Pain and health-related quality of life (HRQoL): a national observational study in community-dwelling older adults.

PURPOSE: Regarding the epidemiology of pain in older adults, data are lacking about the association between pain severity and its impact on health-related quality of life (HRQoL). This study was aimed to investigate pain prevalence and sites, self-reported interferences with daily life activities, and the effect of pain severity on HRQoL in a Swiss community-dwelling population aged ≥ 65 years. METHODS: This is a cross-sectional survey conducted with a national sample of individuals randomly selected from population records, stratified by age and gender. Respondents answered a face-face interview addressing pain location, intensity and interferences, and quality-of-life variables. Logit regression models were applied for binary outcomes, linear regression for continuous outcomes, and Poisson regression for count outcomes. For each analysis, Wald Chi square and 95% confidence intervals were used. RESULTS: Among the 2995 individuals considered, 36.4% reported pain. The results indicate that pain prevalence and intensity increased from age 80 onwards. Pain intensity was strongly associated with functional health, i.e., all scales involving physical activities were affected in individuals reporting severe pain; it was also associated with the individuals' perception of their overall HRQoL. CONCLUSION: Our results point to the importance of devoting attention to pain intensity rather than to the number of pain sites. Because of the demographic transition, the management of pain problems should emphasize early referral and timely treatment to prevent the burden of disease and functional loss associated with pain intensity.

The impact of low back pain on health-related quality of life in old age: results from a survey of a large sample of Swiss elders living in the community.

PURPOSE: The present study aims at investigating the effects of low back pain (LBP), i.e., type of symptoms, activity limitations, frequency, duration, and severity on health-related quality of life (HRQoL) in a sample of 707 community-dwelling men and women aged ≥ 65 years living in Switzerland. METHODS: The study is part of a larger survey conducted in Switzerland on a sample of older adults selected randomly from population records, stratified by age and sex. The Standardized Back Pain Definition was used to investigate LBP, and HRQoL was assessed by means of the EQ-5D, including Health Utility Index (HUI) measures. RESULTS: For more than half of the sufferers, pain was chronic, occurred most days or every day and induced activity limitations. One-third of the sufferers reported sciatica symptoms. Individuals reporting every day pain, severe pain and more than 3 years since the last episode without pain lost nearly 10 points of HRQoL. Amongst the dimension of HRQoL, Mobility was the most affected by LBP. CONCLUSIONS: These results provide further insight into the impact of qualitative aspects of LBP and in particular the importance of radiating leg pain and pain frequency and duration. While LBP-related activity limitations had little impact on both self-rated overall health and HUI, radiating leg pain and pain frequency and duration were associated with significantly decreased scores on both dimensions.

Low back pain and health-related quality of life in community-dwelling older adults.

PURPOSE: Investigation of self-reported of low back pain (LBP) over the last month and associated health-related quality of life (HRQoL) in a sample of a community-dwelling population aged ≥65. METHODS: Cross-sectional study including older adults selected randomly from population records. Data were collected within a sample stratified by age and sex. Physical and psychological healths were investigated using a standardized definition of LBP and the EuroQoL-5D for HRQoL. Analyses were first conducted on the entire sample (N = 3042) and subsequently considering the subsample who reported LBP and a paired sample drawn from the pool of LBP-free respondents. RESULTS: 889 (29 %) respondents reported LBP within the past month, present 'most days' or 'every day' in 52 % and limiting activities in the same proportion. Average pain score was 4.6 (SD 2.2; 0-10 scale). Age was associated with pain frequency and duration, with younger groups more often reporting pain 'some days' and 'dating back <3 months'. Results of regression analyses showed that individuals suffering from LBP had significantly more problems than LBP non-sufferers on all EQ-5D subscales, except self-care: pain/discomfort (OR 5.33; 95 % CI [4.19-6.79]), mobility (OR 2.66; 95 % CI [2.04-3.46]), usual activities (OR 1.92; 95 % CI [1.42-2.60]), anxiety/depression (OR 1.59; 95 % CI [1.23-2.04]) and self-care (OR 1.29; 95 % CI [0.84-1.98]). CONCLUSION: LBP appears to be a more permanent condition in the older groups. LBP may be a part of the definition of a subgroup of elderly at risk of becoming frail in relation with higher levels of functional limitations, psychological difficulties and social restrictions, hence globally impaired HRQoL.

Aggressiveness of cancer treatment in patients hospitalized in a supportive care unit.

PURPOSE: This study aimed at determining the aggressiveness of chemotherapy (CT)in patients hospitalized in a supportive care unit (focusing on mortality, patient profiles, survival, readmissions, and CT near death). METHODS: In a prospective cohort study, 247 consecutive patients were investigated at the admission (disease, treatments, oncologist's theoretical survival prognosis, internist's clinical global impression (CGI)). A 3-and 6-month follow-up was performed. Survival was assessed up to 3 years. RESULTS: Various cancer diagnoses were represented in polymorbid patients. Since disease onset, 69.6 % had received a first line of CT only; 147 patients (59.5 %) had CT at the admission; median CGI was 3 (range = 0-10); and theoretical survival prognosis was <12 months in 65.2 %. In-hospital mortality rate was 21 %. Odds of receiving CT was inversely associated with age (OR for patients ≥ 71 years vs. patients <50 years 0.19; 95 % CI 0.06-0.65; p = 0.02) and number of previous CT lines (OR for patients with 2-4 lines vs. those with 1 line 0.14; 95 % CI 0.06-0.34; p = 0.000). In the multi-adjusted model, 6-month survival remained associated with CT at the admission (HR 1.86; 95 % CI 1.31-2.65; p = 0.001), CGI (per point HR 0.84; 95 % CI 0.73-0.96; p = 0.013), and theoretical survival prognosis (per category HR 0.53; 95 % CI 0.44-0.66; p = 0.000). Very few patients needed readmission related to CT's adverse effects. From admission and throughout follow-up, 24 patients (9.7 %) had received CT during their last 14 days of life. CONCLUSION: This study showed that a supportive care program can benefit a heterogeneous population as it contributes to assess clinical risks and benefits of CT and prevent aggressive care near death.

Seizures after single-agent overdose with pharmaceutical drugs: analysis of cases reported to a poison center.

CONTEXT: Seizures during intoxications with pharmaceuticals are a well-known complication. However, only a few studies report on drugs commonly involved and calculate the seizure potential of these drugs. OBJECTIVES: To identify the pharmaceutical drugs most commonly associated with seizures after single-agent overdose, the seizure potential of these pharmaceuticals, the age-distribution of the cases with seizures and the ingested doses. METHODS: A retrospective review of acute single-agent exposures to pharmaceuticals reported to the Swiss Toxicological Information Centre (STIC) between January 1997 and December 2010 was conducted. Exposures which resulted in at least one seizure were identified. The seizure potential of a pharmaceutical was calculated by dividing the number of cases with seizures by the number of all cases recorded with that pharmaceutical. Data were analyzed using descriptive statistics. RESULTS: We identified 15,441 single-agent exposures. Seizures occurred in 313 cases. The most prevalent pharmaceuticals were mefenamic acid (51 of the 313 cases), citalopram (34), trimipramine (27), venlafaxine (23), tramadol (15), diphenhydramine (14), amitriptyline (12), carbamazepine (11), maprotiline (10), and quetiapine (10). Antidepressants were involved in 136 cases. Drugs with a high seizure potential were bupropion (31.6%, seizures in 6 of 19 cases, 95% CI: 15.4-50.0%), maprotiline (17.5%, 10/57, 95% CI: 9.8-29.4%), venlafaxine (13.7%, 23/168, 95% CI: 9.3-19.7%), citalopram (13.1%, 34/259, 95% CI: 9.5-17.8%), and mefenamic acid (10.9%, 51/470, 95% CI: 8.4-14.0%). In adolescents (15-19y/o) 23.9% (95% CI: 17.6-31.7%) of the cases involving mefenamic acid resulted in seizures, but only 5.7% (95% CI: 3.3-9.7%) in adults (≥ 20y/o; p < 0.001). For citalopram these numbers were 22.0% (95% CI: 12.8-35.2%) and 10.9% (95% CI: 7.1-16.4%), respectively (p = 0.058). The probability of seizures with mefenamic acid, citalopram, trimipramine, and venlafaxine increased as the ingested dose increased. CONCLUSIONS: Antidepressants were frequently associated with seizures in overdose, but other pharmaceuticals, as mefenamic acid, were also associated with seizures in a considerable number of cases. Bupropion was the pharmaceutical with the highest seizure potential even if overdose with bupropion was uncommon in our sample. Adolescents might be more susceptible to seizures after mefenamic acid overdose than adults. "Part of this work is already published as a conference abstract for the XXXIV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 27-30 May 2014, Brussels, Belgium." Abstract 8, Clin Toxicol 2014;52(4):298.

Acute neurotoxicity associated with recreational use of methylmethaqualone confirmed by liquid chromatography tandem mass spectrometry.

Methylmethaqualone is a sedative designer drug created by adding a methyl group to the 3-phenyl ring of methaqualone, and is at present not subject to restrictive regulation in many countries. To our knowledge, no case of methylmethaqualone abuse has been published to date in the scientific literature, and the only sources of information are users' reports on Web discussion forums and data from preclinical animal studies. We report a case of oral methylmethaqualone abuse confirmed by liquid chromatography tandem mass spectrometry in a 24-year-old previously healthy Caucasian male. Observed symptoms and signs such as central nervous system depression alternating with excitation, psychomotor agitation, muscle hyperactivity, and tachycardia were compatible with methaqualone-induced adverse effects. Except for the mild tachycardia (115 beats/min), other vital signs were normal: blood pressure 134/89 mmHg, body temperature 36.2°C (97.16°F), and peripheral oxygen saturation 99% while breathing room air. The ECG showed no prolongation of the QT interval and the QRS duration was normal. Laboratory analysis revealed a slight increase in creatine kinase (368 U/L) and alanine aminotransferase (90 U/L) serum concentrations. Blood alcohol concentration was 0.32 g/L. Methylmethaqualone was identified in a serum sample collected on admission which was analyzed by a liquid chromatography tandem mass spectrometry toxicological screening method using turbulent flow online extraction. After a few days the patient ingested the same amount of substance with identical symptoms. Based on the chemical structure and animal data, and according to this case report and users' Web reports, methylmethaqualone appears to have a similar acute toxicity profile to methaqualone, with marked psychomotor stimulation. Symptoms of acute toxicity can be expected to resolve with supportive care.

Acute calcineurin inhibitor overdose: analysis of cases reported to a national poison center between 1995 and 2011.

Transplant recipients and other patients requiring immunosuppression with calcineurin inhibitors or their household contacts may be exposed to overdose. This study investigated the circumstances, pharmacokinetics and outcomes of overdose with cyclosporine and tacrolimus reported to the Swiss Toxicological Information Centre between 1995 and 2011. Of 145,396 reports by healthcare professionals, 28 (0.02%) concerned enteral or parenteral overdose with these calcineurin inhibitors. Thirteen (46%) were iatrogenic errors, 12 (43%) were with suicidal intent and 3 (11%) were accidental. Iatrogenic overdoses usually involved noncapsule drug formulations. Acute enteral overdoses caused symptoms in a dose-dependent fashion but were generally well tolerated; the mean multiple of patient's usual dose was 20.8 ± 28.8 for symptomatic versus 4.4 ± 3.4 for asymptomatic cases (p = 0.037). The most common symptoms were nausea, headache, somnolence, confusion, hypertension and renal impairment. In contrast, acute intravenous overdoses were often poorly tolerated and resulted in one fatality due to cerebral edema after a cyclosporine overdose. Enteral decontamination measures were performed in six cases involving oral ingestion and appeared to reduce drug absorption, as shown by pharmacokinetic calculations. In the one case where it was used, pharmacoenhancement appeared to accelerate tacrolimus clearance after intravenous overdose.

[Opioid rotation: from theory to practice. Interdisciplinary recommendations from the Geneva University Hospitals pain network]. / Rotation des opioïdes: de ta théorie à la pratique. Recommandations interdisciptinaires du réseau douleur des HUG.

Opioids are widely used to treat moderate to severe pain of cancer or non cancer origin. Although opioids provide an adequate analgesia in many patients, their use can be limited by inefficacy and/or intolerable side effects. Opioid rotation is one of the strategies that have been proposed to overcome these therapeutic difficulties. This article revisits the concept of opioid rotation, from pharmacological rational to clinical application.

Clinical supervisors' perceived needs for teaching communication skills in clinical practice.

BACKGROUND: Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills. AIMS: To explore clinical supervisors' needs and perceptions regarding their role as communication skills trainers. METHODS: Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda software for qualitative data analysis. RESULTS: Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere. CONCLUSIONS: Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

[Chronic pain and depression]. / Douleurs chroniques et dépression: un aller-retour?

Chronic pain and depression are frequently associated. Links between them are numerous and well documented. It is known for example that depression is associated with a greater number and higher intensity of pain symptoms. Similarly the presence of pain complicates the diagnostic evaluation and aggravates the prognosis of depression. The question of the causality link has no clear answer. Taking care of these patients implies to acknowledge the different aspects of their suffering in a holistic bio-psycho-social model. Treatment or medication, for instance antidepressants, should be a post-scriptum to the construction of a therapeutic relationship.

Difficulties of residents in training in end-of-life care. A qualitative study.

Residents in training are first-line physicians in hospital settings and they are in the process of developing knowledge and mastering clinical skills. They have to confront complex tasks calling upon their personal background, professional identity and relationships with the patients. We conducted a qualitative study investigating the difficulties they perceive in end-of-life care. In all, 24 consecutive residents were presented with a written query asking them to indicate the difficulties they identify in the management of patients hospitalised for end-of-life care. Their responses were submitted to content analysis. Physicians' mean age was 28 +/- 2.2 years, 37% were women, average postgraduate training duration was 2.5 +/- 1.3 years. Content analysis elicited eight categories of difficulties: ability to provide adequate explanations, understand the patients' needs, have sufficient theoretical knowledge, avoid flight, avoid false reassurance, manage provision of time, face one's limits as a physician and be able to help despite everything. Residents' responses showed that they identify the complexity of care in terminally-ill patients early in their training. Their responses pointed to the 'right distance' in-between getting involved and preserving oneself as a dimension of major importance.

[Supportive care in oncology: a concept of rehabilitation]. / Soins de support en oncologie: un concept de réhabilitation.

The prevalence and prognosis of cancer are changing. The number of diagnosed cancers is rising in Western countries. These diseases often become chronic illnesses and necessitate major efforts of adjustment and coping for patients and families, but also for health professionals. This paper focuses on the question of the follow-up of cancer patients and highlights some of the difficulties faced by professionals and institutions when attempting to improve the quality of care in this field. We describe how the divisions of general medical rehabilitation and of oncology of the Geneva university hospitals promote the implementation of supportive oncological care practice in a rehabilitation centre.

[Length of hospital stay, discharge planning, and policy regarding the shortening of hospital stays: patients'and hospital care providers'point of view]. / Durée d'hospitalisation, programmation de la sortie et politique de raccourcissement des séjours: avis des patients et des soignants.

BACKGROUND: In the context of health care cost containment, we interviewed hospitalized patients and their health care teams concerning the length of stay they considered necessary and hospital discharge. Patients were also interviewed on the present tendency to shorten hospital stays. METHODS: Prospective study conducted in a subacute internal medicine ward with 254 consecutive patients and their health care teams. RESULTS: The mean evaluation of the length of stay considered as necessary was not significantly different between patients (9.7 days, SD=9.5) and their health care teams (9.6, SD=8.5). However, agreement between the two parties was moderate (r=0.64). Hospital discharge was considered as planned in similar proportions (18% vs 22% respectively), but was reported as more 'assured' by health care teams than by patients (p<0.001). Health care teams and patients approved discharge planning in 200 cases (63.3%), but agreement was only moderate (Kappa 0.43, IC 95%=0.34-0.51). Regarding the tendency to shorten hospital stays, patients'responses were favorable in only 9%, clearly unfavorable in 17% and disclosed explicit fears in 54% of the cases. CONCLUSIONS: These results show that what patients and health care teams consider the necessary length of stay and the right time for hospital discharge can diverge notably. They highlight the difficulties of medical decisions in the context of cost containment, and the fundamentally asymmetrical character of the relationship between patients and health care teams.

7-(4,6-Dimethoxypyrimidinyl)oxy- and -thiophthalides as novel herbicides: Part 1. CGA 279 233: a new grass-killer for rice.

A series of novel types of 7-(4,6-dimethoxypyrimidin-2-yl)oxy- and -thio-3-methyl-1 (3H)-isobenzofuranones were discovered at Dr R Maag AG. From the thio-isobenzofuranyl series, CGA 279 233--BSI-proposed common name pyriftalid--was chosen for further development as a grass herbicide for use in rice. General synthetic approaches to these new phthalic acid-derived compounds are given, with emphasis on the synthesis of pyriftalid and its physico-chemical behaviour.

The fourfold Democritus on the stage of early modern science.

The renewed success of ancient atomism in the seventeenth century has baffled historians not only because of the lack of empirical evidence in its favor but also because of the exotic heterogeneity of the models that were proposed under its name. This essay argues that one of the more intriguing reasons for the motley appearance of early modern atomism is that Democritus, with whose name this doctrine was most commonly associated, was a figure of similar incoherence. There existed in fact no fewer than four quite different Democriti of Abdera and as many literary traditions: the atomist, the "laughing philosopher," the moralizing anatomist, and the alchemist. Around the year 1600 the doctrines of these literary figures, three of whom had no tangible connection with atomism, began to merge into further hybrid personae, some of whom possessed notable scientific potential. This essay offers the story of how these Democriti contributed to the rise of incompatible "atomisms."

Circulating ionized and total magnesium in end-stage kidney disease.

BACKGROUND: Circulating magnesium exists in the ionized state and in the undissociated form, either bound to albumin, or complexed to various anions. Until recently, only the measurement of total plasma magnesium has been possible. Now circulating ionized magnesium can be assessed as well. METHODS: Total and ionized plasma magnesium were determined in 43 patients on maintenance hemodialysis (dialysate composition: calcium 1.75 mmol/l, magnesium 0.75 mmol/l) before a dialysis session and in a group of 23 healthy subjects. RESULTS: The total (1.16 [1.03-1.31] versus 0.81 [0.78-0.89] mmol/l; median and interquartile range) and the ionized (0.71 [0.66-0.78] versus 0.54 [0.53-0.59] mmol/l) plasma magnesium levels were significantly higher (p < 0.01) and the ionized plasma magnesium fraction lower (0.61 [0.58-0.65] versus 0.67 [0.64-0.70]; p < 0.02) in patients than in controls. CONCLUSION: The determination of circulating ionized magnesium using selective electrodes is an attractive method to evaluate extracellular magnesium in kidney disease.

Free circulating magnesium and renal magnesium handling during acute metabolic acidosis in humans.

Ion-selective electrodes have been designed for determining the ionized concentration of magnesium in blood, the biologically active form of this ion. The effect of acute acidosis induced by ammonium loading on circulating and urinary magnesium was investigated in 11 volunteers. No changes in plasma total and ionized magnesium were noted following administration of ammonium chloride. On the contrary, administration of ammonium chloride increased the plasma free magnesium fraction and the urinary magnesium excretion. The study demonstrates that the hypermagnesiuria induced by acute acidosis is not caused by ionized hypermagnesemia and supports the theory that acidosis decreases the circulating magnesium fraction that is bound to proteins.