Characterizing palliative care needs in people with or at risk of developing diabetic foot ulcers.

Aims: Diabetic foot ulcers (DFUs) have a significant impact on a patient's quality of life and life expectancy, with mortality rates comparable with malignant diseases. However, there is a lack of data regarding palliative care needs in this population. We aimed to characterize palliative care needs in people under diabetic foot surveillance using the Integrated Palliative care Outcome Scale (IPOS) and EuroQol-5D three-level version (EQ-5D-3L) and to assess differences between those with and without a DFU. Methods: We conducted a cross-sectional study with consecutive sampling inclusion of patients followed in a tertiary hospital's Diabetic Foot Clinic between February and October 2019 with (n = 20) and without (n = 42) active DFU. Results: The most frequent symptoms encountered were pain, weakness or lack of energy, sore or dry mouth and drowsiness. Patients with an active DFU were significantly more likely to report feeling anxious or worried in comparison with those without (95% versus 55%, p = 0.002). Only 10% of the participants with an active DFU said that they were always able to share how they felt with family and friends as much as they wanted in comparison with 45% of those without (p = 0.006). Conclusion: Our study identified palliative care needs in patients under diabetic foot surveillance with and without DFU, including a significant presence of physical symptoms. Patients in both groups showed signs of emotional/psychological distress, with a higher manifestation in patients with DFU. To the best of our knowledge, this is the first study addressing and characterizing palliative care needs in this population.

A qualitative study of patient and carer experiences with home respiratory therapies: Long-term oxygen therapy and home mechanical ventilation.

Studies exploring the experience of patients receiving home respiratory therapies (HRT), such as long-term oxygen therapy (LTOT) and home mechanical ventilation (HMV), are still limited. This study focused on patients' and carers' experience with LTOT and HMV. An exploratory, cross-sectional qualitative study, using semi-structured focus groups, was carried out with 18 patients receiving HRT (median 71y, 78% male, 56% on both LTOT and HMV) and 6 carers (median age 67y, 67% female). Three focus groups were conducted in three regions of Portugal. Thematic analysis was performed by two independent researchers. Patients' and carers' experience was reflected in seven major topics, linked to specific time points and settings of the treatment: Initial symptoms/circumstances (n = 41), Prescription (n = 232), Implementation (n = 184), Carer involvement (n = 34), Quality of life impact (n = 301), Health care support/navigability (n = 173) and Suggestions (n = 14). Our findings demonstrate a general good perception of the HRT by patients and carers recognizing a significative quality of life impact improvement, while identifying specific points where improvements in healthcare are needed, particularly about navigability issues, articulation between the hospital, primary care and homecare teams, especially regardingprescriptionrenewal. This knowledge is crucial to promote a long-term HRT adherence and to optimize HRT delivery in line with patients' experience, needs, and values. Moreover, these key points can inform the development of a specific patient-reported experience measure (PREM) for patients on HRT, which is not currently available, and foster a more integrated respiratory care model.

The Portuguese Model of Home Respiratory Care: Healthcare Professionals' Perspective.

Patients' and carers' views regarding the Portuguese model of home respiratory care were recently described, yet the complementary perspective of healthcare professionals (HCPs) is still to be investigated. Thus, this study explored HCPs experience in the management of patients needing home respiratory therapies (HRT), and their perspective about the Portuguese model. A phenomenological descriptive study, using focus groups, was carried out with 28 HCPs (median 42 y, 68% female) with distinct backgrounds (57% pulmonologists, 29% clinical physiologists, 7% physiotherapists, 7% nurses). Three focus groups were conducted in three regions of Portugal. Thematic analysis was performed by two independent researchers. HCPs have in general a positive view about the organization of the Portuguese model of home respiratory care, which was revealed in four major topics: Prescription (number of references, n = 171), Implementation and maintenance (n = 162), Carer involvement (n = 65) and Quality of healthcare (n = 247). Improvements needed were related to patients' late referral, HRT prescription (usability of the medical electronic prescription system and renewals burden), patients' education, access to hospital care team, lack of multidisciplinary work and articulation between hospital, primary and home care teams. This study describes the perspective of HCPs about the Portuguese model of home respiratory care and identifies specific points where improvements and reflections are needed. This knowledge may be useful to decision makers improve the current healthcare model.

Translation and adaptation of the STOPP-START screening tool to Portuguese for detecting inappropriate prescriptions in older people: a protocol.

INTRODUCTION: Rational prescribing for older adults is a challenge because they usually exhibit multimorbidity and multimedication. One available and reliable tool to tackle this issue consists of the Screening Tool of Older People's Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START), which has been associated with improvements in clinical outcomes. Our goal here is to translate and validate the STOPP-START screening tool for use with Portuguese general practitioners/family physicians. METHODS AND ANALYSIS: The study will be conducted in four phases: phase I-translation of the STOPP-START screening tool to Portuguese; phase II-data collection of patient data; phase III-intrarater reliability and agreement study; and phase IV-inter-rater reliability and agreement study. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee of the Central Health Region of Portugal (where the study will take place). Every participant will sign a written consent form. We intend to publish the full article in a related peer-reviewed journal, conference presentations, reports and in a PhD thesis.

Effectiveness of Opioids for Chronic Noncancer Pain: A Two-Year Multicenter, Prospective Cohort Study With Propensity Score Matching.

Opioid use in chronic non cancer pain (CNCP) is still controversial regarding their effectiveness and safety. We conducted a 2-year prospective cohort study in 4 multidisciplinary chronic pain clinics to assess long-term opioid effectiveness in CNCP patients. All adult CNCP patients consecutively admitted to their first consultation were recruited. Demographic and clinical data were collected, and propensity score matching was used to adjust for differences between opioid users and nonusers. The Brief Pain Inventory and the Short version of Treatment Outcomes in Pain Survey were used to measure pain outcomes and quality of life. A total of 529 subjects were matched and included in our analysis. Rate of prescription opioid use was 59.7% at baseline, which increased to 70.3% over 2 years, of which 42.7% of the prescriptions were for strong opioids. Opioid users reported no improvement regarding pain symptoms, physical function, emotional function, and social/familiar disability. Opioid users reported higher satisfaction with care and outcomes at 1 year of follow-up, but at 2 years, they only reported improvement in satisfaction with outcomes. Opioids have shown limited effectiveness in long-term CNCP management, as opioid users presented no improvements regarding functional outcomes and quality of life. These findings emphasize the need for proper selection and outcome assessment of CNCP patients prescribed opioids. PERSPECTIVE: This study adds important additional evidence concerning the controversial use of opioids in CNCP management. Opioid users presented no improvement regarding pain relief, functional outcomes and quality of life over 2 years of follow-up. Therefore, our results support and highlight the limited effectiveness of opioids in long-term CNCP management.

The Impact of Anxiety and Depression on the Outcomes of Chronic Low Back Pain Multidisciplinary Pain Management-A Multicenter Prospective Cohort Study in Pain Clinics with One-Year Follow-up.

OBJECTIVE: The psychological health of patients with chronic low back pain (CLBP) influences their response to a number of conservative and invasive pain treatments. However, evidence is still scarce regarding the impact of anxiety and depression in the clinical outcomes of multidisciplinary pain management over time. This study, based on longitudinal data from a clinical practice setting, aimed to assess the effectiveness of the usual multidisciplinary approach provided to CLBP patients and to explore the impact of anxiety and depression symptoms and their interaction on clinical outcomes. METHODS: In this study, participants included were adult patients in their first consultation in a multidisciplinary chronic pain clinic. Anxiety and depression symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS). The Brief Pain Inventory (BPI) and the Shortened Treatment Outcomes in Pain Survey (S-TOPS) were used to assess outcomes. Linear mixed effects models were used to assess the impact of anxiety, depression, and their interaction on treatment outcomes. RESULTS: A total of 284 patients (age 60.4 ± 13.7 years, 74.6% female) with CLBP were included at baseline. The majority of patients had both anxiety and depression and experienced higher pain severity (P < 0.001) and higher pain-related disability (P < 0.001). Anxiety and depression mainly predicted changes in pain interference over time. Their interaction significantly predicted changes in pain interference. CONCLUSIONS: Anxiety, depression, and their interaction are associated with changes in pain disability at one-year follow-up. These findings encourage the pretreatment screening of anxiety and depression as independent symptoms in patients with CLBP in order to design more tailored and effective multidisciplinary treatments.

A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors.

OBJECTIVES: Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes. METHODS: A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months. RESULTS: Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores. CONCLUSIONS: This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.

Prediction of clinical outcomes in individuals with chronic low back pain: a protocol for a systematic review with meta-analysis.

BACKGROUND: Low back pain (LBP) is one of the most prevalent and recurrent conditions in the general population, with personal, professional, social and economic impact. However, there is a lack of consistent evidence about chronic low back pain (CLBP) prognosis, especially highlighting predictors that influence CLBP outcome. Existing systematic reviews are scarce, outdated and incomplete. The primary aim of this systematic review is to identify multivariable models and/or predictors associated with clinical outcomes in subjects with CLBP (namely pain intensity, disability, return to work, psychological well-being and quality of life). METHODS: We will systematically search Ovid MEDLINE (PubMed), Scopus and Web of Science databases for longitudinal studies, published until June 2017, including adults with CLBP (defined as persistent pain with ≥ 3 months duration), which studied the association between multivariable models and/or predictors with at least one of the selected clinical outcomes after ≥ 3 months of follow-up. Articles' screening and selection will be conducted by two reviewers, blindly and independently. Disagreements will be resolved by a third reviewer. Models' discriminative ability will be assessed using C-statistic. The link between multivariable models and predictors with the clinical outcome will be analysed through association measures. Qualitative and quantitative synthesis of the available evidence will be performed. Meta-analysis will be conducted to aggregate each type of measure. In the absence or in the presence of only slight to moderate of heterogeneity, we will use the fixed or random effects model, respectively. In case of moderate to severe heterogeneity, an attempt to explain variability in detail will be made through subgroups and sensitivity analyses. Subgroup analysis will be conducted according to clinical outcome, follow-up duration (≤ 6 months versus > 6 months) and type of context (pain management clinics versus other therapeutic settings). DISCUSSION: We consider that it is urgent to highlight the available evidence about CLBP prognosis. This systematic review will help identify multivariable models and individual predictors that may enhance pain management success. One potential limitation will be the difficulty of aggregating quantitative measures from several prognostic models and predictors, with different clinical outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017079233.

Incidence and Health Related Quality of Life of Opioid-Induced Constipation in Chronic Noncancer Pain Patients: A Prospective Multicentre Cohort Study.

BACKGROUND: High rates of opioid use for chronic noncancer pain (CNCP) have been reported worldwide, despite its association with adverse events, inappropriate use, and limited analgesic effect. Opioid-induced constipation (OIC) is the most prevalent and disabling adverse effect associated with opioid therapy. Our aim was to assess the incidence, health related quality of life (HRQOL), and disability in OIC patients. METHODS: A prospective cohort study was performed, with 6 months of follow-up, of adult CNCP patients consecutively admitted in 4 multidisciplinary pain clinics (MPC). Demographic and clinical data have been collected. Brief Pain Inventory (BPI) and Short version of Treatment Outcomes in Pain Survey (S-TOPS) were used to measure functional outcomes and HRQOL. OIC was assessed using Bowel Function Index (BFI). RESULTS: 694 patients were recruited. OIC prevalence at baseline was 25.8%. At 6 months, OIC incidence was 24.8%. Female gender (OR = 1.65, p = 0.039), opioid therapy (OR 1.65, p = 0.026), and interference pain score on BPI (OR 1.10, p = 0.009) were identified as OIC independent predictors. OIC patients presented higher disability and pain interference and severity scores. OIC patients reported less satisfaction with outcome (p = 0.038). DISCUSSION: Constipation is a common adverse event among opioid users with major functional and quality of life impairment. These findings emphasise the need of OIC adequate assessment and management.

Impact of the economic crisis on pain research: a bibliometric analysis of pain research publications from Ireland, Greece, and Portugal between 1997 and 2017.

Background and aims The recent economic crisis started in the USA in 2008 but quickly had worldwide impact. Ireland, Greece, and Portugal were in economic distress in 2009 and received rescue monetary packages from the European Union (EU) and the International Monetary Fund (IMF) in the following years. Meanwhile, the economic recovery has begun for those countries, but at different paces. The aim of the present study was to evaluate if the economic crisis influenced pain research outcomes, by performing a bibliometric analysis based on the ISI Web of Science to evaluate the evolution of the scientific production and performance in the field of pain research between 1997 and 2017. Methods Articles search was conducted using the ISI Web of Science, search keywords "pain or nocicep*", between 1997 and 2017, and one author affiliated in an Irish, Greek or Portuguese institution. The total number of published articles per country, total citations, h-index, document types and authors' institution were tabulated to determine the quantity and quality of the publications in this field. Results The search retrieved 2,368 publications over the 20 years' period, increasing from 26 in 1997 to 230 in 2017. The number of Irish publications per year increased steadily along the studied period, while the number of Greek publications stabilized from 2008 onward and Portuguese publications started to increase only in 2007 but declined slightly after 2014. In total, Irish authors published 1,143 articles, Greek authors 624 and Portuguese authors 618. There were nine articles with more than 100 citations, and Irish publications had a higher h-index (52) than Greek's (45) or Portuguese's (36) publications. Ireland had the highest number of pain publications per capita, but in 2016 Portugal had the lowest cost per publication, as measured by the GDP per capita per publication (in 1997 Portugal had the highest cost). The three major research fields of the publications were neurosciences/neurology (19%), general internal medicine (16%) and anaesthesiology (13%), and the affiliation institutions were mostly universities or universities hospitals. Conclusions The number of Irish, Greek, and Portuguese pain publications increased between 1997 and 2017, but at different paces. It appears that the economic crisis had no impact on the rate of pain publications in Ireland, had a delayed impact in Portugal, and affected mostly Greek pain scientific research. This may be related to the fact that Greece was the country that received more rescue packages and where the economic crisis was deepest and lasted longer. Implications Economics and scientific production have a mutual influence: usually research investment decreases in recession times (reducing grants and scientific employment), but health scientific production can improve health and quality of life and also benefit the economy. So in crisis periods, governments should create means to protect and foster scientific work.

Interventional Pain Management in Multidisciplinary Chronic Pain Clinics: A Prospective Multicenter Cohort Study with One-Year Follow-Up.

BACKGROUND: Interventional Pain Management (IPM) is performed in multidisciplinary chronic pain clinics (MCPC), including a range of invasive techniques to diagnose and treat chronic pain (CP) conditions. Current patterns of use of those techniques in MCPC have not yet been reported. OBJECTIVE: We aimed to describe quantitatively and qualitatively the use of IPM and other therapeutic procedures performed on-site at four Portuguese MCPC. METHODS: A prospective cohort study with one-year follow-up was performed in adult patients. A structured case report form was systematically completed at baseline and six and 12 months. RESULTS: Among 808 patients referred to the MCPC, 17.2% had been prescribed IPM. Patients with IPM were on average younger and had longer CP duration and lower levels of maximum pain and pain interference/disability. The three main diagnoses were low back pain (n = 28), postoperative CP, and knee pain (n = 16 each). From 195 IPM prescribed, nerve blocks (n = 108), radiofrequency (n = 31), and viscosupplementation (n = 22) were the most prevalent. Some IPM techniques were only available in few MCPC. One MCPC did not provide IPM. CONCLUSIONS: IPM are seldom prescribed in Portuguese MCPC. Further studies on IPM safety and effectiveness are necessary for clear understanding the role of these techniques in CP management.

Reliability and validity of the Bowel Function Index for evaluating opioid-induced constipation: translation, cultural adaptation and validation of the Portuguese version (BFI-P).

OBJECTIVE: The Bowel Function Index (BFI) is a simple and sound bowel function and opioid-induced constipation (OIC) screening tool. We aimed to develop the translation and cultural adaptation of this measure (BFI-P) and to assess its reliability and validity for the Portuguese language and a chronic pain population. METHODS: The BFI-P was created after a process including translation, back translation and cultural adaptation. Participants (n = 226) were recruited in a chronic pain clinic and were assessed at baseline and after one week. Internal consistency, test-retest reliability, responsiveness, construct (convergent and known groups) and factorial validity were assessed. RESULTS: Test-retest reliability had an intra-class correlation of 0.605 for BFI mean score. Internal consistency of BFI had Cronbach's alpha of 0.865. The construct validity of BFI-P was shown to be excellent and the exploratory factor analysis confirmed its unidimensional structure. The responsiveness of BFI-P was excellent, with a suggested 17-19 point and 8-12 point change in score constituting a clinically relevant change in constipation for patients with and without previous constipation, respectively. CONCLUSIONS: This study had some limitations, namely, the criterion validity of BFI-P was not directly assessed; and the absence of a direct criterion for OIC precluded the assessment of the criterion based responsiveness of BFI-P. Nevertheless, BFI may importantly contribute to better OIC screening and its Portuguese version (BFI-P) has been shown to have excellent reliability, internal consistency, validity and responsiveness. Further suggestions regarding statistically and clinically important change cut-offs for this instrument are presented.

The economic impact of chronic pain: a nationwide population-based cost-of-illness study in Portugal.

In addition to its high frequency and relevant individual and social impact, chronic pain (CP) has been shown to be a major contributor to increased healthcare utilisation, reduced labour productivity, and consequently large direct and indirect costs. In the context of a larger nationwide study, we aimed to assess the total annual direct and indirect costs associated with CP in Portugal. A population-based study was conducted in a representative sample of the Portuguese adult population. The 5,094 participants were selected using random digit dialling and contacted by computer-assisted telephone interviews. Questionnaires included the brief pain inventory and pain disability index. Estimates were adequately weighted for the population. From all CP subjects identified, a subsample (n = 562) accepted to participate in this economic study. Mean total annualised costs per CP subject of €1,883.30 were observed, amounting to €4,611.69 million nationally, with 42.7% direct and 57.3% indirect costs, and corresponding to 2.71% of the Portuguese annual GDP in 2010. Only socio-demographic variables were significantly and independently associated with CP costs, and not CP severity, raising the possibility of existing inequalities in the distribution of healthcare in Portugal. The high economic impact of CP in Portugal was comprehensively demonstrated. Given the high indirect costs observed, restricting healthcare services is not a rational response to these high societal costs; instead improving the quality of CP prevention and management is recommended.

A population-based study on chronic pain and the use of opioids in Portugal.

Although increasing doubts exist regarding the long-term effectiveness and safety of opioids in patients with chronic pain (CP), most guidelines still recognize opioids as an option in effective management of CP. We aimed to describe the prevalence and factors associated with opioid use in subjects with CP in Portugal and to evaluate satisfaction and self-assessed treatment effectiveness. A nationwide study was conducted in a representative sample of the adult Portuguese population. The 5094 participants were selected using random digit dialing and estimates were adequately weighted for the population. The prevalence of opioid use by subjects with CP was 4.37% (95% confidence interval [CI] 3.4-5.5); and in subjects experiencing CP with and without cancer, it was 10.13% and 4.24%, respectively. Use of strong opioids was reported by only 0.17% of CP subjects. Sex, pain severity and symptoms of depression and anxiety were significantly associated with opioid use; however, in multivariate modeling, only pain-related disability remained significant. No significant differences among users and nonusers of opioids were observed regarding treatment satisfaction and self-assessed effectiveness. Although extremely high rates of use of opioids exist in a few countries, it should not be seen as a ubiquitous problem. Indeed, we showed that in Portugal, as in many other regions in the world, opioids are used much less frequently than in those few countries. Moreover, we did not find significant differences among users and nonusers of opioids regarding satisfaction and self-assessed effectiveness, eventually showing the results to be in line with reports that show doubt about opioids' effectiveness. Further research and particular attention to and continuous monitoring of the trends of use and abuse of opioids worldwide are recommended.

Chronic pain and health services utilization: is there overuse of diagnostic tests and inequalities in nonpharmacologic treatment methods utilization?

BACKGROUND: Few studies have described patterns and determinants of health services utilization (HSU) in chronic pain (CP) subjects. We aimed to describe these, in particular, regarding medical consultations (MCs), diagnostic tests (DTs), pain medicines (PMs) and nonpharmacologic treatment methods (NTM) utilization. METHODS: A cross-sectional nationwide study was conducted in a representative sample of the Portuguese population. The 5094 participants were selected using random digit dialling and were contacted by computer-assisted telephone interviews. Questionnaires included the brief pain inventory and pain disability index. Estimates were adequately weighted for the population. RESULTS: Prevalence of CP and CP with moderate to severe disability was 36.7% and 10.8%, respectively. Most CP subjects were being managed/treated by health professionals (81%) and had high levels of HSU. More than half of them had used imaging DT in the previous 6 months. Main factors associated with HSU were as follows: pain-related disability, intensity, duration, and depressive symptoms for MC utilization; sex, pain-related disability, and duration for PM utilization; and education level and depression diagnosis for NTM utilization. CONCLUSIONS: The main drivers behind HSU are pain severity, psychological distress, and socio-economic determinants. An important set of benchmarks are presented regarding HSU in CP subjects, comprising useful tools for public health policy and decision-making. Results presented may suggest possible inequalities in the access to NTM, and interventions to improve access are encouraged. Moreover, possible indirect evidence of imaging DT overuse is presented, and it is recommended that their use in CP subjects should more closely follow existing guidelines.

Epidemiology of chronic pain: a population-based nationwide study on its prevalence, characteristics and associated disability in Portugal.

UNLABELLED: A cross-sectional nationwide epidemiological study was performed in a random sample of the Portuguese adult population, aiming to describe the prevalence and impact of chronic pain (CP). The 5,094 participants were selected by random digit dialing, between January 2007 and March 2008, and estimates were adequately weighted for the population. Prevalence of CP was 36.7% (95% confidence interval [CI] [35.3-38.2]), based on the definition of the International Association for the Study of Pain. Recurrent or continuous pain was present in 85% of those with CP, and moderate-to-severe intensity and disability were present in 68 and 35%, respectively. Highest CP prevalence was observed among the elderly, retired, unemployed, and less educated. Highest disability was found in relation with family/home responsibilities, recreational activities, occupation/work, and sleep/rest; 13% reported a diagnosis of depression and 49% reported interference in their job. The main factors associated with disability were sex, pain intensity, and depression or depressive symptoms. CP is highly prevalent, causes high personal and social burden, and affects particularly the most vulnerable subgroups. Portugal, depending on CP definition, could be placed in the lower prevalence group in Europe. Improvement in pain intensity management and special attention to affective components of CP are recommended. PERSPECTIVE: In this cross-sectional nationwide epidemiological study, we showed that chronic pain is a significant problem that is present in 37% of the Portuguese adult general population, is associated with high personal, family, and social burden, and affects in particular the most vulnerable subgroups of the population.