Are there reliable predictors of postoperative pain?

BACKGROUND: The purpose of this study was to identify the preoperative determinants of severe postoperative pain. METHODS: Potential predictors were assessed using a questionnaire submitted on the day before surgery. Pain at rest, and pain during coughing/mobilization, were measured using visual analog scales on the day of surgery and on the following 2 days. The type of postoperative pain management was not standardized and was prescribed by the anesthesiologist in charge. Multivariate logistic regression models explaining postoperative pain were developed in Group I, comprising 304 consecutive patients undergoing orthopedic or intraperitoneal surgery, and validated in Group II, comprising 145 independent patients. RESULTS: Of the 62 variables examined by univariate analysis, only five were found to increase the risk of severe postoperative pain in Group I at rest and six factors during cough/mobilization. In the multivariate model for pain at rest, general anesthesia, expectation of postoperative pain, and chronic sleeping difficulties increased the risk of severe postoperative pain. In Group II, only chronic sleeping difficulties remained (OR: 3.97, 95% Cl: 1.69-9.29). In the multivariate model during cough/mobilization, intraperitoneal surgery, fear of postoperative pain, and having a relative with a history of pain increased the risk of severe postoperative pain in Group I. Intraperitoneal surgery OR 2.45 (95% Cl = 1.01-4.50) and having a relative with a history of pain OR 2.06 (95% Cl = 1.005-4.50) remained in Group II. CONCLUSION: Of the many factors that may influence postoperative pain, chronic sleeping difficulties emerge in this population of patients as the strongest determinant of pain at rest. Intraperitoneal surgery and having a relative with a history of pain are the strongest determinants of pain during cough/mobilization. These findings make physiological sense and deserve more attention by anesthesiologists.

Definition and prevalence of sedentarism in an urban population.

OBJECTIVES: The present study sought to formulate a precise definition of sedentarism and to identify activities performed by active people that could serve as effective preventive goals. METHODS: A population-based sample of 919 residents of Geneva, Switzerland, aged 35 to 74 years, completed a 24-hour recall. Sedentary people were defined as those expending less than 10% of their daily energy in the performance of moderate- and high-intensity activities (at least 4 times the basal metabolism rate). RESULTS: The rates of sedentarism were 79.5% in men and 87.2% in women. Among sedentary and active men, average daily energy expenditures were 2600 kcal (95% confidence interval [CI] = 2552, 2648) and 3226 kcal (95% CI = 3110, 3346), respectively; the corresponding averages for women were 2092 kcal (95% CI = 2064, 2120) and 2356 kcal (95% CI = 2274, 2440). The main moderate- and high-intensity activities among active people were sports (tennis, gymnastics, skiing), walking, climbing stairs, gardening, and (for men only) occupational activities. CONCLUSIONS: The definition of sedentarism outlined in this article can be reproduced in other populations, allows comparisons across studies, and provides preventive guidelines in that the activities most frequently performed by active people are the ones most likely to be adopted by their sedentary peers.

Data-based approach for developing a physical activity frequency questionnaire.

Measurement of total energy expenditure may be crucial to an understanding of the relation between physical activity and disease and in order to frame public health intervention. To devise a self-administered physical activity frequency questionnaire (PAFQ), the following data-based approach was used. A 24-hour recall was administered to a random sample of 919 adult residents of Geneva, Switzerland. The data obtained were used to establish the list of activities (and their median duration) that contributed to 95% of the energy expended, separately for men and women. Activities that were trivial for the whole sample but that contributed to > or = 10% of an individual's energy expenditure were also selected. The final PAFQ lists 70 activities or group of activities with their typical duration. About 20 minutes are required for respondents to indicate the number of days and the number of hours per day that they performed each activity. The PAFQ method was validated against a heart rate monitor, a more objective method. The total energy estimated by the PAFQ in 41 volunteers correlated well (r = 0.76) with estimates using a heart rate monitor. The authors conclude that the design of their self-administered physical activity frequency questionnaire based on data from 24-hour recall appeared to accurately estimate energy expenditure.

Appropriateness of indications for surgery of lumbar disc hernia and spinal stenosis.

STUDY DESIGN: This prospective study examines the appropriateness of indications for surgery of herniated intervertebral disc and spinal stenosis in patients undergoing surgery in a university hospital setting. OBJECTIVE: To evaluate the appropriateness of surgery using explicit criteria developed by an expert panel in the United States. SUMMARY OF BACKGROUND DATA: The use of surgery for herniated intervertebral disc and spinal stenosis varies widely within and among countries. It has been postulated that the main reason for treatment failure is poor selection of candidates for the procedure. METHODS: The authors prospectively evaluated appropriateness of surgical indications for herniated lumbar intervertebral disc or spinal stenosis in 328 consecutive patients undergoing the operation in two university neurosurgery departments. Outcome was measured 1 year after surgery by a standardized interview. RESULTS: Indications for surgery were considered to be appropriate or equivocal in 202 (62%) patients and inappropriate in 126 (38%). Among the 126 inappropriate procedures, 66 were so rated because of insufficient activity restriction before the procedure. One year after surgery, 74% of the patients perceived the results of the operation as good or very good. CONCLUSIONS: Appropriateness as measured by the criteria established by the American panel identified a large percentage of day-to-day practice in the two surgical units as inappropriate. However, use of criteria that include new findings about lack of efficacy of bed rest probably would lower this percentage. Criteria of appropriateness of medical and surgical procedures, developed through the panel process, need to be updated regularly.

Importance of albumin, 25(OH)-vitamin D and IGFBP-3 as risk factors in elderly women and men with hip fracture.

The relative importance of vitamin D deficiency, secondary hyperparathyroidism, nutritional deficiency and low bone mineral density (BMD) as risk factors for hip fracture is not definitely established. In the framework of a case-control study of risk factors for hip fractures, biochemical markers of bone metabolism and nutrition and femoral BMD data were compared in 136 female and 43 male hip fracture patients, 136 female and 44 male age-matched hospitalized controls, and 47 healthy elderly women (8 men). Patients with hip fracture had lower albumin (-10%) and 25(OH)-vitamin D (25(OH)D; -19%) compared with hospitalized controls, and lower albumin (-28%) and 25(OH)D levels (-52%) compared with the elderly controls. Serum values of IGFBP-3 were also significantly lower (-33%) in hip fracture patients than in community controls. BMD of femoral neck was lower (p < 0.001) in patients than in hospitalized and community controls. In hip fracture patients, parathyroid hormone (PTH) correlated weakly with BMD (neck: r = -0.19, trochanter: r = -0.17; both p < 0.05). When all women were pooled (n = 233), albumin correlated significantly (age-adjusted) with BMD at all sites (neck: r = 0.27, trochanter: r = 0.25; all p < 0.001). Albumin, but not 25(OH)D, also correlated with skinfold thickness (r = 0.19, p < 0.0025) and with body mass index (BMI) (r = 0.14, p < 0.05). Male patients with hip fracture had lower BMD and albumin (both p < 0.001), 25(OH)D (p = 0.02) and IGFBP-3 levels (p < 0.005) compared with the controls. When male patients and controls were pooled together, albumin, skinfold thickness and BMI were significantly correlated with each other, but not with BMD. IGFBP-3 was highly correlated with albumin (p < 0.0001), 25(OH)D (p < 0.005) and, less significantly, with PTH (p < 0.05), but not with BMI or skinfold thickness. IGFBP-3 was significantly correlated with BMD at all sites (neck: r = 0.27, p < 0.05; trochanter: r = 0.40, p < 0.0005). In conclusion, low albumin and low BMD were both important risk factors for hip fracture. Low serum albumin was the strongest independent variable correlated with hip fractures. In men. IGFBP-3 was correlated with BMD. The femoral BMD depended only weakly on PTH and 25(OH)D, but was correlated at all sites with albumin, a non-specific parameter of nutrition and general health.

[Consumption of calcium-rich food in the adult population of French-speaking Switzerland and of Tessin]. / Consommation d'aliments riches en calcium dans la population adulte de suisse romande et du Tessin.

Food intake high in calcium content is important in the development of skeleton and the prevention of osteoporosis. From a public health perspective, it is therefore important to know the dietary calcium intake of a population. Two population surveys in the French and Italian parts of Switzerland (MONICA, 1988-1989, and Geneva, 1991), were combined to study nutritional habits related to calcium intake. A random population sample, aged 35 et 65 years, answered to a 24 hour recall questionnaire, either self-administered (MONICA, cantons of Vaud, Fribourg and Tessin, N = 2734) or by phone (canton of Geneva, N = 475). In the 4 cantons, for the previous day, 60% of participants ate dairy products, particularly whole milk and cheese. They drunk 3-4 dl/day of milk. A significant proportion (10%) of french and italian speaking Swiss did not consume any food high in calcium content. In Geneva, the mean daily calcium intake was 656 mg in men and 489 mg in women. In conclusion 1) eating habits related to calcium intake are similar across cantons; 2) women consume dairy products more frequently than men, but in smaller quantities; 3) about 60% of men and 80% of women do not get the daily amount of calcium recommended for the prevention of osteoporosis.

Hypnosis and self-hypnosis, administered and taught by nurses, for the reduction of chronic pain: a controlled clinical trial.

Hypnosis is a technique whereby an individual can reach a particular state, quite unrelated to sleep, characterized by aroused, attentive and focused concentration. Although there are numerous clinical applications of hypnosis, there are virtually no controlled clinical trials to support its effectiveness. We propose a controlled randomized clinical trial comparing a "control" group of chronic pain patients treated by a programme including conventional oral medication combined with various nerve blocks and/or spinal administration of drugs, with a "treatment" group having a similar treatment programme plus hypnosis carried out by nurses. Outcome measurements include mainly the variation of pain intensity, the amount of analgesic drug consumption, spontaneous physical activity, and the change in health-related quality of life. The assessment of the outcome variable is done at the initial workup, weekly for the first 3 weeks, and at 6 and 12 weeks. A follow-up survey is conducted at 6 months.

Serum 25-hydroxyvitamin D: distribution and determinants in the Swiss population.

The serum 25-hydroxyvitamin D [25(OH)D] concentration was measured in a representative sample of the general adult population in Switzerland (n = 3276). The median concentration was 46 nmol/L and no significant difference was found between men and women. Between the ages of 25 and 74 y, 25(OH)D was not significantly correlated with age (r2 = 0.01). Six percent of the population was vitamin D deficient [ie, 25(OH)D less than or equal to 20 nmol/L] and between 34% and 95% had a relatively low concentration of vitamin D (ie, less than 38 or less than 95 nmol/L, respectively). Among the determinants of low 25(OH)D were indicators of little sunshine exposure, such as the winter season [odds ratio (OR) 2.4, 1.5-3.7 (95% confidence interval)] and less than 30 min of time spent outdoors daily by individuals greater than 65 y of age (OR 5.6, 1.5-21.2), as well as indicators of low nutritional intake of vitamin D, such as the absence of regular intake of butter or margarine (OR 2.0, 1.3-3.1) and the consumption of few dairy products (OR 1.7, 1.2-2.4).

Thiazide diuretics and the risk of hip fracture. Results from the Framingham Study.

Thiazide diuretics may preserve bone mass and prevent elderly women's osteopenic fractures, but studies have not distinguished between thiazide preparations or examined former users. We performed a case-control study looking at thiazide use and subsequent hip fracture in postmenopausal female members of the Framingham Study cohort. Cases who had experienced a first hip fracture (n = 176) were compared with age-matched controls (n = 672). Results showed a modest protective effect of any recent thiazide use (not significant). However, recent pure thiazide users experienced significant protection against fracture (adjusted odds ratio, 0.31; 95% confidence interval, 0.11 to 0.88), whereas recent users of combination drugs containing thiazides experienced no protection (adjusted odds ratio, 1.16; 95% confidence interval, 0.44 to 3.05). Combination drugs generally contained only 25 mg of hydrochlorothiazide, suggesting that the small amount of thiazide was insufficient to preserve bone mass. Former thiazide users were not protected against fracture. In sum, recent pure thiazide use in women protects against hip fracture.