Better drug use in advanced disease: an international Delphi study.

Patients with a limited life expectancy use many medications, some of which may be questionable. OBJECTIVES : To identify possible solutions for difficulties concerning medication management and formulate recommendations to improve medication management at the end of life. METHODS : A two-round Delphi study with experts in the field of medication management and end-of-life care (based on ranking in the citation index in Web of Science and relevant publications). We developed a questionnaire with 58 possible solutions for problems regarding medication management at the end of life that were identified in previously performed studies. RESULTS : A total of 42 experts from 13 countries participated. Response rate in the first round was 93%, mean agreement between experts for all solutions was 87 % (range 62%-100%); additional suggestions were given by 51%. The response rate in the second round was 74%. Awareness, education and timely communication about medication management came forward as top priorities for guidelines. In addition, solutions considered crucial by many of the experts were development of a list of inappropriate medications at the end of life and incorporation of recommendations for end-of-life medication management in disease-specific guidelines. CONCLUSIONS : In this international Delphi study, experts reached a high level of consensus on recommendations to improve medication management in end-of-life care. These findings may contribute to the development of clinical practice guidelines for medication management in end-of-life care.

Orofacial pain and its potential oral causes in older people with mild cognitive impairment or dementia.

BACKGROUND: The number of people with dementia and natural dentition is growing. As dementia progresses, the degree of self-care decreases and the risk of oral health problems and orofacial pain increases. OBJECTIVES: To examine and compare the presence of orofacial pain and its potential causes in older people with Mild Cognitive Impairment (MCI) or dementia. METHODS: In this cross-sectional observational study, the presence of orofacial pain and its potential causes was studied in 348 participants with MCI or dementia with all levels of cognitive impairment in two outpatient memory clinics and ten nursing homes. RESULTS: Orofacial pain was reported by 25.7% of the 179 participants who were considered to present a reliable pain self-report (Mini-Mental State Examination score ≥14 points), while it could not be determined in people with more severe cognitive impairment. The oral health examination of the 348 participants indicated that potential painful conditions, such as coronal caries, root caries, tooth root remnants or ulcers were present in 50.3%. There was a significant correlation between the level of cognitive impairment and the number of teeth, r = 0.185, P = 0.003, teeth with coronal caries, r = -0.238, P < 0.001, and the number of tooth root remnants, r = -0.229, P = 0.004, after adjusting for age. CONCLUSIONS: This study indicated that orofacial pain and its potential causes were frequently present in participants with MCI or dementia. Therefore, a regular oral examination by (oral) healthcare providers in people with MCI or dementia remains imperative, even if no pain is reported.

Refill Procedures of Intrathecal Drug Delivery Systems With a Recessed Fill Port on the Pump Surface: A Prospective Comparison Study of Ultrasound-Guided vs. Blind Refill Technique.

OBJECTIVES: Structural differences of implantable drug delivery systems (IDDSs) might have an impact on the efficiency of needle access to the reservoir fill port (RFP). The aim of this study was to assess the efficiency of RFP needle access with an ultrasound (US)-guided vs. a blind refill technique in IDDSs with a Recessed RFP (Recessed-RFP-IDDS). MATERIALS AND METHODS: The primary outcome was the number of attempts needed to enter the RFP with a needle comparing the US-guided technique vs. the blind refill technique. The time to enter the RFP with the needle was a secondary outcome. We compared the amount of attempts between both techniques with the non-parametric Wilcoxon rank sum test. RESULTS: Fourteen adult patients underwent a total of 75 refills of their Recessed-RFP-IDDS during a period of 24 months. The median number of attempts to enter the RFP did not differ significantly between the US-guided technique and the blind refill technique (2.0 (IQR: 1-5) vs. 1.5 (IQR: 1-5.0), p = 0.572). The median time to enter the RFP with the needle did not differ significantly between both techniques (35.0 sec (IQR: 26.0-58.0) vs. 41.0 sec (IQR: 25.5-46.8), p = 0.878). CONCLUSION: The results of this study suggest that there is no difference in the RFP needle access efficiency between the US-guided and the blind refill technique in superficially located Recessed-RFP-IDDSs, if performed by experienced practitioners. However, the study did not address efficiency of the RFP needle access in IDDSs with aberrancy in pump location or refills performed by inexperienced staff.

Effectiveness of dorsal root ganglion stimulation and dorsal column spinal cord stimulation in a model of experimental painful diabetic polyneuropathy.

AIMS: Conventional dorsal root ganglion stimulation (DRGS) is known to achieve better pain-paresthesia overlap of difficult-to-reach areas like the feet compared to dorsal column spinal cord stimulation (SCS). As in painful diabetic polyneuropathy (PDPN) pain is mostly present in the feet, we hypothesized that DRGS is more effective in relieving pain in PDPN when compared to SCS. METHODS: Diabetes was induced in female Sprague-Dawley rats with an intraperitoneal injection of 65 mg/kg of streptozotocin (STZ; n = 48). Rats with a significant decrease in mechanical paw withdrawal response to von Frey filaments 4 weeks after injection were implanted with DRGS electrodes (n = 18). Rats were assigned to DRGS (n = 11) or sham-DRGS (n = 7). Mechanical paw withdrawal thresholds (WT, measured in grams) in response to DRGS (50 Hz, 0.18 ± 0.05 mA) were assessed with von Frey testing. The results of the experiments on these animals were compared to the results of a previous study using exactly the same model on PDPN animals selected for SCS (n = 8) (40-50 Hz, 0.19 ± 0.01 mA) and sham-SCS (n = 3). RESULTS: In the SCS group, the log10 (10 000 × 50% WT) increased from 4910 to 5211 at t = 15 minutes (P < 0.05) and 5264 at t = 30 minutes (P = 0.11). In the DRGS group, the log10 (10,000 × 50% WT) increased from 4376 to 4809 at t = 15 minutes (P < 0.01) and 5042 at t = 30 minutes (P < 0.01). Both DRGS and SCS induced a similar and complete reversal of mechanical hypersensitivity. After cessation of stimulation (t = 60), the return of the log10 (10 000 × 50% WT) response was significantly faster with DRGS than that of SCS (P < 0.05). CONCLUSIONS: We conclude that conventional DRGS is as effective as SCS in reduction of PDPN-associated mechanical hypersensitivity in STZ-induced diabetic rats. The wash-in effect of DRGS and SCS was similar, but DRGS showed a faster washout course. Long-term efficacy should be studied in future animal research.

Oral function of older people with mild cognitive impairment or dementia.

OBJECTIVES: The aim of this study was to examine and compare the oral function of older people with mild cognitive impairment (MCI) or dementia. METHODS: This cross-sectional observational study included participants with MCI or dementia aged 60 years or older. Global cognitive functioning was evaluated with the Mini Mental State Examination (MMSE) and the oral function was evaluated with subjective and objective assessments, including the perceived quality of chewing and swallowing, the function of the prostheses, the number of occluding pairs (OP), the degree of tooth wear and the active and passive maximum mouth opening. RESULTS: The quality of chewing and swallowing was perceived as good in, respectively, 86.0% and 90.9% of the participants. Full or partial prostheses were worn by 63.8% of the participants, and the retention was good in 58.4% of the upper and 50.0% of the lower prostheses. Participants with MCI had a median of 3.0 (Inter Quartile Range [IQR] 0.0-7.5) occluding pairs, while participants with dementia had a median of 0.0 (IQR 0.0-1.0) occluding pairs, U = 3838.50, P < 0.001. There was a weak positive correlation between the number of occluding pairs and the MMSE score, r = 0.267, also when adjusted for age, r = 0.230. The median tooth wear score was 2.0 (IQR 2.0-2.0) in participants with MCI or dementia. The active maximum mouth opening was 45.8 (SD 9.3) mm in participants with dementia, while it was 49.8 (SD 8.1) mm in those with MCI, t(253) = 2.67, P = 0.008. CONCLUSION: For most participants with MCI or dementia, the swallowing ability and chewing ability were perceived as good. In addition, more than half of the prostheses had good retention and occlusion. Participants with more severe cognitive impairment had fewer occluding pairs and a smaller active mouth opening. The degree of tooth wear was less than one-third of the clinical crown in most participants with MCI or dementia.

Psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals as a screening tool for orofacial pain in people with dementia.

OBJECTIVE: The aim of this study was to describe the psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI) as a screening tool for orofacial pain in people with dementia. BACKGROUND: The OPS-NVI has recently been developed and needs psychometric evaluation for clinical use in people with dementia. The pain self-report is imperative as a reference standard and can be provided by people with mild-to-moderate cognitive impairment. METHODS: The presence of orofacial pain during rest, drinking, chewing and oral hygiene care was observed in people with mild cognitive impairment (MCI) and dementia using the OPS-NVI. Participants who were considered to present a reliable self-report were asked about pain presence, and in all participants, the oral health was examined by a dentist for the presence of potential painful conditions. After item-reduction, inter-rater reliability and criterion validity were determined. RESULTS: The presence of orofacial pain in this population was low (0%-10%), resulting in an average Positive Agreement of 0%-100%, an average Negative Agreement of 77%-100%, a sensitivity of 0%-100% and a specificity of 66%-100% for the individual items of the OPS-NVI. At the same time, the presence of oral problems, such as ulcers, tooth root remnants and caries was high (64.5%). CONCLUSION: The orofacial pain presence in this MCI and dementia population was low, resulting in low scores for average Positive Agreement and sensitivity and high scores for average Negative Agreement and specificity. Therefore, the OPS-NVI in its current form cannot be recommended as a screening tool for orofacial pain in people with MCI and dementia. However, the inter-rater reliability and criterion validity of the individual items in this study provide more insight for the further adjustment of the OPS-NVI for diagnostic use. Notably, oral health problems were frequently present, although no pain was reported or observed, indicating that oral health problems cannot be used as a new reference standard for orofacial pain, and a regular oral examination by care providers and oral hygiene care professionals remains indispensable.

Medication Discontinuation at the End of Life: A Questionnaire Study on Physicians' Experiences and Opinions.

BACKGROUND: Many patients who are in the last phase of life use multiple medications that are continued until shortly before they ultimately die. Little is known about physicians' opinions and experiences regarding medication discontinuation at the end of patients' lives. OBJECTIVE: To explore physicians' opinions and experiences regarding medication discontinuation during the last phase of life, and to identify factors influencing the continuation of potentially inappropriate medications. DESIGN: Questionnaire study, including a vignette and several statements. SETTING/SUBJECTS: A random sample of general practitioners and clinical specialists working in three regions in the Netherlands that represent more than half of the Dutch population. RESULTS: Questionnaires were returned by 321 physicians (response rate: 37%). The majority of them (73%) agreed with the statement that patients who are in the last phase of life use too many medications. When presented with a vignette of a patient with end-stage COPD with different limited life expectancies, preventive medications would be stopped right early before death. Medications to relieve symptoms would not be stopped or stopped right before death. For medications to treat (chronic) illnesses, there was a huge interphysician variability. All statements about possible reasons why medications are continued in the last phase of life, for example, patients feeling abandoned and lack of time, were agreed upon by a small minority of respondents. CONCLUSIONS: Although physicians agree that patients use too many medications at the end of life, they quite regularly seem to give patients medications for chronic diseases, for which the benefit at the end of life may be debatable. More scientific evidence on whether or not these types of medication might be discontinued in the last phase of life is needed.

Complex regional pain syndrome - phenotypic characteristics and potential biomarkers.

Complex regional pain syndrome (CRPS) is a pain condition that usually affects a single limb, often following an injury. The underlying pathophysiology seems to be complex and probably varies between patients. Clinical diagnosis is based on internationally agreed-upon criteria, which consider the reported symptoms, presence of signs and exclusion of alternative causes. Research into CRPS biomarkers to support patient stratification and improve diagnostic certainty is an important scientific focus, and recent progress in this area provides an opportunity for an up-to-date topical review of measurable disease-predictive, diagnostic and prognostic parameters. Clinical and biochemical attributes of CRPS that may aid diagnosis and determination of appropriate treatment are delineated. Findings that predict the development of CRPS and support the diagnosis include trauma-related factors, neurocognitive peculiarities, psychological markers, and local and systemic changes that indicate activation of the immune system. Analysis of signatures of non-coding microRNAs that could predict the treatment response represents a new line of research. Results from the past 5 years of CRPS research indicate that a single marker for CRPS will probably never be found; however, a range of biomarkers might assist in clinical diagnosis and guide prognosis and treatment.

Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues.

BACKGROUND: The number of older people with dementia and a natural dentition is growing. Recently, a systematic review concerning the oral health of older people with dementia with the focus on diseases of oral hard tissues was published. OBJECTIVE: To provide a comprehensive literature overview following a systematic approach of the level of oral hygiene and oral health status in older people with dementia with focus on oral soft tissues. METHODS: A literature search was conducted in the databases PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. A critical appraisal of the included studies was performed with the Newcastle-Ottawa scale (NOS) and Delphi list. RESULTS: The searches yielded 549 unique articles, of which 36 were included for critical appraisal and data extraction. The included studies suggest that older people with dementia had high scores for gingival bleeding, periodontitis, plaque, and assistance for oral care. In addition, candidiasis, stomatitis, and reduced salivary flow were frequently present in older people with dementia. CONCLUSIONS: The studies included in the current systematic review suggest that older people with dementia have high levels of plaque and many oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, stomatitis, mucosal lesions, and reduced salivary flow. SCIENTIFIC RATIONALE FOR STUDY: With the aging of the population, a higher prevalence of dementia and an increase in oral health problems can be expected. It is of interest to have an overview of the prevalence of oral problems in people with dementia. PRINCIPAL FINDINGS: Older people with dementia have multiple oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, mucosal lesions, and reduced salivary flow. PRACTICAL IMPLICATIONS: The oral health and hygiene of older people with dementia is not sufficient and could be improved with oral care education of formal and informal caregivers and regular professional dental care to people with dementia.

Ease of Fill Port Access During the Ultrasound-Guided vs. the Blind Refill Technique of Intrathecal Drug Delivery Systems With a Raised Septum, a Prospective Comparison Study.

OBJECTIVES: The localization of the reservoir fill port of Intrathecal Drug Delivery Devices (IDDS) can be difficult. The purpose of this study was to assess the ease of fill port access during the ultrasound-guided refill technique compared to the blind refill technique in IDDSs with a raised septum on the pump surface. MATERIALS AND METHODS: Written informed consent was obtained from 19 adult patients undergoing regular refills of their Raised Septum IDDSs (RS-IDDSs). The primary outcome of this single center prospective comparison study was the number of attempts to enter the reservoir fill port with the needle comparing the ultrasound-guided technique vs. the blind technique. The number of skin punctures per refill procedure and time to enter the reservoir fill port was secondary outcomes. For between group comparisons the Friedman test for repeated measures on ranks was used. RESULTS: One hundred and eleven refill procedures were assessed in 19 patients over a period of 24 months. The median number of attempts to enter the reservoir fill port with the needle differed significantly between the ultrasound-guided technique and the blind technique (4 [IQR: 1-6] vs. 1 [IQR: 1-3], p = 0.018), in favor of the blind technique. The median time to enter the reservoir fill port differed significantly between the ultrasound-guided technique and the blind technique (58 sec [IQR: 38-94] vs. 22 sec [IQR: 16-40], p < 0.001). CONCLUSIONS: The results of this study suggest that for a RS-IDDS the blind refill technique needs significantly less attempts to enter the reservoir fill port than the US-guided refill technique.