Psychological profiles and prescription opioid misuse, craving, and withdrawal in people with chronic pain.

BACKGROUND: The negative consequences of prescription opioid misuse and opioid use disorder make it relevant to identify factors associated with this problem in individuals with chronic pain. This cross-sectional study aimed at identifying subgroups of people with chronic pain based on their psychological profiles, prescription opioid misuse, craving, and withdrawal. METHODS: The sample comprised 185 individuals with chronic pain. We performed hierarchical cluster analysis on impulsivity, anxiety sensitivity, pain acceptance, pain intensity, opioid misuse, craving, and withdrawal. RESULTS: The four-cluster solution was the optimal one. Misuse, craving, and anxiety sensitivity were higher among people in the Severe-problems cluster than among people in the other three clusters. Withdrawal was the highest in the High-withdrawal cluster. Impulsivity was higher among people in the Severe-problems and High-withdrawal clusters than those in the Moderate-problems and Mild-problems clusters. Pain acceptance was higher among people in the Mild-problems cluster than among people in the other three clusters. Anxiety sensitivity and misuse were higher among people in the Moderate-problems cluster than among people in the Mild-problems cluster. CONCLUSIONS: These results support that impulsivity, anxiety sensitivity, and pain acceptance are useful constructs to identify subgroups of people with chronic pain according to their level of prescription opioid misuse, craving, and withdrawal. The results of this study may help in selecting the early intervention most suitable for each of the identified profiles. SIGNIFICANCE: The psychological profile of individuals with chronic pain, prescription opioid misuse, craving, and withdrawal is characterized by fearing anxiety-related symptoms due to the catastrophic interpretation of such symptoms and reacting impulsively to negative moods. In contrast, participants with high pain acceptance had less prescription opioid misuse, craving, and withdrawal. The profiles identified in this study could help clinicians select targets for intervention among profiles with similar needs and facilitate early interventions to prevent opioid misuse onset or aggravation.

El papel de los sistemas de aproximación e inhibición conductual (SAC/SIC) en la adaptación psicológica al dolor crónico / No disponible

La Teoría de la Sensibilidad al Reforzamiento propone un modelo neuropsicológico, el cual trata de explicar cómo las personas responden a los estímulos, incluyendo el dolor. De acuerdo con la misma, las personas difieren en su sensibilidad a la recompensa o al castigo, y son estas disimilitudes las que van a marcar las distintas formas de comportamiento, siendo esta la base de las diferencias individuales en personalidad. Estas diferencias individuales se explicarían, fundamentalmente, por la acción de dos sistemas cerebrales, con sustratos neurobiológicos diferenciados: el Sistema de Inhibición Conductual (SIC) y el Sistema de Aproximación Conductual (SAC). El primero se activa ante estímulos relacionados con el castigo o intensos, y se ha asociado a la ansiedad o a estados de ánimo negativos. El segundo, se activa ante estímulos relacionados con la recompensa, asociándose a emociones como el placer, la esperanza o el alivio. Ambos sistemas han sido propuestos como factores relevantes en el desarrollo de trastornos mentales, en los que la ansiedad desempeñaría un papel central. Habida cuenta de las críticas recibidas por el Modelo de Miedo-Evitación del Dolor, recientemente se ha postulado que tanto el SIC como el SAC podrían explicar también las diferencias en la experiencia y adaptación psicológica de las personas aquejadas de una patología de dolor crónico. La aún incipiente evidencia empírica disponible hasta la fecha ha mostrado que el nivel de activación de estos sistemas podría contribuir a explicar los factores que subyacen a los procesos cognitivos, emocionales, conductuales y motivacionales presentes en el dolor crónico y, por ende, los factores definitorios del ajuste psicológico a esta patología. El análisis del papel que estos sistemas pueden desempeñar en la experiencia psicológica del dolor crónico no solo abre futuras líneas de investigación para una mayor comprensión de la misma, sino que permite efectuar recomendaciones relativas a la elección de tratamientos psicológicos para personas aquejadas de dolor crónico. El objetivo de este trabajo es presentar la teoría y hallazgos más relevantes en relación al SIC y el SAC y el dolor

Reinforcement Sensitivity Theory proposes a neuropsychological model that attempts to explain how people respond to stimuli, including pain stimuli. The theory suggests that differences in sensitivity to reward or punishment, which could entail different forms of behaviour, may be the basis of individual differences in personality. The activity of two brain systems with differentiated neurobiological substrates may underlie these differences: the Behavioural Inhibition System (BIS) and the Behavioural Approach System (BAS). BIS is activated by punishment- related or intense stimuli and has been associated with anxiety or negative moods. BAS is activated by reward-related stimuli and has been associated with emotions such as pleasure, hope, or relief. Both systems have been proposed as relevant to the development of mental disorders in which anxiety plays a central role. Given the criticism received by the Fear-Avoidance Model of Pain, it has recently been postulated that BIS and BAS could explain differences in the psychological experience and adaptation of people with chronic pain pathology. The initial empirical evidence available has shown that the level of activation of these systems may contribute to explaining the factors underlying the cognitive, emotional, behavioural, and motivational processes present in individuals with chronic pain, and thus the defining factors of psychological adjustment to this pathology. The analysis of the role of these systems in the psychological experience of chronic pain may open future lines of research, deepen our understanding of the issues, and guide recommendations on the choice of psychological treatment for people with chronic pain. The objective of this study was to present the theory and the most relevant findings on BIS and BAS and pain

The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain.

PURPOSE: This study investigated the role of anxiety sensitivity, resilience, pain catastrophizing, depression, pain fear-avoidance beliefs, and pain intensity in patients with acute back pain-related disability. METHOD: Two hundred and thirty-two patients with acute back pain completed questionnaires on anxiety sensitivity, resilience, pain catastrophizing, fear-avoidance beliefs, depression, pain intensity, and disability. RESULTS: A structural equation modelling analysis revealed that anxiety sensitivity was associated with pain catastrophizing, and resilience was associated with lower levels of depression. Pain catastrophizing was positively associated with fear-avoidance beliefs and pain intensity. Depression was associated with fear-avoidance beliefs, but was not associated with pain intensity. Finally, catastrophizing, fear-avoidance beliefs, and pain intensity were positively and significantly associated with acute back pain-related disability. CONCLUSION: Although fear-avoidance beliefs and pain intensity were associated with disability, the results showed that pain catastrophizing was a central variable in the pain experience and had significant direct associations with disability when pain was acute. Anxiety sensitivity appeared to be an important antecedent of catastrophizing, whereas the influence of resilience on the acute back pain experience was limited to its relationship with depression.

An examination of the structural link between post-traumatic stress symptoms and chronic pain in the framework of fear-avoidance models.

BACKGROUND: The tendency to respond with fear and avoidance can be seen as a shared vulnerability contributing to the development of post-traumatic stress disorder (PTSD) and chronic pain. Although several studies have examined which specific symptoms of PTSD (re-experiencing, avoidance, emotional numbing and hyperarousal) are associated with chronic pain, none has considered this association within the framework of fear-avoidance models. METHODS: Seven hundred fourteen patients with chronic musculoskeletal pain were assessed. Of these, 149 patients were selected for the study based upon the following inclusion criteria: exposure to a traumatic event before the onset of pain (with scores equal to or higher than 8 points on the fear and hopelessness scales of the Stressful Life Event Screening Questionnaire Revised) and scores equal to or higher than 30 on the Davidson Trauma Scale. RESULTS: Structural equation modelling was used to test the association between PTSD symptoms and pain outcomes (pain intensity and disability) using the mediating variables considered in the fear-avoidance models. The results show that emotional numbing and hyperarousal symptoms, but neither re-experiencing nor avoidance, affected pain outcome via anxiety sensitivity (AS), catastrophizing and fear of pain. PTSD symptoms increased the levels of AS, which predisposes to catastrophizing and, in turn, had an effect on the tendency of pain patients to respond with more fear and avoidance. CONCLUSIONS: This study provides empirical support for the potential role of PTSD symptoms in fear-avoidance models of chronic pain and suggests that AS is a relevant variable in the relationship between both disorders.

Empirical evidence of the validity of the Spanish version of the pain vigilance awareness questionnaire.

BACKGROUND: The Spanish version of the Pain Vigilance and Awareness Questionnaire has not been validated. PURPOSE: The aims of this study were to examine the factor structure of the Spanish version of the Pain Vigilance and Awareness Questionnaire and present empirical evidence regarding its validity. METHOD: A sample of 468 chronic back pain patients completed a battery of instruments to assess fear-avoidance beliefs, pain anxiety, pain catastrophizing, pain vigilance and awareness, pain acceptance, depression, anxiety, disability, and pain intensity. RESULTS: Confirmatory factor analysis supported the validity of a nine-item version with two subscales: Active Vigilance and Passive Awareness. Both subscales and the total score were positively and significantly correlated with other fear-related constructs: fear-avoidance beliefs, pain anxiety, and pain catastrophizing. Regression analyses showed that Active Vigilance and the two subscales of the Fear-Avoidance Beliefs Questionnaire were significantly associated with higher anxiety and that the Acceptance Activity Engagement subscale was significantly associated with lower anxiety. The Fear-Avoidance Beliefs Questionnaire-Physical subscale was associated with higher disability and the Acceptance Pain Willingness subscale was associated with lower disability. The Fear-Avoidance Beliefs Questionnaire-Work subscale was significantly associated with higher pain intensity and depression; the Acceptance Activity Engagement and Pain Willingness subscales were significantly associated with lower pain intensity and depression. CONCLUSION: The Spanish version of the Pain Vigilance and Awareness Questionnaire is a reliable and valid instrument. Pain Acceptance and Fear Avoidance beliefs are better predictors of adjustment to pain than pain hypervigilance.

Experiential avoidance and anxiety sensitivity as dispositional variables and their relationship to the adjustment to chronic pain.

Anxiety sensitivity has been included in the fear-avoidance model as a vulnerability factor to explain individual differences in fear of pain. Several studies have suggested that the relationship between anxiety sensitivity and some psychopathological disorders is mediated by experiential avoidance, an affect-related regulatory process that involves unwillingness to endure private experiences. The role of these constructs as vulnerability variables has not been investigated in chronic pain patients. The aim of this study was to investigate the role of anxiety sensitivity and experiential avoidance as dispositional variables in pain fear-avoidance. Two alternative hypothetical models were tested: one in which anxiety sensitivity and experiential avoidance would be independently associated with pain fear-avoidance; and second, one in which experiential avoidance would mediate the relationship between anxiety sensitivity and pain fear-avoidance. The sample was composed of 299 patients with chronic back pain. The postulated relationships were tested using LISREL 8.20 software (Scientific Software International, Chicago, IL, USA) and the generally weighted least squares. The structural equation modelling analyses showed that experiential avoidance and anxiety sensitivity were independently associated with pain fear-avoidance and that anxiety sensitivity had a stronger association with pain fear-avoidance than experiential avoidance. The alternative model, in which experiential avoidance mediates the relationship between anxiety sensitivity and pain fear-avoidance, gave a much worse fit. These results highlight the importance of both anxiety sensitivity and experiential avoidance as variables which could explain individual differences in pain fear-avoidance. Thus, in terms of prevention, it should be a priority to identify patients with increased anxiety sensitivity and experiential avoidance during the first stages of the development of chronic pain conditions.

Comorbilidades y consumo de recursos sanitarios en población fumadora. Un análisis desde Atención Primaria / Comorbidity and health resources use in smokers. An analysis from a primary care setting

FundamentoMedir el perfil de morbilidad, la consecución de objetivos terapéuticos, el uso de recursos y la incidencia de eventos cardiovasculares (ECV) de sujetos fumadores en Atención Primaria (AP).Pacientes y métodosDiseño retrospectivo y multicéntrico. Se incluyó a todos los pacientes fumadores de más de treinta años de edad de cinco equipos de AP (año 2006). Se formó una cohorte comparativa formada por no fumadores. Las principales medidas fueron presencia de ECV, edad, sexo, índice de Charlson, comorbilidad, parámetros clínicos y costes directos (fijos y variables; visitas, medicamentos, pruebas y derivaciones). Se empleó un análisis de regresión logística y un análisis de la covarianza para la corrección del modelo (p<0,05).ResultadosSe incluyó a 55.653 pacientes. Un 20,8% (intervalo de confianza del 95%: 20,5–21,1%) fueron fumadores. El promedio de edad de los fumadores fue menor (48,2 frente a 55,9 años), con predominio de varones (60,8%) (p<0,01) y similar índice de Charlson (0,3 frente a 0,3; p=no significativa [NS]). La proporción de fumadores en hipertensos fue del 18,8% y en diabéticos del 9,6%. La prevalencia de ECV en fumadores fue del 4,9 frente al 4,2% y la incidencia acumulada/anual del 14,2 frente al 12,5‰ (p<0,028). Los fumadores mostraron mayores niveles de triglicéridos séricos (136,3 mg/dl) y colesterol ligado a lipoproteínas de baja densidad (128,0 mg/dl) (p<0,001). El tabaquismo tuvo una relación independiente con el alcoholismo (odds ratio [OR]=5,3) y la enfermedad pulmonar obstructiva crónica (OR=2,5) en presencia de ECV (OR=1,2) (p<0,001). Los costes directos corregidos no mostraron diferencias: 660,10 frente a 654,11 € (p=NS) (en todos sus componentes)...(AU)

BackgroundTo ascertain the morbidity profile, achievement of the clinical control objectives, resources use and the incidence of cardiovascular events (CVE) in smoking subjects in Primary Care settings (PC).MethodsRetrospective multicentric study. All smoker subjects older than thirty years attended in any of five PC settings were included. A comparative cohort was established with non-smokers. Primary measures were: presence of CVE, age, gender, Charlson index, history/co-morbidity and clinics parameters and direct costs (fixed and variable; visits, drugs, diagnostic test and referrals). Multiple logistic regression analysis and ANCOVA models were applied for models correction, P<0.05.Results55,653 patients were included. 20.8% (95% confidence intervals [CI]:20.5–21.1%) were smokers. Non-smokers were younger (48.2 versus 55.9 years), with more men (60.8%), P<0.01; and a similar Charlson index (0.3 versus 0.3; P=NS). The proportion of smokers in hypertensive population was 18.8% and in diabetics 9.6%. CVE presence in smokers were 4.9% versus 4.2% and the accumulated incidence/annual of 14.2‰ versus 12.5‰, P<0.028. Smokers showed higher levels of serum triglycerides (136.3 mg/dl) and LDL-cholesterol (128.0 mg/dl, P<0.001). Smoking habit was independent related to the alcoholism (Odds ratio, OR=5.3) and the EPOC (OR=2.5), in presence of CVE (OR=1.2, P<0.001). Adjusted direct costs non differences showed: €660.10 versus €654.11, P=NS (in all components).ConclusionsCVE annual incidence in smoking subjects was greater, with a minor average of age. Smokers presented a similar number of co-morbidities and total/patient costs. Clinical control objectives should be better in Primary prevention of the cardiovascular risk factors. To give up smoking should be the best strategy to diminish CVE incidence(AU)

[Comorbidity and health resources use in smokers. An analysis from a primary care setting]. / Comorbilidades y consumo de recursos sanitarios en población fumadora. Un análisis desde Atención Primaria.

BACKGROUND: To ascertain the morbidity profile, achievement of the clinical control objectives, resources use and the incidence of cardiovascular events (CVE) in smoking subjects in Primary Care settings (PC). METHODS: Retrospective multicentric study. All smoker subjects older than thirty years attended in any of five PC settings were included. A comparative cohort was established with non-smokers. Primary measures were: presence of CVE, age, gender, Charlson index, history/co-morbidity and clinics parameters and direct costs (fixed and variable; visits, drugs, diagnostic test and referrals). Multiple logistic regression analysis and ANCOVA models were applied for models correction, P<0.05. RESULTS: 55,653 patients were included. 20.8% (95% confidence intervals [CI]:20.5-21.1%) were smokers. Non-smokers were younger (48.2 versus 55.9 years), with more men (60.8%), P<0.01; and a similar Charlson index (0.3 versus 0.3; P=NS). The proportion of smokers in hypertensive population was 18.8% and in diabetics 9.6%. CVE presence in smokers were 4.9% versus 4.2% and the accumulated incidence/annual of 14.2 per thousand versus 12.5 per thousand, P<0.028. Smokers showed higher levels of serum triglycerides (136.3 mg/dl) and LDL-cholesterol (128.0 mg/dl, P<0.001). Smoking habit was independent related to the alcoholism (Odds ratio, OR=5.3) and the EPOC (OR=2.5), in presence of CVE (OR=1.2, P<0.001). Adjusted direct costs non differences showed: euro660.10 versus euro654.11, P=NS (in all components). CONCLUSIONS: CVE annual incidence in smoking subjects was greater, with a minor average of age. Smokers presented a similar number of co-morbidities and total/patient costs. Clinical control objectives should be better in Primary prevention of the cardiovascular risk factors. To give up smoking should be the best strategy to diminish CVE incidence.

[Effect of intensive treatment with atorvastatin versus standard doses of statins on the risk of stroke. A meta-analysis from five randomized trials including 25,709 patients]. / Efecto del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas en el riesgo de ictus de pacientes con enfermedad coronaria previa. Metaanálisis de cinco ensayos aleatorizados con 25.709 pacientes.

AIM: To evaluate the efficacy of intensive lipid lowering treatment with atorvastatin versus standard doses of statins (simvastatin, atorvastatin, lovastatin or pravastatin) on the risk of stroke, using meta-analytic techniques. PATIENTS AND METHODS: The meta-analysis included 5 randomized trials that met the inclusion criteria: comparison between intensive atorvastatin treatment (atorvastatin 80 mg or target LDL < 70 mg/dL) and standard doses of statins, with a clinical follow-up of more than 12 months and stroke as clinical endpoint. TNT (n = 9,917) atorvastatin 80 mg vs. 10 mg; IDEAL (n = 8,888) atorvastatin 80 mg vs. simvastatin 20-40 mg; PROVE-IT (n = 4,162) atorvastatin 80 mg vs. pravastatin 40 mg; ALLIANCE (n = 2,442) atorvastatin 80 mg or target LDL < 70 mg/dL vs. standard treatment; and VBBS (n = 300) atorvastatin 80 mg vs. low dose lavastatin. The selected studies included secondary prevention patients (acute coronary syndrome, stable coronary disease and patients eligible for angioplasty). 25,709 patients were included (12,910 allocated to intensive atorvastatin treatment, and 12,799 to standard doses of statins). Stroke incidence, as reported from each trial, was compared between both treatments. RESULTS: Out of the 25,709 patients, 713 (2.77%) suffered a stroke during follow-up. The incidence of stroke was significantly reduced with intensive atorvastatin treatment in comparison with conventional doses of statins: 2.52% (n = 325) vs. 3.03% (n = 388); relative risk = 0.83; 95% confidence interval = 0.72-0.96; p = 0.0121. CONCLUSIONS: Intensive lipid lowering treatment with atorvastatin is associated with a 17% relative risk reduction of stroke in comparison with conventional doses of statins in secondary prevention population.

Efecto del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas en el riesgo de ictus de pacientes con enfermedad coronaria previa. Metaanálisis de cinco ensayos aleatorizados con 25.709 pacientes / Effect of intensive tretament with atorvastatin versus standard doses of statins on the risk of stroke. A meta analysis form five randomized trials incluiding 25, 709 patients

Objetivo. Evaluar, mediante técnicas de metaanálisis, la eficacia hipolipemiante del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas (sinvastatina, atorvastatina, lovastatina o pravastatina) en el riesgo de ictus en pacientes con enfermedad coronaria previa. Pacientes y métodos. Se incluyeron los cinco ensayos clínicos realizados hasta enero de 2006 que cumplieron los siguientes criterios: comparación de atorvastatina intensiva –80 mg u objetivo de lipoproteínas de baja densidad (LDL) < 70 mg/dL– con dosis estándar de estatinas; duración de más de 12 meses e ictus como objetivo del estudio (secundario o principal combinado). TNT (n = 9.917): atorvastatina 80 mg frente a 10 mg; IDEAL (n = 8.888): atorvastatina 80 mg frente a sinvastatina 20-40 mg; PROVE-IT (n = 4.162): atorvastatina 80 mg frente a pravastatina 40 mg; ALLIANCE (n = 2.442): atorvastatina 80 mg u objetivo LDL < 70 mg/dL frente a dosis estándar de estatinas; y VBSS (n = 300): atorvastatina 80 mg frente a dosis bajas de lovastatina. Los estudios considerados incluyeron población en prevención secundaria (síndrome coronario agudo, enfermedad coronaria estable, pacientes elegibles para angioplastia). Se incluyeron 25.709 pacientes (12.910 en la rama con atorvastatina intensiva y 12.799 en la rama con dosis estándar de estatinas). Se comparó la incidencia de ictus entre ambas ramas. Resultados. 713 pacientes (2,77%) de los 25.709 sufrió un ictus durante el seguimiento. La incidencia de ictus fue significativamente menor en la rama atorvastatina intensiva que en la rama tratada con dosis estándar de estatinas: 2,52% (n = 325) frente a 3,03% (n = 388); riesgo relativo = 0,83; intervalo de confianza al 95% = 0,72-0,96; p = 0,0121. Conclusiones. En pacientes con enfermedad coronaria previa, el tratamiento hipolipemiante intensivo con atorvastatina se asocia a una reducción del 17% en el riesgo de ictus en comparación con dosis estándar de estatinas (AU)

Aim. To evaluate the efficacy of intensive lipid lowering treatment with atorvastatin versus standard doses of statins (simvastatin, atorvastatin, lovastatin or pravastatin) on the risk of stroke, using meta-analytic techniques. Patients and methods. The meta-analysis included 5 randomized trials that met the inclusion criteria: comparison between intensive atorvastatin treatment (atorvastatin 80 mg or target LDL < 70 mg/dL) and standard doses of statins, with a clinical follow-up of more than 12 months and stroke as clinical endpoint. TNT (n = 9,917) atorvastatin 80 mg vs. 10 mg; IDEAL (n = 8,888) atorvastatin 80 mg vs. simvastatin 20-40 mg; PROVE-IT (n = 4,162) atorvastatin 80 mg vs. pravastatin 40 mg; ALLIANCE (n = 2,442) atorvastatin 80 mg or target LDL < 70 mg/dL vs. standard treatment; and VBBS (n = 300) atorvastatin 80 mg vs. low dose lavastatin. The selected studies included secondary prevention patients (acute coronary syndrome, stable coronary disease and patients eligible for angioplasty). 25,709 patients were included (12,910 allocated to intensive atorvastatin treatment, and 12,799 to standard doses of statins). Stroke incidence, as reported from each trial, was compared between both treatments. Results. Out of the 25,709 patients, 713 (2.77%) suffered a stroke during follow-up. The incidence of stroke was significantly reduced with intensive atorvastatin treatment in comparison with conventional doses of statins: 2.52% (n = 325) vs. 3.03% (n = 388); relative risk = 0.83; 95% confidence interval = 0.72-0.96; p = 0.0121. Conclusions. Intensive lipid lowering treatment with atorvastatin is associated with a 17% relative risk reduction of stroke in comparison with conventional doses of statins in secondary prevention population (AU)

Análisis coste-efectividad de vareniclina (Champix®) en el tratamiento del tabaquismo en España / Cost effectiveness analysis of varenicline (Champix®) for the treatment of smoking in Spain

Objetivos: Analizar la eficiencia de la vareniclina (Champix®) versus bupropion y TSN (terapia sustitutiva con nicotina) y tratamiento no farmacológico en España. Métodos: Se utilizó un modelo de Markov para analizar las consecuencias clínicas y económicas del tabaquismo y distintas intervenciones para dejar de fumar. Las probabilidades fueron tomadas de la literatura y ensayos clínicos, siendo utilizadas para estimar la efectividad de las opciones comparadas (vareniclina, bupropión, TSN y no tratamiento farmacológico), para distintos horizontes temporales. Los resultados se expresaron en años de vida (AV) ganado y coste por años de vida ajustados por calidad (AVAC) ganado de vareniclina vs comparadores. El análisis se realizó desde la perspectiva del Sistema Nacional de Salud, descontando los costes al 3,5% anual. Resultados: La mayor eficacia de vareniclina supone una reducción de la morbi-mortalidad asociada al tabaquismo, que a largo plazo, compensa totalmente el coste adicional del tratamiento respecto a los comparadores.Vareniclina se muestra como una opción dominante respecto a todas las alternativas en el análisis a largo plazo (toda la vida de los sujetos). Incluso tomando horizontes temporales más cortos (20 años) resulta coste efectivo, siempre menos de 9.000 €/AVAC ganado en comparación con cualquier alternativa. Conclusiones: Vareniclina es una opción dominante (más efectiva amenor coste) comparada con los demás tratamientos, cuando se considera toda la vida del sujeto. Vareniclina es una terapia coste-efectiva incluso cuando se consideran horizontes temporales más cortos (a partir de 20 años), con un coste efectividad incremental muy por debajo del umbral aceptado en nuestro entorno

Objective: To analyse the efficiency of varenicline compared with bupropion, NRT (nicotine replacement therapy) and no pharmacological treatment in Spain. Methods: A Markov model was developed to analyse the health and economic consequences of smoking cessation therapies. The transition probabilities were taken from published studies. The model allows cost effectiveness analyses for different time frames (10 years, 20 years and life time). Outcomes are measured in terms of incremental life years gained (LYG) and QALYs. Pharmacological costs and costs of medical visits with varenicline and bupropion were considered. Treatment costs of smoking associated morbidity were taken from Spanish studies. Results: The analyses were done under the perspective of the National Health System, discounting costs and health benefits at 3%. Results:The life time cost-effectiveness analysis shows that varenicline dominates all other smoking cessation interventions (more effective at a lower cost).This is due to the higher efficacy of varenicline associated with a reductionin smoking related morbimortality, which, in the long term, accounts for health care cost savings that overcome the extra cost of varenicline. Even when shorter time frames are considered (20 years), vareniclin is cost-effective in comparison with any other alternative. Conclusions: Varenicline is a dominant option (more effective at a lower cost) compared with all other smoking cessation treatments when the timeframe is the life span of the patient. Varenicline is cost-effective even when shorter timeframes are considered (20 years or more), withan estimated incremental cost per QALY far bellow any thresh old commonly accepted in our environment

[Estimation of the prevalence, incidence, comorbidities and direct costs associated to stroke patients requiring care in an area of the Spanish population]. / Estimación de la prevalencia, incidencia, comorbilidades y costes directos asociados en pacientes que demandan atención por ictus en un ámbito poblacional español.

AIM: To determinate the prevalence, incidence, co-morbidities and therapeutic objectives and costs of stroke among Spanish population. PATIENTS AND METHODS: A retrospective study was performed based on data from patients attended for stroke, aged > 30 years, from five Spanish primary care centres and two hospitals in 2006. Comparative group: patients without stroke. Main analysed variables were: age, sex, co-morbidity (cardiovascular/others), clinical parameters and direct costs (pharmacy, derivations, visits, emergencies, procurement, and hospitalisation). An ANCOVA analysis and logistic regression were used to fit the model. RESULTS: A 4.5% of 57.026 patients (n = 2.585; CI 95% = 4.3-4.7%) suffered stroke. The incidence of stroke was 220 new-cases/100.000 populations. Main differences between patients suffering stroke/control group were: age (72.5 vs. 53.5), men (58.2% vs. 44.6%), episodes/year (7,9 vs. 4,8), visits/year (15,8 vs. 8,1), p < 0,001. Stroke had an independent relation with age (OR = 1,4), male (OR = 2,3), diabetes (OR = 1,6), hypertension (OR = 1,5), smoking (OR = 1,5), alcohol (OR = 1,4), depression (OR = 1,4), dyslipidemia (OR = 1,3) and dementia (OR = 1,2). Some of the results were: systolic pressure (134.1 vs. 127.6 mmHg) and LDL-cholesterol (116.4 vs. 126.2 mg/dL), in presence/absence of stroke, p < 0,001. The average of annual costs of stroke was 2,590.36 vs. 985.26 euros, p < 0.001. After the correction of the logistic model results did not change: 1,774.33 (CI 95% = 1,720.10-1.828.55) vs. 1,021.98 euros (CI 95% = 1,010.92-1,033.03), p < 0,001. All components of costs were higher in the stroke group. CONCLUSIONS: Patients that demanded assistance for stroke had a higher number of co-morbidities and a higher total cost/patient/year. Therapeutic objectives could be improved, mainly in primary prevention of cardiovascular risk factors.

Estimación de la prevalencia, incidencia, comorbilidades y costes directos asociados en pacientes que demandan atención por ictus en un ámbito poblacional español / Estimation of the prevalence, incidence, comorbidities and direct costs associated to stroke patients requiring care in an area of the Spanish population

Estimar la prevalencia e incidencia, así como la comorbilidad, objetivos terapéuticos y costes del ictusen un ámbito poblacional español. Pacientes y métodos. Es un diseño retrospectivo-multicéntrico. Se incluyeron pacientes mayores de 30 años que demandaron asistencia por ictus, pertenecientes a cinco equipos de atención primaria y dos hospitales durante el año 2006. Grupo comparativo: pacientes sin ictus. Principales variables: edad, sexo, casuística/comorbilid (cardiovascular/otras), parámetros bioquímicos y modelo de costes directos (medicamentos, procedimientos, derivaciones, visitas, hospitalizaciones y urgencias). Análisis estadístico: regresión logística y de análisis de covarianza (ANCOVA) para la corrección de los modelos, p < 0,05. Resultados. De los 57.026 pacientes, el 4,5% (n = 2.585; IC 95% = 4,3-4,7%) presentóictus. Incidencia: 220 casos nuevos por cada 100.000 habitantes. Los pacientes con/sin ictus mostraron: edad, 72,5/53,5 años; varones, 58,2/44,6%; episodios al año, 7,9/4,8; visitas al año, 15,8/8,1; p < 0,001. El ictus tuvo relación independiente con: edad (OR = 1,4), varones (OR = 2,3), diabetes (OR = 1,6), hipertensión (OR = 1,5), fumadores (OR = 1,5), alcoholismo(OR = 1,4), depresión (OR = 1,4), dislipemia (OR = 1,3) y demencias (OR = 1,2). Algunos resultados metabólicos fueron: tensión sistólica (134,1 frente a 127,6 mmHg) y colesterol-LDL (116,4 frente a 126,2 mg/dL), en presencia/ausencia de ictus,p < 0,001. El promedio de coste anual fue de 2.590,36 frente a 985,26 euros, p < 0,001, y se mantuvo después de corregir por edad-sexo y comorbilidades: 1.774,33 (IC 95% = 1.720,10-1.828,55) frente a 1.021,98 euros (IC 95% = 1.010,92-1.033,03), p < 0,001. Todos los componentes del coste fueron mayores en el ictus. Conclusiones. Los pacientes que demandaron atenciónpor ictus presentaron un elevado número de comorbilidades y un mayor coste total/paciente/año. Los objetivos terapéuticos de control siguen siendo mejorables, sobre todo en la prevención primaria de los factores de riesgo cardiovascular

To determinate the prevalence, incidence, co-morbidities and therapeutic objectives and costs of strokeamong Spanish population. Patients and methods. A retrospective study was performed based on data from patients attended for stroke, aged > 30 years, from five Spanish primary care centres and two hospitals in 2006. Comparative group: patientswithout stroke. Main analysed variables were: age, sex, co-morbidity (cardiovascular/others), clinical parameters and direct costs (pharmacy, derivations, visits, emergencies, procurement, and hospitalisation). An ANCOVA analysis and logisticregression were used to fit the model. Results. A 4.5% of 57.026 patients (n = 2.585; CI 95% = 4.3-4.7%) suffered stroke. The incidence of stroke was 220 new-cases/100.000 populations. Main differences between patients suffering stroke/control groupwere: age (72.5 vs. 53.5), men (58.2% vs. 44.6%), episodes/year (7,9 vs. 4,8), visits/year (15,8 vs. 8,1), p < 0,001. Stroke had an independent relation with age (OR = 1,4), male (OR = 2,3), diabetes (OR = 1,6), hypertension (OR = 1,5), smoking (OR =1,5), alcohol (OR = 1,4), depression (OR = 1,4), dyslipidemia (OR = 1,3) and dementia (OR = 1,2). Some of the results were: systolic pressure (134.1 vs. 127.6 mmHg) and LDL-cholesterol (116.4 vs. 126.2 mg/dL), in presence/absence of stroke, p <0,001. The average of annual costs of stroke was 2,590.36 vs. 985.26 euros, p < 0.001. After the correction of the logisticmodel results did not change: 1,774.33 (CI 95% = 1,720.10-1.828.55) vs. 1,021.98 euros (CI 95% = 1,010.92-1,033.03), p <0,001. All components of costs were higher in the stroke group. Conclusions. Patients that demanded assistance for stroke had a higher number of co-morbidities and a higher total cost/patient/year. Therapeutic objectives could be improved, mainly inprimary prevention of cardiovascular risk factors

[Cost effectiveness analysis of varenicline (Champix) for the treatment of smoking in Spain]. / Análisis coste-efectividad de vareniclina (Champix) en el tratamiento del tabaquismo en España.

OBJECTIVE: To analyse the efficiency of varenicline compared with bupropion, NRT (nicotine replacement therapy) and no pharmacological treatment in Spain. METHODS: A Markov model was developed to analyse the health and economic consequences of smoking cessation therapies. The transition probabilities were taken from published studies. The model allows cost effectiveness analyses for different time frames (10 years, 20 years and life time). Outcomes are measured in terms of incremental life years gained (LYG) and QALYs. Pharmacological costs and costs of medical visits with varenicline and bupropion were considered. Treatment costs of smoking associated morbidity were taken from Spanish studies. RESULTS: The analyses were done under the perspective of the National Health System, discounting costs and health benefits at 3%. The life time cost-effectiveness analysis shows that varenicline dominates all other smoking cessation interventions (more effective at a lower cost). This is due to the higher efficacy of varenicline associated with a reduction in smoking related morbimortality, which, in the long term, accounts for health care cost savings that overcome the extra cost of varenicline. Even when shorter timeframes are considered (20 years), vareniclin is cost-effective in comparison with any other alternative. CONCLUSIONS: Varenicline is a dominant option (more effective at a lower cost) compared with all other smoking cessation treatments when the timeframe is the life span of the patient. Varenicline is cost-effective even when shorter timeframes are considered (20 years or more), with an estimated incremental cost per QALY far bellow any threshold commonly accepted in our environment.

Ciática causada por quiste sinovial facetario. Revisión en pacientes menores de 60 años / Sciatica due to synovial facet cyst. Review of patients under 60 years

Objetivo. Estudio clínico retrospectivo de la presencia de quistes sinoviales yuxtafacetarios en el canal medular, como causa de síntomas ciáticos y lumbares, y análisis del resultado a largo plazo de su tratamiento quirúrgico. Material y método. Se estudian retrospectivamente ocho pacientes intervenidos de un quiste yuxtafacetario en el canal medular. Todos los casos fueron diagnosticados mediante resonancia magnética (RM), e intervenidos ante la falta de mejoría de la sintomatología ciática con el tratamiento conservador. El seguimiento medio fue de 25 meses. El resultado ha sido analizado mediante evaluación clínica que incluía: e scala visual (EVA) del dolor residual y porcentaje de discapacidad (Oswestry). Resultados. La edad media fue de 48 años. El síntoma principal fue la ciática unilateral. Un 37,5% presentaron un cuadro de claudicación neurógena y un 50% mostraron un déficit neurológico. El segmento lumbar L4-L5 (62,5%) fue la localización más frecuente. En el 50% existía una espondilolistesis asociada. En cuatro pacientes se realizó una hemilaminectomía y extirpación del quiste, y en cuatro se añadió una artrodesis vertebral por espondilolistesis concomitante. El resultado ha sido bueno en seis de los ocho pacientes, con una EVA media de 2,6 y un porcentaje de discapacidad de Oswestry del 22,5%. Conclusiones. Los quistes yuxtafacetarios constituyen un hallazgo de la RM, en pacientes mayores afectados de patología degenerativa, especialmente con espondilolistesis. La resección del quiste y la fusión vertebral, en caso de espondilolistesis degenerativa asociada, proporciona resultados clínicos excelentes

Objective. Retrospective clinical study of the presence of synovial facet cysts in the spinal canal as the cause of sciatic and lumbar symptoms. Analysis of the long-term outcome of surgical treatment. Materials and methods. A retrospective study was made of 8 patients who underwent surgical treatment of a facet cyst in the spinal canal. All patients were diagnosed by MRI and treated surgically due to the failure of conservative treatment to relieve sciatica. The mean follow-up was 25 months. Results were evaluated clinically by grading pain on a visual analog scale (VAS) and assessing the percentage disability. Results. Mean patient age was 48 years. The main symptom was unilateral sciatica. Neurogenic claudication was present in 37.5% and neurologic deficit in 50%. The L4-L5 lumbar segment (62.5%) was the most frequent location. Spondylolisthesiswas associated in 50%. Hemilaminectomy and cyst excision was performed in 4 patients and the same procedure was complemented by vertebral fusion for concomitant spondylo listhesis in 4 patients. The result was good in 6 of the 8 patients, with a mean VAS score of 2.6 and a Oswestry disability rate of 22.5%. Conclusions. Facet cysts are an MRI finding in older patients or patients with degenerative disease, especially spondylolisthesis. Cyst resection, and spinal fusion in the case of associated degenerative spondylolisthesis, yields excellentclinical results

Diferencias en la percepción del dolor relacionadas con las variables sexo y edad / Differences in the perception of pain related to sex and age variables

Numerosos estudios indican que las características personales pueden actuar como variables diferenciales en la vivencia de la experiencia de dolor. Objetivo: En este sentido, el objetivo del presente estudio es analizar las diferencias entre sujetos en la percepción de dolor en función de las variables edad y sexo. Material y método: Para ello, contamos con una muestra compuesta por 165 hombres y 165 mujeres con dolor crónico, de edades comprendidas entre los 15 y los 92 años. El instrumento de evaluación utilizado para medir el dolor es el Cuestionario McGill de Dolor (1) adaptado al español por Lázaro, Bosch, Torfubia y Baños (2). Las hipótesis establecen relaciones positivas entre la edad y las diferentes dimensiones del dolor: dimensión sensorial, afectiva y evaluativa. De igual forma se espera encontrar diferencias significativas en dichas dimensiones en función del sexo, obteniendo las mujeres puntuaciones medias más altas que los hombres. Se aplicó MANOVA para analizar las diferencias entre los diferentes grupos de edad y sexo en las dimensiones de dolor. Resultados y conclusiones: Los resultados muestran que las mujeres presentan medias superiores a los hombres en las tres dimensiones, así como en la puntuación total. Por otro lado, sólo se encuentran diferencias en las dimensiones afectiva y sensorial en función de la edad. Los pacientes con mayor edad (mayores de 65 años) obtienen puntuaciones medias significativamente más elevadas en la dimensión afectiva, mientras que en la dimensión sensorial las puntuaciones más altas las obtienen los sujetos de menor edad (AU)

Ansiedad y depresión / Anxiety and depression

En este artículo se hace una revisión del tratamiento farmacológico de la ansiedad y depresión, precedida de una somera descripción de estas patologías. Analizaremos las drogas ansiolíticas y antidepresivas de uso común y las más reciente; ya que el médico debe conocer las indicaciones precisas de los distintos medicamentos, la farmacocinética y farmacodinamia de los mismos, dosis, efectos adversos, interacciones con otros fármacos y complicaciones; para así poder aplicarlos al paciente en forma individual, de manera que éste se beneficie lo mejor posible

The use of general anaesthesia for tooth extraction in young handicapped adults in France.

The anaesthetic management of handicapped young adults is often difficult. However, few examples were found in the literature that attempted to specifically measure the frequency of general anaesthesia in the dental treatment of this group of patients. This paper focuses on the management of mentally or physically handicapped young patients undergoing extractions at a specialist dental service in Southern France. A survey of 184 young patients treated during a 39-month period, either under general (34 cases) or local (150 cases) anaesthesia was carried out. A minimum one-year follow-up period was used for each patient. The main characteristics of the patients who received general or local anaesthesia were compared and the factors which indicated the choice of general rather than local anaesthesia were assessed. This study attempts to define precise selection criteria, including dental and non-dental factors. Limited past treatment history was found to be a strong indicator of the need for general anaesthesia. The results of this study suggest that non-dental background factors were also important. The need for general anaesthesia was markedly increased in the groups with severe behavioural disturbances or low levels of contact with the general dental practitioner. If provision of regular dental services for disabled young patients can significantly reduce the need for general anaesthesia, care will have to be taken in developing the relationships between the hospital and general dental practitioner.

Involvement of platelet-activating factor and tumour necrosis factor in the pathogenesis of joint inflammation in rabbits.

We have studied the participation of platelet-activating factor (PAF) in antigen-induced arthritis in rabbits, as well as the possible co-operation between PAF and tumour necrosis factor (TNF) in their ability to induce joint inflammation when injected into the knees of healthy rabbits. The administration of two structurally different PAF receptor antagonists, BN52021 and Alprazolam, from 4 h before the intra-articular injection of ovalbumin in preimmunized rabbits, induced an important reduction in the synovial fluid volume, in the amount of cells infiltrating the articular cavity and the synovial membrane, as well as in the prostaglandin E2 (PGE2) concentration. Furthermore, proteoglycans of the articular cartilage, which were found diminished in animals with non-treated arthritis, were well preserved in rabbits treated with PAF antagonists. All the synovial fluids from joints with arthritis had detectable amounts of PAF. The injection of either TNF or PAF into the joints of normal rabbits induced a mild inflammation. When TNF was administered 1 h before PAF, a synergistic response was noted in the synovial fluid volume, in the accumulation of leucocytes, and in the amount of PGE2. The administration of BN50726, a hetrazepine with a potent PAF-receptor antagonist effect, induced a diminution in those parameters. Our results suggest that PAF may be an early and important mediator of joint damage, and that TNF can amplify the inflammatory response induced by PAF. PAF receptor antagonists could play some role in the treatment of inflammatory joint diseases.