Burden of illness in patients with reflux disease--evidence from a recent comparative methodological study in Hungary.

BACKGROUND: The clinical and socioeconomic burden of gastro-esophageal reflux disease (GERD) is considerable. The primary symptom of GERD is heartburn, but it may also be associated with extraesophageal manifestations, such as asthma, chest pain and otolaryngologic disorders. AIM: To describe the impact of heartburn on patients' Health-Related Quality of Life (HRQL) in Hungary, using validated generic and disease-specific instruments to measure patient-reported outcomes. METHOD: Patients with symptoms of heartburn completed the Hungarian versions of the Gastrointestinal Symptom Rating Scale (GSRS), the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), the Short Form-36 (SF-36) and the Hospital Anxiety and Depression (HAD) scale. Frequency and severity of heartburn during the previous 7 days were also recorded. RESULTS: 136 patients completed the assessments (mean age of 47 years, SD = 13; 58% female). 53% of patients had moderate symptoms and two thirds (69%) had symptoms on 3 or more days in the previous week. Patients were most bothered by symptoms of reflux (mean GSRS score of 3.4, on a scale of 1 [not bothered] to 7 [very bothered]), abdominal pain (2.8) and indigestion (2.6). As a result of their symptoms, patients experienced problems with food and drink (mean QOLRAD score of 4.6, on a scale of 1 to 7, where 1 represents the most severe impact on daily functioning), emotional distress (4.6), impaired vitality (4.7), and sleep disturbance (4.8). This led to impaired overall HRQL across all domains (mean SF-36 score of this heartburn population compared to a general population in Hungary). Using HAD, 29% of patients were anxious and 17% were depressed. CONCLUSION: There is consistent evidence that GERD substantially impairs all aspects of health-related quality of life.

Psychometric validation of the Hungarian translation of the gastrointestinal symptom rating scale (GSRS) and quality of life in reflux and dyspepsia (QOLRAD) questionnaire in patients with reflux disease.

BACKGROUND: Symptoms of heartburn and their impact on health-related quality of life (HRQL) are often evaluated in clinical trials. When a questionnaire is translated into a new language, a linguistic validation is necessary but not sufficient unless the psychometric characteristics have been verified. The aim of the paper is to document the psychometric characteristics of the Hungarian translation of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire. METHODS: One hundred and thirty-six patients with symptoms of heartburn (age: M = 47.3, SD = 13.4; females = 58.1%) completed the Hungarian translation of GSRS, the heartburn version of QOL-RAD, the Short-Form-36 (SF-36) and the Hospital Anxiety and Depression (HAD) scale. Eighty-seven patients were scheduled for a second visit a week later to complete the GSRS and QOLRAD again. RESULTS: The internal consistency reliability of GSRS ranged from 0.62-0.84 and of QOLRAD from 0.88-0.94, and the test-retest reliability of GSRS ranged from 0.52-0.82 and of QOLRAD from 0.68-0.82. The relevant domains of the GSRS, 'Reflux', 'Abdominal Pain' and 'Indigestion', and QOLRAD domain scores significantly correlated. All GSRS domains except 'Reflux' strongly correlated (negatively) with all SF-36 domains. All QOLRAD domains significantly correlated with all SF-36 domains. CONCLUSIONS: The psychometric characteristics of the Hungarian translations of GSRS and QOLRAD were found to be good, with satisfactory reliability and validity. The test-retest reliability of the GSRS 'Reflux' domain was, however, not optimal.

Forensic issues in pain: review of current practice.

Forensic activity in pain practice is reviewed with reference to the differing roles of the pain clinician and the independent expert. Ethical guidelines and recommendations for assessment, documentation, record review, and court testimony are discussed. Specific issues include the assessment of disability and impairment, malingering, and application of the Daubert standard in forensic pain practice. Examples of case law are reviewed for civil liability and CRPS, malpractice with opioid prescribing, and practice issues in a correctional setting.

Comorbidity of post-traumatic stress disorder and chronic pain: implications for clinical and forensic assessment.

A summary of the current state of science is presented with reference to post-traumatic stress disorder (PTSD) and pain. Historical development of the diagnosis, current nosology, epidemiology, pathophysiology, and controversies are discussed. Issues of evaluation are reviewed, with specific reference to forensic assessment. Treatment outcome studies are briefly reviewed, with a review of currently accepted treatment interventions, including pharmacologic and behavioral modalities. An emphasis is placed on an integrated treatment plan in which chronic pain and PTSD both are present.

Aerobic fitness testing in patients with chronic low back pain: which test is best?

STUDY DESIGN: This is a randomized comparison of three exercise tests in a sample of 30 patients with chronic low back pain. OBJECTIVES: To determine, by comparing three exercise tests, which test yields the highest peak and predicted oxygen consumption in a sample of patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Little is known about the level of aerobic fitness in patients with chronic low back pain, although many rehabilitation programs emphasize aerobic exercise as an important part of their therapy. Measurement of aerobic fitness levels in these patients remains a problem. In healthy individuals, the highest oxygen consumption values come from exercise tests that use the largest muscle groups. For a number of reasons, this may not be true in patients with chronic low back pain. METHODS: In this study, 30 participants with chronic low back pain performed three symptom-limited maximal exercise tests: a treadmill, an upper extremity ergometer, and a bicycle ergometer. The tests were administered in randomized order. Heart rate was continuously monitored and oxygen consumption in terms of mL/kg/minute was measured by indirect calorimetry each 30 seconds. RESULTS: The statistical difference among the tests was highly significant (P < 0.0001). The treadmill test yielded the highest peak and predicted oxygen consumption followed by the bicycle and the upper extremity ergometer test, respectively. CONCLUSIONS: The treadmill test is the best test for measuring aerobic fitness levels in patients with chronic low back pain. It yielded the highest peak oxygen consumption compared with the other tests, coming closest to measuring maximal oxygen consumption.

Posttraumatic gustatory neuralgia: a clinical model of trigeminal neuropathic pain.

Six cases are reported in which the primary complaint was episodic, recurrent facial pain that was triggered by a taste stimulus. The pain first occurred days to weeks after head and neck surgery. Patients reported that a food stimulus placed in the mouth evoked episodic, electric shock-like pain in a preauricular location on the surgical side. The smell of food or, less reliably, emotional excitement could also trigger pain. Mandibular movement did not evoke the pain, and between lancinating attacks there was either no pain or only mild discomfort. Following an episode of pain, there was a refractory period during which the pain could not be elicited. Physical examination demonstrated a preauricular sensory loss of variable distribution. No abnormal sweating or vasomotor findings were clinically apparent. No odontogenic, muscular, salivary gland, neurologic, or psychologic pathology was found to explain the clinical symptoms. The pain was not relieved with standard doses of anticonvulsants that are commonly used to treat trigeminal neuralgia. The duration of the recurrent pain symptoms in this group was 8 to 132 months without remission. Gustatory neuralgia may be a discrete syndrome that results from abnormal interactions between salivary efferent fibers and trigeminal sensory afferent fibers in the injured auriculotemporal nerve. The unique features of the disorder make it a potentially useful clinical model for the investigation of autonomic/sensory interactions in neuropathic pain.

Claims payment issues: an HMO perspective.

One of the primary objectives of a complete healthcare delivery system is to provide appropriate and timely payment to providers. One major health maintenance organization (HMO) meets that objective by refining database management, fee uniformity, and electronic claims submission.

Behavioral medicine. Broadening the interface between medicine and behavioral science.

The work of psychotherapists who have a cognitive-behavioral orientation and are trained in time-limited, focused psychotherapy has proved to be beneficial in the setting of a comprehensive medical and health maintenance organization. Group interventions that deal with relaxation, social skills, depression, agoraphobia, smoking cessation, problem drinking, weight modification, and Type A behavior, to mention a few, are conducted on an ongoing basis, allowing staff to treat large numbers of people in a time-efficient and cost-effective way. These groups also help the staff to provide a coordinated set of therapeutic and training experiences for patients through their participation in appropriate group treatment during the course of their individual treatment.