RESUMEN
PURPOSE: Naloxegol has been shown to be an efficient alternative to treat opioid-induced constipation (OIC). This study aimed at describing the characteristics of naloxegol users and assessing patterns of naloxegol use and associated factors. METHODS: This drug utilization cohort study used observational registry data on patients newly prescribed naloxegol in four European countries. Patient characteristics and patterns of naloxegol use and associated factors were described. RESULTS: A total of 17 254 naloxegol users were identified across the countries. Their median age was 56-71 years, and each country had a majority of women (ranging 57.5%-62.9%). Multiple comorbidities, including cancer, were common. Natural opium alkaloids and osmotically acting laxatives (excluding saline) were the most frequently used opioids and laxatives. Overall prior use of opioids ranged from 91.9% to 99.6% and overall prior use of laxatives ranged from 69.9% to 92.4%. Up to 77.7% had prior use of medications with interaction potential, and up to 44.5% used them concurrently with naloxegol. Naloxegol was discontinued by 55.1%-90.9% of users, typically during the first 30 days. Approximately 10%-30% switched to or augmented the treatment with another constipation medication or restarted naloxegol after discontinuation. Augmentation with another constipation medication was relatively common, suggesting that naloxegol was used for multifactorial constipation. CONCLUSION: The present study reflects real-world clinical use of naloxegol, including in vulnerable patient groups. Some naloxegol users lacked laxative or regular opioid use within six months before index date or used naloxegol concomitantly with medications presenting an interaction potential.
Asunto(s)
Morfinanos , Polietilenglicoles , Anciano , Femenino , Humanos , Persona de Mediana Edad , Analgésicos Opioides/efectos adversos , Estudios de Cohortes , Estreñimiento/inducido químicamente , Estreñimiento/tratamiento farmacológico , Estreñimiento/epidemiología , Laxativos/efectos adversos , Morfinanos/efectos adversos , Polietilenglicoles/efectos adversos , MasculinoRESUMEN
PURPOSE: To explore nurses' perceptions of their educational role, pedagogical competence, and practice in teaching children with rheumatic diseases and their parents to manage subcutaneous injections at home. DESIGN AND METHODS: In this qualitative study, we used thematic analysis to analyze data from three focus groups with 14 nurses responsible for patient education at one pediatric ward and two outpatient clinics. RESULTS: We identified three main themes capturing nurses' perceptions of their educational role: myriad expectations, awareness of own competence, and facilitation and prioritization of patient education. Nurses perceived patient education as an expected but challenging duty of their work. They described a lack of pedagogical competence, insecurity in managing parents' and children's fears and worries, and limited organizational structures guiding their educational role. Nurses who worked in outpatient clinics felt freer to individualize education compared to ward nurses. CONCLUSIONS: Nurses perceive their educational role as significant in enabling children and parents to manage subcutaneous injections at home; however, they require pedagogical competence integrated with daily practice to provide high-quality care. Short-term admissions require a different organization of patient education than before. PRACTICAL IMPLICATIONS: Nurses need increased training in communication and management of children's pain and fear during needle injections. Competence development should include opportunities for reflection and guidance in clinical practice. Pediatric specialist nurses at outpatient clinics seem to have better competence to provide individual patient education for these families. The potential advantage of web-based solutions for nurses' patient education is a promising avenue for future research.
Asunto(s)
Enfermeras y Enfermeros , Enfermedades Reumáticas , Niño , Grupos Focales , Humanos , Percepción , Investigación CualitativaRESUMEN
OBJECTIVE: We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery. SUMMARY BACKGROUND DATA: The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery. METHODS: Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0-10). RESULTS: The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104âh, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group. CONCLUSIONS: IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.
Asunto(s)
Analgesia Epidural , Analgesia Controlada por el Paciente , Analgésicos Opioides/administración & dosificación , Antiinflamatorios no Esteroideos/administración & dosificación , Hepatectomía/efectos adversos , Dolor Postoperatorio/prevención & control , Analgesia Epidural/métodos , Analgesia Controlada por el Paciente/métodos , Neoplasias Colorrectales/patología , Diclofenaco/administración & dosificación , Estudios de Equivalencia como Asunto , Humanos , Infusiones Intravenosas , Ketorolaco/administración & dosificación , Tiempo de Internación , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Estudios ProspectivosRESUMEN
BACKGROUND: Chronic pain is a widespread health problem. The four regional interdisciplinary pain management centres in Norway receive approximately 5 000 referrals from GPs and the specialist health service annually. Equality in service provision requires referrals to be identically assessed. The objective of the study was to evaluate the degree of correspondence between the admission teams in the pain management centres in their assessment of the quality of the referrals received and in their assessment of the patients' right to necessary health care. MATERIAL AND METHOD: Each admission team assessed 40 referrals. They undertook a 'primary assessment' of 10 referrals received in the regular manner and a 'secondary assessment' of 30 referrals sent in the regular manner to the other centres. Each referral was assessed for quality and rights in each centre. The proportion of agreement and the intra-class correlation coefficient (ICC) were used to assess correspondence between the admission teams. RESULTS: The quality of the referrals was deemed 'not good' in 45 % of the primary assessments and 43 % of the secondary assessments. The degree of correspondence varied from low (ICC = 0.19) to moderate (ICC = 0.74). The primary and secondary assessments both granted 63 % of the patients 'the legal right to health care'. The overall degree of correspondence was 69 %, i.e. lower than what is considered 'acceptable agreement' (75 %). INTERPRETATION: The study shows that there is a need for structured referrals, and for the admission teams to harmonise their assessments to a greater degree in order to ensure equality in service provision across the health regions.
Asunto(s)
Clínicas de Dolor , Admisión del Paciente/normas , Derivación y Consulta/normas , Dolor Crónico/terapia , Humanos , Noruega , Manejo del Dolor , Derechos del PacienteRESUMEN
BACKGROUND: Pain is common among elderly patients in nursing homes. However, pain assessment and treatment are inadequate. Interprofessional treatment is recommended, and consequently interprofessional education in pain management is necessary. AIMS: This pilot project aimed to describe how two interprofessional groups of students approached pain management in two nursing home patients. DESIGN: We formed two teams comprising one student from the nursing, physical therapy, pharmacy, and medical educations. Each team spent one day examining a patient with chronic pain at a nursing home and they developed pain management plans. METHODS: We collected data through video recordings during teamwork before and after examining the patients and field notes during the patient examination. We analysed the video-recordings applying the seven-step model including 1) viewing the video data, 2) describing the video data, 3) identifying critical events, 4) transcribing, 5) coding, 6) constructing storyline and 7) composing a narrative. Field notes supplied the transcripts. RESULTS: Both teams succeeded in making a pain management plan for their patient. The common examination of the patient was crucial for the students' approaches to pain management and changed their pre-assumptions about the patients' pain. By sharing knowledge and reflecting together, the students reached a common consensus on suggestions for management of the patients' problems. Interprofessional collaboration fostered enthusiasm and a more holistic pain management approach. However, students' lack of knowledge limited their understanding of pain. CONCLUSION: Knowledge of pain management in nursing home patients and the practice of interprofessional cooperation should be included in pain curricula for health care professionals.
Asunto(s)
Personal de Salud/psicología , Manejo del Dolor/normas , Dolor/tratamiento farmacológico , Adulto , Actitud del Personal de Salud , Curriculum/tendencias , Femenino , Personal de Salud/estadística & datos numéricos , Humanos , Masculino , Noruega , Casas de Salud/organización & administración , Dolor/psicología , Manejo del Dolor/métodos , Proyectos PilotoRESUMEN
AIM: To study health related quality of life (HRQOL) and depressive symptoms in adolescents with chronic fatigue syndrome (CFS) and to investigate in which domains their HRQOL and depressive symptoms differ from those of healthy adolescents. BACKGROUND AND OBJECTIVE: Several symptoms such as disabling fatigue, pain and depressive symptoms affect different life domains of adolescents with CFS. Compared to adolescents with other chronic diseases, young people with CFS are reported to be severely impaired, both physiologically and mentally. Despite this, few have investigated the HRQOL in this group. METHOD: This is a cross-sectional study on HRQOL including 120 adolescents with CFS and 39 healthy controls (HC), between 12 and 18 years. The Pediatric Quality of Life Inventory™, 4.0 (PedsQL) was used to assess HRQOL. The Mood and Feelings Questionnaire assessed depressive symptoms. Data were collected between March 2010 and October 2012 as part of the NorCAPITAL project (Norwegian Study of Chronic Fatigue Syndrome in Adolescents: Pathophysiology and Intervention Trial). Linear and logistic regression models were used in analysis, and all tests were two-sided. RESULTS: Adolescents with CFS reported significantly lower overall HRQOL compared to HCs. When controlling for gender differences, CFS patients scored 44 points lower overall HRQOL on a scale from 0-100 compared to HCs. The domains with the largest differences were interference with physical health (B = -59, 95 % CI -54 to -65) and school functioning (B = -52, 95 % CI -45 to -58). Both depressive symptoms and being a patient were independently associated with lower levels of HRQOL CONCLUSION: The difference in HRQOL between CFS patients and healthy adolescents was even larger than we expected. The large sample of adolescents with CFS in our study confirms previous findings from smaller studies, and emphasizes that CFS is a seriously disabling condition that has a strong impact on their HRQOL. Even though depressive symptoms were found in the group of patients, they could not statistically explain the poor HRQOL.
Asunto(s)
Conducta del Adolescente/psicología , Síndrome de Fatiga Crónica/psicología , Conductas Relacionadas con la Salud , Estado de Salud , Calidad de Vida/psicología , Adolescente , Estudios Transversales , Depresión/psicología , Síndrome de Fatiga Crónica/epidemiología , Femenino , Humanos , Masculino , Noruega/epidemiología , Factores Socioeconómicos , Encuestas y CuestionariosRESUMEN
AIMS: To investigate attitudes, beliefs and self-reported competence with regard to pain management in nurses and physicians on surgical wards. Interprofessional differences between physicians and nurses were also examined. METHODS: A total of 795 physicians and nurses from different surgical departments in Norway were invited to complete a questionnaire measuring attitudes, beliefs and self-reported competence about postoperative pain. FINDINGS: In total, 128 physicians and 407 nurses completed the questionnaire (response rate 68%). Of these, 77% of physicians and 57% of nurses reported more than 4 years' work experience with postoperative pain. Most of the physicians (95%) and nurses (86%) reported that patients 'often' or 'very often' achieved satisfactory pain relief. Overall, 69% of the sample evaluated themselves as being highly competent or competent in treating nociceptive pain, while only 16% reported they were highly competent or competent in treating neuropathic pain. There were no statistically significant differences between the professions regarding their self-reported competence in pain management, and nurses and physicians only differed on three out of 18 conditions regarding their appraisal of conditions related to postoperative pain management after controlling for years of experience. Only 20% of respondents were satisfied with the annual updates for staff about pain relief for patients with postoperative pain. CONCLUSIONS: Even though the majority of physicians and nurses described themselves as competent in management of nociceptive pain, and thought that patients often or very often achieved satisfactory pain relief, the respondents reported dissatisfaction with the annual updates in pain management and poor competence in treatment of neuropathic pain.
Asunto(s)
Actitud del Personal de Salud , Competencia Clínica , Enfermeras y Enfermeros , Dolor Postoperatorio , Médicos , Servicio de Cirugía en Hospital , Estudios Transversales , Humanos , NoruegaRESUMEN
BACKGROUND: Relief of post-operative pain has a bearing on the patient's well-being, mobilisation and time confined to bed. The article discusses indications, contraindications and the efficacy of the various treatment modalities. MATERIAL AND METHOD: We have examined review articles, meta-analyses and randomised controlled trials, identified through literature searches in PubMed. RESULTS: The use of several medicines and techniques (multimodal pain treatment) is necessary to achieve a good balance between pain relief, side effects and risk. Systemic administration of paracetamol, NSAIDs, opioids and glucocorticoids is effective for post-operative pain. The same applies to epidural analgesia, peripheral nerve blocks and local anaesthetic wound infiltration. Subanaesthetic doses of ketamine have an opioid-sparing effect, but the optimal dosing regimen is uncertain. Gabapentinoids have an effect on post-operative pain, but the effect appears to vary depending on the type of operation and analgesic regimen. The effect of one analgesic will depend on which other drugs are used in multimodal pain treatment. Epidural analgesia, peripheral nerve blocks or extensive local infiltration analgesia is often necessary to relieve movement-related pain. INTERPRETATION: Many treatment modalities are effective for post-operative pain. It is crucial that the treatment is well organised and that it includes routines for systematic pain assessment, efficacy and side effects of the pain management.
Asunto(s)
Analgesia/métodos , Analgésicos/administración & dosificación , Dolor Postoperatorio/terapia , Acetaminofén/administración & dosificación , Analgesia Epidural , Analgésicos/efectos adversos , Analgésicos no Narcóticos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Antiinflamatorios no Esteroideos/administración & dosificación , Enfermedad Crónica , Terapia Combinada , Contraindicaciones , Glucocorticoides/administración & dosificación , Humanos , Pacientes Internos , Bloqueo Nervioso , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Postoperative pain management is important for patients' well-being and mobility. It also reduces the length of hospital stays and prevents complications. Based on our own clinical experience, data on pain in cancer patients from Norway and on postoperative pain from other countries, we expected that a substantial proportion of patients staying in Norwegian hospitals would report postoperative pain of high intensity. MATERIAL AND METHODS: 215 in-patients from 14 Norwegian hospitals participated in a study of pain during the first 24 hours after operations. The study was based on medical records and data reported by the patients themselves. RESULTS: On an 11-point numerical scale, the mean intensity of pain was 3.0 (SD 2.1) during the first 24 hours. 8 % of patients reported that the intensity of even the weakest pain during rest had been ≥ 4, 38 % reported a mean intensity ≥ 4 and 11 % reported a mean ≥ 6. The medical records contained information about the intensity of postoperative pain for only 22 % of the patients. Reports from patients indicated that 52 % had been asked to report the intensity of pain on a scale as part of the hospital routine, while 78 % and 74 % had been asked about the need for additional pain alleviation and whether the medication was effective. INTERPRETATION: Many patients reported pain of strong intensity during the first 24 hours after operations. There is a great potential for improved documentation and treatment of pain.
Asunto(s)
Dolor Postoperatorio , Adulto , Anciano , Analgesia/métodos , Analgésicos/administración & dosificación , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Noruega/epidemiología , Dimensión del Dolor , Percepción del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/epidemiología , Dolor Postoperatorio/terapia , Admisión del Paciente , Prevalencia , Sistema de Registros , Factores de TiempoRESUMEN
OBJECTIVES: Opioids are the most potent analgesics in the treatment of postoperative pain. Respiratory depression is, however, a serious side effect. The aims of this study were to evaluate current practice and routines for post-operative administration of opioids in a Norwegian university hospital and to evaluate whether the clinical safeguards adequately protected patients' safety regarding risk of respiratory depression. METHODS: The study had a retrospective cross-sectional design and included 200 patients, treated with opioids postoperatively. The patients were treated in a post-anesthesia care unit (PACU) before transferal to a surgical ward. Relevant data such as opioid dosages, routes of administration, sedation and respiratory function, routines for patient monitoring, and numbers of patients with opioid induced respiratory depression was collected. RESULTS: Two patients (1%) developed respiratory depression that needed naloxone to reverse the effect, and 32 patients (16%) had a respiratory rate (RR) <10/min, which may have been caused by opioids. In the PACU, the patient's RR was evaluated on a routine base, but after transferal to a surgical ward RR documented in only 7% of the patients. CONCLUSIONS: The lack of routines for patient monitoring, especially RR, represented a risk of not detecting opioid induced respiratory depression.
Asunto(s)
Analgésicos Opioides , Insuficiencia Respiratoria , Analgésicos Opioides/efectos adversos , Estudios Transversales , Humanos , Insuficiencia Respiratoria/inducido químicamente , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
BACKGROUND: Overall outcomes of pediatric rheumatic diseases (RD) have improved due to treatment with biologic agents and methotrexate. For many children, this treatment often entails regular needle injections. Pain and fear of needle injections are common in childhood, but how children and parents handle long-term needle injections at home has not been fully explored. This study aimed to explore how regular needle injections affect children with RD and their parents in their daily living. METHODS: This explorative qualitative study used individual interviews and focus groups to ensure a comprehensive investigation of the topic. Children aged 6 to 16 years (n = 7) and their parents (n = 8) were interviewed individually 4 to 6 months after the onset of needle injection treatment. The focus groups included children aged 11 to 17 years (n = 9) and parents (n = 8) with a minimum of 6 months of experience with injection treatment. Data were analyzed using thematic analysis. RESULTS: The main themes; "challenges," "motivational factors," and "routines" captured experiences and strategies that influenced the continuation of needle injections at home. Many children feared the moment immediately before the needle stick, although they had become accustomed to the pain. Most parents felt insecure about handling needle injections and lacked follow-up from healthcare providers. The children's experience of treatment effects and self-confidence were essential to maintain motivation for further injections. A number of coping strategies helped children focus away from injection related discomfort, often discovered by chance. Facilitating firm routines and shared responsibility within families helped children develop self-confidence during the procedure. Children and parents struggled to find suitable information on the Internet. CONCLUSIONS: Children and parents experienced long-term needle injections challenging. They used their own limited resources and cooperated within the families to create routines and to introduce coping strategies necessary to manage and keep up with the procedure. Although the injection itself was not experienced very painful, the discomfort, worries and impact on daily life represented far more than a little needle stick, and thus needs more attention from healthcare providers.
Asunto(s)
Antirreumáticos/administración & dosificación , Inyecciones/psicología , Padres/psicología , Enfermedades Reumáticas/psicología , Adolescente , Antirreumáticos/uso terapéutico , Niño , Grupos Focales , Humanos , Entrevistas como Asunto , Investigación Cualitativa , Enfermedades Reumáticas/tratamiento farmacológicoRESUMEN
OBJECTIVES: The pathogeneses of chronic tension-type headache (CTTH) and cervicogenic headache (CEH) are not well established. Peripheral activation or sensitization of myofascial nociceptors is suggested as a potential mechanism and injections of botulinum toxin (BONTA) have thus been used in the treatment for both headache conditions. BONTA inhibits the release of acetylcholine at the neuromuscular junction and inhibits contraction of skeletal muscles. If the pain is precipitated by increased tone in cervical muscles, local injections of BONTA could represent a prophylactic measure. However, the treatment is still controversial, and a thorough assessment of the current evidence is required. This review aims to assess the evidence of BONTA injection as a prophylactic treatment for CTTH and CEH by reviewing and examining the quality of placebo-controlled, randomized trials. METHODS: Data sources: we searched in the following databases: PubMed (including Medline), Embase, Cochrane Central register of Controlled Trials, Cinahl, Amed, SCOPUS and Google Scholar including other repository sources. Both MeSH and free keywords were used in conducting the systematic search in the databases. The search covered publications from the root of the databases to November 2020. STUDY ELIGIBILITY CRITERIA: The review included RCTs, comparing single treatment of BONTA with placebo on patients with CTTH or CEH above 18 years of age, by measuring pain severity/relief or headache frequency. DATA EXTRACTION: The following data were extracted: year of publication, country, setting, trial design, number of participants, injection procedure, BONTA dosages, and clinical outcome measures. STUDY APPRAISAL: To assess validity and quality, and risk of bias, the Oxford Pain Validity Scale, Modified Jadad Scale, last version of Cochrane Collaboration's tool for assessing risk of bias (RoB 2), and the CONSORT 2010 Checklist were used. The trials were assessed, and quality scored independently by two of the reviewers. A quantitative synthesis and meta-analyses of headache frequency and intensity were performed. RESULTS: We extracted 16 trials, 12 on prophylactic BONTA treatment for CTTH and four on CEH. Of these 12 trials (8 on CTTH and 4 on CEH) were included in the quantitative synthesis. A majority of the trials found no significant difference on the primary outcome measure when BONTA treatment was compared with placebo. Three "positive" trials, reporting significant difference in favor of BONTA treatment, but two of these were hampered by low validity and quality scores and high risk of bias. CONCLUSIONS: There is no clear clinical evidence supporting prophylactic treatment with BONTA for CTTH or CEH.
Asunto(s)
Toxinas Botulínicas Tipo A , Trastornos de Cefalalgia , Cefalea Postraumática , Cefalea de Tipo Tensional , Toxinas Botulínicas Tipo A/uso terapéutico , Cefalea/tratamiento farmacológico , Trastornos de Cefalalgia/tratamiento farmacológico , Humanos , Cefalea Postraumática/tratamiento farmacológico , Ensayos Clínicos Controlados Aleatorios como Asunto , Cefalea de Tipo Tensional/tratamiento farmacológicoRESUMEN
BACKGROUND: Punction of blood vessels is a necessity in modern medicine, but there is a paucity of knowledge about the close relation between vessels and nerves. MATERIAL AND METHODS: We refer to two cases that show possible consequences of cannulation of v. cephalica and a. radialis. RESULTS: Both patients developed clinical symptoms and neurological findings indicating injury of the radial nerve. One of the patients is not likely to develop chronic neuropathic pain, but in the other patient the similar injury of the radial nerve has lead to chronic and disabling pain. INTERPRETATION: We advise against using the distal part of v. cephalica (the intern's vein) as the first choice for training of inexperienced students. The vein should only be used in patients that lack other venous alternatives and in acute situations where quick infusions or blood transfusions are needed.
Asunto(s)
Cateterismo Periférico/efectos adversos , Internado y Residencia , Nervio Radial/lesiones , Competencia Clínica , Femenino , Humanos , Hiperalgesia/etiología , Masculino , Persona de Mediana Edad , Neuralgia/etiología , Arteria Radial , Factores de RiesgoRESUMEN
PURPOSE: Chronic pain is often multifactorial and accompanied by psychological distress, catastrophizing thoughts, reduced physical function, and socio-economic worries. In this explorative study, we investigated potential mediators in the relationships of psychological and demographic variables with chronic pain and physical function in women and men. PATIENTS AND METHODS: The study included 301 patients admitted to a multidisciplinary pain clinic. Prior to their first consultation, patients completed a questionnaire including items on demographics (age, education, occupational and financial situation), catastrophizing thoughts, psychological distress, pain intensity, and physical function. Hierarchical multiple regression analyses examined demographic and psychological factors associated with pain intensity and physical function. Mediation and reversed mediation models were tested and developed based on calculated relations in the regression analyses between demographic, psychological, pain intensity and physical function variables. RESULTS: Fifty-eight percent were females and mean age 43.8 and 46.0 years for women and men, respectively. In the regression analyses, psychological factors accounted better for pain intensity than demographic variables, while physical function was best accounted for by demographic variables. Among women, catastrophizing thoughts mediated significantly the relationships between education and pain intensity, and between education and physical function. Psychological distress mediated significantly the relationships between financial situation and pain intensity, and between financial situation and physical function in women. In men, the only significant mediation model was psychological distress mediating the relationship between financial situation and pain intensity. Some of the reversed models revealed indirect effects, indicating bidirectionality. CONCLUSION: The results indicate that there might be gender-specific mediators in how demographic variables are associated with pain intensity and physical function. This suggests an awareness among clinicians of potential gender-specific factors mediating pain problems, and the need for a gender-specific, multidisciplinary approach in the treatment of chronic pain.
RESUMEN
BACKGROUND: Treatment of rheumatic diseases in children often includes long-term needle injections, which represent a risk for refusing medication based on potential needle-fear. How nurses manage children's fear and pain during the initial educational training session of subcutaneous injections, may affect the management of the subsequent injections in the home settings. The aim of this study was to explore how children expressed fear and pain during these training sessions, and how adults' communication affected children's expressed emotions. METHODS: This qualitative explorative study used video observations and short interviews during training sessions in a rheumatic hospital ward. Participants were children between five and fifteen years (n = 8), their parents (n = 11) and nurses (n = 7) in nine training sessions in total. The analysis followed descriptions of thematic analysis and interaction analysis. RESULTS: The children expressed fears indirectly as cues and nonverbal signs more often than direct statements. Three children stated explicit being afraid or wanting to stop. The children worried about needle-pain, but experienced the stinging pain after the injection more bothersome. The technical instructions were detailed and comprehensive and each nurse shaped the structure of the sessions. Both nurses and parents frequently offered coping strategies unclearly without sufficient time for children to understand. We identified three main adult communication approaches (acknowledging, ambiguous and disregarding) that influenced children's expressed emotions during the training session. CONCLUSIONS: Children's expression of fear was likely to be indirectly, and pain was mostly related to the injection rather than the needle stick. When adults used an acknowledging communication and offered sufficient coping strategies, children seemed to become involved in the procedure and acted with confidence. The initial educational training session may have a great impact on long-term repeated injections in a home setting by providing children with confidence at the onset.
Asunto(s)
Antirreumáticos/administración & dosificación , Miedo/psicología , Inyecciones Subcutáneas/psicología , Agujas , Relaciones Enfermero-Paciente , Relaciones Padres-Hijo , Educación del Paciente como Asunto , Enfermedades Reumáticas/tratamiento farmacológico , Adalimumab/administración & dosificación , Adolescente , Adulto , Anticuerpos Monoclonales Humanizados/administración & dosificación , Niño , Preescolar , Etanercept/administración & dosificación , Femenino , Humanos , Masculino , Metotrexato/administración & dosificación , Enfermeras y Enfermeros , Dolor Asociado a Procedimientos Médicos/psicología , Padres , Investigación CualitativaRESUMEN
Introduction There is limited evidence for effect of interventional treatment, and pragmatic studies are needed to assess these interventions within a clinical setting. The aim of this study was to describe patients referred to an interventional pain clinic and investigate responses after spinal intervention in general and for radiofrequency ablation (RFA) and transforaminal epidural corticosteroid administration (TECA), specifically. Methods This is a prospective, non-controlled study of patients with chronic spinal pain. The procedures were performed in accordance with the Spine Intervention Society recommendations. Outcome data after a median of 4.5 months are presented, and for those treated with RFA also after 6 and 12 months. Results Among 815 patients, 190 patients underwent diagnostic blocks only and 625 interventional treatment, of these 94 RFA and 246 TECA. Of the whole sample 70% reported pain reduction, for 49% ≥ 50%, while 9% were pain free (p < 0.001). Highest pain intensity decreased from 7.1 to 5.4 [95% Confidence Interval of the Difference (95%-CI): 1.4-1.9] (p < 0.001), while Euroqual - visual analogue scale for general health (EQ-VAS) improved from 48 to 58 (95%-CI: 7.6-11.9) (p < 0.001), and Euroqual-5 Dimensions-5 Levels Index for health related quality of life (EQ-5D-5L Index) from 0.489 to 0.628 (95%-CI: 0.123-0.157) (p < 0.001). The proportions, not taking analgesics, increased from 16% to 30%, and proportion taking strong opioids decreased from 14% to 9% (p < 0.001). We found no significant change in proportion receiving physiotherapy/other treatment nor occupational status. No complications were reported. Among patients treated with RFA, 77% reported pain reduction, for 56% ≥ 50%, while 9% were pain free (p < 0.001). Highest pain intensity decreased from 6.9 to 4.6 (95%-CI: 1.6-3.0) (p < 0.001), while EQ-VAS improved from 47 to 57 (95%-CI: 4.8-13.6 (p < 0.001), and EQ-5D-5L Index from 0.489 to 0.643 (95%-CI: 0.117-0.191) (p < 0.001). The proportion not taking analgesics, increased from 7% to 23% and proportion taking strong opioids decreased from 16% to 10%. Among patients who responded at 6- and 12-month follow up, the proportions reporting pain reduction, EQ-VAS, and EQ-5D-5L Index remained significantly improved from baseline, and the change in proportions taking analgesic and opioids achieved statistical significance. We found no significant change in proportion receiving physiotherapy/other treatment nor occupational status. Among patients treated with TECA, 58% reported pain reduction, for 36% ≥ 50%, while 5% were pain free (p < 0.001). Highest pain intensity decreased from 7.2 to 6.2 (95%-CI 0.5-1.4) (p < 0.001), while EQ-VAS improved from 46 to 52 (95%-CI: 2.0-3.6) (p < 0.001), and EQ-5D-5L Index from 0.456 to 0.571 (95%-CI: 0.077-0.138) (p < 0.001). The proportions, not taking analgesics, increased from 17% to 27% and proportion taking strong opioids decreased from 15% to 10%, but the changes did not reach statistical significance. We found no significant changes in the proportion who recieved physiotherapy/other treatment nor occupational status. Conclusion The study demonstrates substantial short-term responses after spinal intervention and long-lasting improvement for a subsample of the RFA treated patients. We observed larger proportions reporting pain reduction among those treated with cervical RFA. Implementation Quality assessment should be implemented in interventional pain clinics to improve treatment quality.
Asunto(s)
Analgesia Epidural/métodos , Dolor Crónico/terapia , Dolor de la Región Lumbar/terapia , Dolor de Cuello/terapia , Ablación por Radiofrecuencia/métodos , Corticoesteroides/administración & dosificación , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Dimensión del Dolor/métodos , Estudios Prospectivos , Calidad de Vida , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Background and aims A bio-psycho-social approach has been recommended in multidisciplinary pain clinics, and in Norway patients with severe chronic nonmalignant pain (CNMP, defined as pain that has persisted for more than 3 months) might be treated at a regional multidisciplinary pain center. The specific aims of this study were (1) to describe characteristics of a sample of outpatients referred and accepted for treatment/management to three regional multidisciplinary pain centers in Norway, (2) to examine patient differences between the centers and (3) to study associations between symptom scores (insomnia, fatigue, depression, anxiety) and patient characteristics. Methods Patients, aged 17 years or older with CNMP admitted to and given a date for first consultation at one of three tertiary, multidisciplinary pain centers: St. Olavs Hospital Trondheim University Hospital (STO), Haukeland University Hospital (HUS) and University Hospital of North Norway (UNN), were included in the study. Data on demographics, physical activity, characteristics of pain, previous traumatic events, social network, Insomnia Severity Index (ISI), Chalder Fatigue Questionnaire (CFQ), Hopkins Symptom Checklist-25 (HSCL-25) and SF-36v2® were retrieved from the local quality registry at each pain center. Results Data from 1563 patients [mean age 42 (SD 15) years and 63% females] were available for analyses. Average years with pain were 9.3 (SD 9.1). Primary education as highest level of education was reported by 20%, being actively working/student/military by 32%, and no physical activity by 31%. Further, 48% reported widespread pain, 61% reported being exposed to serious life event(s), and 77% reported having a close friend to talk to. Non-worker status, no physical activity, lack of social network, reports of being exposed to serious life event(s) and widespread pain were all characteristics repeatedly associated with clinically high symptom scores. No significant differences between the centers were found in the proportions of patients reporting fatigue nor mean levels of insomnia symptoms. However, the proportion of patients reporting symptoms of anxiety and depression was a little lower at UNN compared with STO and HUS. Conclusions Analyses of registry data from three tertiary multidisciplinary pain centers in Norway support previous findings from other registry studies regarding patient characterized: A large proportion being women, many years of pain, low employment rate, low physical activity rate, and a large proportion reporting previous traumatic event(s). Characteristics such as non-work participation, no physical activity, lack of social network, have been exposed to serious life event(s), and chronic widespread pain were all associated with high clinical score levels of insomnia, fatigue, and mental distress. Health related quality of life was low compared to what has been reported for a general population and a range of other patient groups. Implications The findings of this study indicate that physical activity and work participation might be two important factors to address in the rehabilitation of patients with chronic non-malignant pain. Future studies should also explore whether pre consultation self-reported data might give direction to rehabilitation modalities.
Asunto(s)
Dolor Crónico/psicología , Estado de Salud , Distrés Psicológico , Calidad de Vida , Adolescente , Adulto , Anciano , Dolor Crónico/complicaciones , Estudios Transversales , Ejercicio Físico , Femenino , Humanos , Acontecimientos que Cambian la Vida , Masculino , Persona de Mediana Edad , Noruega , Clínicas de Dolor/estadística & datos numéricos , Sistema de Registros , Factores Socioeconómicos , Adulto JovenRESUMEN
Background and aims Cervicogenic headache (CEH) is a debilitating condition and analgesics have limited effect. Percutaneous cryoneurolysis is thus still in use although the clinical evidence is lacking. We present a randomized, controlled study to assess the clinical efficacy of cryoneurolysis compared with a corticosteroid combined with a local anaesthetic. Methods In a university-based outpatient pain clinic we performed a randomized, double blinded, comparative study with an 18-week follow-up. After positive diagnostic test blocks 52 eligible patients were randomly allocated in a ratio of 3:2, 31 participants to occipital cryoneurolysis and 21 participants to injections of 1 mL methylprednisolone 40 mg/mL (Depo-Medrol®) combined with 1 mL bupivacaine 5 mg/mL. Results We observed a significant pain reduction of more than 50% in both treatment groups, slightly improved neck function and reduced number of opioid consumers. After 6-7-weeks, however, pain intensity increased gradually, but did not reach baseline within 18 weeks. Although cryoneurolysis provided a more prolonged effect, the group differences did not reach statistical significance. Health related quality of life and psychological distress improved minimally. A large number reported minor and transient side effects, but we found no significant group differences. After 18 weeks, 29% rated the headache as much improved, and 12 (24%) somewhat improved, but a large proportion (78%) reported need for further intervention/treatment. Conclusions Cryoneurolysis provided substantial, but temporary pain relief, and the effect was not significantly different from injections of a corticosteroid combined with a local anaesthetic. Participants were selected by a single test block, and the neurolytic procedure was guided by anatomical landmarks and nerve stimulation. A stricter patient selection and an ultrasound-guided technique might have improved the results. Cryoneurolysis provides temporary pain relief not significantly superior to corticosteroid injection, and the results question the value of occipital cryoneurolysis for a chronic pain condition like CEH. Implications Occipital cryoneurolysis may be considered when non-invasive treatments appear insufficient, but only for patients who have responded substantially to test blocks. A risk of local scar and neuroma formation by repeated cryoneurolysis, leading to neuropathic pain has been discussed by other researchers.
Asunto(s)
Anestésicos Locales/uso terapéutico , Antiinflamatorios/administración & dosificación , Bupivacaína/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Metilprednisolona/administración & dosificación , Manejo del Dolor , Cefalea Postraumática/tratamiento farmacológico , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Importance: During monopolar electrosurgery in patients, current paths can be influenced by metal implants, which can cause unintentional tissue heating in proximity to implants. Guidelines concerning electrosurgery and active implants such as pacemakers or implantable cardioverter defibrillators have been published, but most describe interference between electrosurgery and the active implant rather than the risk of unintended tissue heating. Tissue heating in proximity to implants during electrosurgery may cause an increased risk of patient injury. Objective: To determine the temperature of tissue close to metal implants during electrosurgery in an in-vitro model. Design, Setting, and Participants: Thirty tissue samples (15 with a metal implant placed in center, 15 controls without implant) were placed in an in vitro measurement chamber. Electrosurgery was applied at 5-60 W with the active electrode at three defined distances from the implant while temperatures at four defined distances from the implant were measured using fiber-optic sensors. Main Outcomes and Measures: Tissue temperature increase at the four tissue sites was determined for all power levels and each of the electrode-to-implant distances. Based on a linear mixed effects model analysis, the primary outcomes were the difference in temperature increase between implant and control tissue, and the estimated temperature increase per watt per minute. Results: Tissues with an implant had higher temperature increases than controls at all power levels after 1 min of applied electrosurgery (mean difference of 0.16°C at 5 W, 0.50°C at 15 W, 1.11°C at 30 W, and 2.22°C at 60 W, all with p < 0.001). Temperature increase close to the implant was estimated to be 0.088°C/W/min (95% CI: 0.078-0.099°C/W/min; p < 0.001). Temperature could increase to above 43°C after 1 min of 60 W. Active electrode position had no significant effect on temperature increases for tissues with implant (p = 0.6). Conclusions and Relevance: The temperature of tissue close to a metal implant increases with passing electrosurgery current. There is a significant risk of high tissue temperature when long activation times or high power levels are used.