in depression favoured patients who had experienced an insidious or spontaneous and non-traumatic onset of pain. Consistent with this, posttraumatic stress symptoms were a significant predictor of treatment outcome, with higher levels of symptoms being associated with smaller improvements in pain-related disability and distress. Notably, this study also revealed that certain cognitive variables (i.e. catastrophising, self-efficacy, and fear-avoidance beliefs) were also significant predictors of treatment outcome, consistent with previous findings in the pain literature. This provided some perspective on the relative roles of both PTSD symptoms and cognitive variables in adjustment to persisting pain and treatment response. These findings were all consistent with expectations and with previous research. Implications for future research and for the assessment and treatment of chronic pain patients who present with posttraumatic stress symptoms are discussed.

Doctor of Philosophy / Despite the demonstrated efficacy of cognitive-behavioural therapy for chronic pain, recent research has attempted to identify predictors of treatment outcome in order to improve the effectiveness of such treatments. This research has indicated that variables such as the nature of the onset of the pain and psychopathology are associated with poor adjustment to chronic pain. Accordingly, these variables might also be predictive of poor response to treatment. Individuals who experience a sudden onset of pain following an injury or accident, particularly when the instigating event is experienced as psychologically traumatic, may present for treatment with high levels of distress, including symptoms consistent with a posttraumatic stress response. The impact of this type of onset of pain and posttraumatic stress symptoms on adjustment to chronic pain and treatment outcome is the focus of this thesis. Three studies were conducted to clarify and extend earlier research findings in this area. Using 536 patients referred for treatment in a tertiary referral pain management centre, the first study examined the psychometric properties of a widely used self-report measure of posttraumatic stress symptoms (the PTSD Checklist, or PCL), modified for use in a chronic pain sample. This study provided preliminary support for the suitability of the PCL as a self-report measure of Posttraumatic Stress Disorder (PTSD) symptoms in chronic pain patients. However, the study also highlighted a number of issues with the use of self-report measures of posttraumatic stress symptoms in chronic pain patient samples. In particular, PCL items enquiring about symptoms which are a common aspect of the chronic pain experience (e.g. irritability, sleep problems) appeared to contribute to high mean scores on the PCL Avoidance and Arousal subscales. Furthermore, application of diagnostic cut-off scores and an algorithm recommended for the PCL in other trauma groups suggested that a much larger proportion of the sample was identified as potentially meeting diagnostic criteria for PTSD than would have been expected from previous research. The second study utilised the modified PCL to investigate the impact of different types of onset of pain (e.g. traumatic onset) and posttraumatic stress symptoms on adjustment to chronic pain in a sample of 196 chronic pain patients referred to the same centre. For patients who experienced the onset of pain related to a specific event, two independent experts in the field of PTSD determined whether these events satisfied the definition of a traumatic event according to DSM-IV diagnostic criteria. Adjustment was assessed through a number of validated measures of mood, disability, pain experience, and pain-related cognitions. Contrary to expectations, comparisons between patients who had experienced different types of onset of pain revealed few significant differences between them. That is, analyses comparing patients presenting with accident-related pain, or pain related to other specific events, to patients who had experienced spontaneous or insidious onset of pain revealed no significant differences between the groups on measures of pain severity, pain-related disability, and symptoms of affective distress after adjustment for age, pain duration, and compensation status. Similarly, comparisons between patients who had experienced a potentially traumatic onset of pain with those who had experienced a non-traumatic or spontaneous or insidious onset of pain also revealed no significant differences on the aforementioned variables. In contrast, compensation status, age, and a number of cognitive variables were significant predictors of pain severity, pain-related disability, and depression. The final study investigated the impact of type of pain onset and posttraumatic stress symptoms on response to a multidisciplinary cognitive-behavioural pain management program. Unlike the previous study, this treatment outcome study revealed a number of differences between onset groups. Most notably, patients who had experienced an insidious or spontaneous onset of pain reported greater improvements in pain severity and maintained these improvements more effectively over a one month period than patients who had experienced pain in the context of an accident or other specific incident. There was also limited evidence that improvements in depression favoured patients who had experienced an insidious or spontaneous and non-traumatic onset of pain. Consistent with this, posttraumatic stress symptoms were a significant predictor of treatment outcome, with higher levels of symptoms being associated with smaller improvements in pain-related disability and distress. Notably, this study also revealed that certain cognitive variables (i.e. catastrophising, self-efficacy, and fear-avoidance beliefs) were also significant predictors of treatment outcome, consistent with previous findings in the pain literature. This provided some perspective on the relative roles of both PTSD symptoms and cognitive variables in adjustment to persisting pain and treatment response. These findings were all consistent with expectations and with previous research. Implications for future research and for the assessment and treatment of chronic pain patients who present with posttraumatic stress symptoms are discussed.

No description available.

The purpose of this study is to replicate and extend earlier work involving cluster analysis of MMPI profiles among persons with chronic low back pain. There are two specific goals. The first goal is to demonstrate the existence in a new sample of four distinct and homogenous profile clusters that have been found in previous research. The second goal is to investigate the relationship of the four profiles to the subjects, self-reported pain history and response to treatment. This study concludes that four distinct MMPI profiles can be identified among chronic low back pain patients. Further, these profiles are the same for males and females, and are the same profiles found in previous research. These profiles are significantly related to subjects' history of behaviors in dealing with pain. However, no relationship to treatment response was found. It was inferred that the MMPI is of value in understanding the nature of patients' pain coping behaviors, but that further research is needed before any statements can be made regarding the utility of the MMPI in understanding their response to treatment.

The topic of this diploma thesis is ?The Nurse?s Contribution to the Management of Pain Treatment of Patients with a Malignant Disease?. The first objective is to ascertain whether nurses know the specifics of care of patients suffering from a cancer pain. The second objective is to ascertain whether nurses use an analogue score to assess the cancer pain. The third objective is to ascertain whether nurses document the pain intensity. The fourth objective is to ascertain whether nurses use non-pharmacological techniques to relieve cancer pains. The fifth objective is to ascertain whether nurses know the strategy of the WHO?s pain relief ladder. The research was conducted in the form of questioning while using the technique of anonymous structured questionnaires completed by the research set consisting of nurses in selected clinical wards with a high probability of occurrence of patients with an oncologic diagnosis. The total of 360 questionnaires was distributed, of which 198 completed questionnaires were returned. 105 questionnaires (53 %) came from the regional hospital in České Budějovice, 51 (26 %) from the St. Anne?s University Hospital in Brno and 42 (21 %) from the district hospital in Tábor. The research took place in March 2012. The results were assessed under the criteria preset by the author of the thesis. Hypothesis 1: Nurses are able to provide specific nursing care to patients suffering from a cancer pain, was confirmed. Hypothesis 2: Nurses assess the pain under the available analogue scores, was confirmed. Hypothesis 3: Nurses document the pain intensity, was disconfirmed. Hypothesis 4: Nurses use non-pharmacological techniques, especially physical ones, was confirmed. Hypothesis 5: Nurses know the strategy of the WHO?s pain relief ladder, was confirmed. In connection with the addressed issue, an educational leaflet about pain monitoring was drawn up for non-medical healthcare workers. This material describes the most frequently used methods of pain assessment and will serve as an overview of individual procedures including their specifics and application possibilities. The diploma thesis may serve for extending the knowledge of nurses in the field of pain treatment management.

Thesis (MTech (Nursing))--Cape Peninsula University of Technology, 2008. / In South Africa the need for palliative care for the terminally ill is exacerbated by the upsurge of the HIV/AIDS epidemic resulting in more patients being in need of palliative care and the provision of effective pain management as part of providing them with palliative care. Effective pain management requires sound knowledge of the pathophysiology of pain and its treatment. Research found the attitudes, beliefs, and knowledge of healthcare professionals regarding pain management impact significantly on how these professionals practice pain control measures of the terminally ill. Despite the increase in knowledge and technological advances people still die in pain. The upsurge of cancer and AIDS cases require that all nursing practitioners be competent to deliver palliative care. Effective pain management is an integral part of palliative care. South Africa has a nurse-driven health care system where Registered Nurses are expected to become competent in among other health care issues, to manage pain in the increasing numbers of terminally ill patients due to especially AIDS epidemic.