Non-Adherence to Pharmacotherapy: A Prospective Multicentre Study About Its Incidence and Its Causes Perceived by Chronic Pain Patients

OBJECTIVE

Pharmacological interventions remain the cornerstone of chronic pain treatment; however, nearly 40% of the prescription medicines are not taken as prescribed. The present study aims at understanding and describing non-adherence from the perspective of chronic pain patients during a 1-year follow-up study.

METHODS

A cohort of 950 consecutive patients referred to a first consultation in Multidisciplinary Chronic Pain Clinics was followed with a standardized protocol for 1 year. This included assessment of pain characteristics; prescribed medication; therapeutic adherence; effectiveness of treatment, non-adherence and its perceived reasons; clinical outcomes and quality of life. We used a mixed methods approach, including qualitative and quantitative analyses.

RESULTS

Forty-nine percent of the 562 patients who responded to all assessments during follow-up were adherent after 1 year of chronic pain treatment. The core associations between each "non-adherence reason" and Anatomical Therapeutic Chemical Code (ATC) group were perceived side effects (p=0.019) and delayed start (p=0.022) for narcotic analgesics (opioids); perceived non-efficacy (p=0.017) and delayed start (p=0.004) for antiepileptics and anticonvulsants; perceived low necessity (p=0.041) and delayed start (p=0.036) for analgesics antipyretics; change in prescriptions because of a new clinical condition for antidepressants (p=0.024); high concerns (p=0.045) and change in prescriptions because of a new clinical condition (p<0.001) for non-steroidal anti-inflammatory drugs; delayed start (p=0.016) and financial constraints (p=0.018) for other medications.

DISCUSSION

This study emphasizes the patient's perspective regarding non-adherence to pharmacological treatment of chronic pain, providing valuable and novel information to be used in future interventions to help patients make an informed choice about their adherence behavior.

What forecasting the prevalence of inflammatory bowel disease may tell us about its evolution on a national scale

Inflammatory bowel disease (IBD) is increasingly prevalent within western societies. Its complex and chronic facets in addition to its increasing prevalence place a great economic burden on our healthcare systems. Our aim was to estimate the national prevalence of IBD through predictive models. We used prevalence data which spans the years 2003-2007 to estimate prevalence until 2030 by means of four forecasting methods. Prevalence rates are estimated to be 4-6-times higher in 2030 when compared with 2003 with an average annual percent change of 5%. IBD is poised to have a substantial impact on healthcare systems in the near future, given its rapidly increasing prevalence. Forecasting methods will allow for a proactive stance on the development of health policies that will be needed to provide high quality and cost-effective care to these patients, while ensuring the economic viability of healthcare systems.

Waiting for ICU admission may increase the risk of death-A plea for better resource organization

BACKGROUND

Mortality is high in critically ill patients. In order to study the risk factors associated with mortality in these patients, we conducted an observational retrospective study in the general Intensive Care Unit (ICU) of Faro Hospital.

METHODS

All patients discharged from the general ICU in the year 2015 were evaluated for inclusion. Mortality was characterized in the first 48 hours of ICU stay, at the time of discharge from ICU, and at discharge from hospital. Collected variables included demographic variables (age), and ICU variables: type of ICU admission (scheduled surgery, urgent surgery, medical and trauma), Simplified Acute Physiology Score (SAPS II), main diagnosis, hospital length of stay (HLS) before ICU (BICULS), in ICU (ICULS) and after ICU (AICULS).

RESULTS

When comparing survivors with non-survivors, we found that age, disease severity expressed by SAPS II and BICULS were significantly higher in non-survivors. After multivariate regression analysis, BICULS was still significantly associated with mortality in the hospital.

CONCLUSION

Further studies are needed to characterize whether this longer BICULS is related to non-modifiable prior conditions or whether it is related to delayed ICU admission, which is a modifiable factor.

Hospitalization trends of the Inflammatory Bowel Disease landscape: A nationwide overview of 16 years

INTRODUCTION

In this study, we aimed to determine the hospitalization rates of Inflammatory Bowel Disease (IBD) in a southern-european country and its associated charges over a period of 16 years.

METHODS

We identified all discharges with a primary diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) between 2000 and 2015 in data provided by the Central Administration of Health Services (ACSS). National estimates of hospitalization rates were assessed and adjusted to gender, age, population, and hospitalizations. Hospitalization charges were also assessed.

RESULTS

There were an estimated 31 358 and 16 669 discharges for CD and UC, respectively. From 2000 to 2015, hospitalization rates per 100000 habitants increased for CD (8.4-11.2) and remained stable for UC (4.4-4.9). The hospitalization rate for IBD increased slightly over time (12.8 per 100 000 habitants in 2000 and 16.1 in 2015). Annual total hospitalization charges amounted to 4.0M€ in 2000 and 5.7M€ in 2015. This increase was mainly due to a rise in the total expenses of CD-related hospitalizations.

CONCLUSION

CD hospitalization rates per 100000 inhabitants increased over time while remaining constant for UC. Hospitalization charges for IBD increased approximately 2.0M€ during the study period, representing an important burden in the national healthcare system.

Comparison of different histological indexes in the assessment of UC activity and their accuracy regarding endoscopic outcomes and faecal calprotectin levels

OBJECTIVE

Histological remission is being increasingly acknowledged as a therapeutic endpoint in patients with UC. The work hereafter described aimed to evaluate the concordance between three histological classification systems-Geboes Score (GS), Nancy Index (NI) and RobartsHistopathologyIndex (RHI), as well as to evaluate their association with the endoscopic outcomes and the faecal calprotectin (FC) levels.

DESIGN

Biopsy samples from 377 patients with UC were blindly evaluated using GS, NI and RHI. The results were compared with the patients' Mayo Endoscopic Score and FC levels.

RESULT

GS, NI and RHI have a good concordance concerning the distinction between patients in histological remission or activity. RHI was particularly close to NI, with 100% of all patients classified as being in remission with NI being identified as such with RHI and 100% of all patients classified as having activity with RHI being identified as such with NI. These scores could also predict the Mayo Endoscopic Score and the FC levels, with their sensitivity and specificity levels depending on the chosen cut-offs. Moreover, higher FC levels were statistically associated with the presence of neutrophils in the epithelium, as well as with ulceration or erosion of the intestinal mucosa.

CONCLUSIONS

GS, NI and RHI histopathological scoring systems are comparable in what concerns patients' stratification into histological remission/activity. Additionally, FC levels are increased when neutrophils are present in the epithelium and the intestinal mucosa has erosions or ulcers. The presence of neutrophils in the epithelium is, indeed, the main marker of histological activity.

Portuguese version of the Medication Adherence Report Scale (MARS-9): Validation in a population of chronic pain patients

AIM

The aim of present study was to perform the translation, cultural adaptation, and validation of the Medication Adherence Report Scale (MARS-P9) for the European Portuguese language in a sample of chronic pain patients.

METHODS

A Portuguese version of the nine-item MARS (©Professor Rob Horne) scale (MARS-P9) was constructed through a process of translation, back translation, and experts' panel evaluation. A total of 141 chronic pain patients were subsequently evaluated at four time assessments during a 1-year pain medication treatment. The protocol interview included the assessment of pain intensity and interference (BPI), clinical outcomes and quality of life (S-TOPS), and MARS-P9.

RESULTS

The internal consistency coefficient was acceptable for the total scale (α = 0.84). Exploratory factor analysis revealed a two-factor structure (intentional and unintentional nonadherence) that explained 61% of the variance. Convergent and discriminant validity were demonstrated by correlations between MARS scores and pain interference (r = 0.180, P ≤ 0.01) and S-TOPS (r = 0.242, P ≤ 0.05).

CONCLUSION

MARS-P9 has been shown to be an adequate instrument for Portuguese researchers and clinicians to assess the pattern of adherence during the management of chronic pain.

Development and Validation of Risk Matrices Concerning Ulcerative Colitis Outcomes-Bayesian Network Analysis

BACKGROUND

Ulcerative colitis [UC] is a chronic inflammatory disease often accompanied by severe and distressing symptoms that, in some patients, might require a surgical intervention [colectomy]. This study aimed at determining the risk of experiencing progressive disease or requiring colectomy.

MATERIAL AND METHODS

This was a multicentre study: patients' data [n = 1481] were retrieved from the Portuguese database of inflammatory bowel disease patients. Bayesian networks and logistic regression were used to build risk matrices concerning the outcomes of interest.

RESULTS

The derivation cohort included a total of 1210 patients, of whom 6% required a colectomy and 37% had progressive disease [over a median follow-up period of 12 syears]. The risk matrices show that previously hospitalised patients with extensive disease, who are not on immunomodulators and who are refractory to corticosteroid treatment, are the ones at the highest risk of undergoing a colectomy [88%]; whereas male patients, with extensive disease and less than 40 years old at diagnosis, are the ones at the highest risk of experiencing progressive disease [72%]. These results were internally and externally validated, and the AUC [area under the curve] of the ROC [receiver operating characteristic] analysis for the derivation cohort yielded a high discriminative power [92% for colectomy and 72% for progressive disease].

CONCLUSIONS

This study allowed the construction of risk matrices that can be used to accurately predict a UC patient's likelihood of requiring a colectomy or of facing progressive disease, and can be used to individualise therapeutic strategies.

Placebo Effect on the Health-related Quality of Life of Inflammatory Bowel Disease Patients: A Systematic Review With Meta-analysis

BACKGROUND AND AIMS

Placebo effect in health-related quality of life [HRQoL] of inflammatory bowel disease [IBD] patients has been poorly characterised. This systematic review and meta-analysis aimed to assess: i] mean improvements in IBDQ [Inflammatory Bowel Disease Questionnaire] and SF-36 [36-Item Short Form Health Survey] scores among placebo-treated IBD patients; and ii] the proportion of placebo-treated patients achieving IBDQ-defined response and remission and correspondent odds ratios [OR].

METHODS

Literature search was performed using four databases. Mean differences and ORs were computed using the random-effects model. Univariate and multivariate regressions were performed to evaluate the weight of different factors on the placebo effect.

RESULTS

From the 328 identified records 26 were included in the study, comprising 2842 placebo-treated IBD patients. Pooled mean differences on IBDQ following placebo administration were above the clinically meaningful improvement [≥16 points] in ulcerative colitis [UC] patients during the induction regimen (17.67; 95% confidence interval [CI]: 12.90, 22.44) and during maintenance in both Crohn's disease [CD] [27.60; 95% CI: 14.29, 40.91] and UC patients [27.50; 95% CI: 18.73, 36.27]. The treatment regimen was the only significant variable in multivariate analysis, with lower placebo-related IBDQ improvements during induction. Maintenance trials' inclusion criteria were also relevant. The proportions of placebo-treated patients achieving IBDQ-defined response and remission were 0.42 [95% CI: 0.49, 0.56] and 0.31 [95% CI: 0.28, 0.34], respectively, with 0.49 and 0.40 the ORs for response and remission. Significant improvements were also observed on SF-36 score.

CONCLUSIONS

Herein we prove that placebo effect on HRQoL is meaningful, providing insights about implications for clinical trials' design and interpretation and for IBD management.

Is it important to assess the ascending aorta after tetralogy of Fallot repair?

INTRODUCTION AND OBJECTIVES

Aortic dilatation can develop late after tetralogy of Fallot repair. Its extension beyond the aortic root is not clearly understood. We aimed to assess the prevalence and predictors of ascending aorta dilatation to set up an imaging protocol.

METHODS

In this prospective study including adult patients after tetralogy of Fallot repair followed at a referral center, we assessed the aorta by cardiovascular magnetic resonance and defined ascending aorta dilatation as an observed-to-expected ratio >1.5.

RESULTS

We included 78 adults (mean age 31±10 years; 56% female), with a mean follow-up of 23±7 years since tetralogy of Fallot repair. The prevalence of ascending aorta dilatation was 11.5%. The ascending aorta was larger than the sinuses of Valsalva in 12.8% of cases. Patients with ascending aorta dilatation were older, predominantly male, with later repair and larger left ventricular mass and volumes. By multivariate analysis left ventricular mass index (LVMI) was the only factor independently associated with ascending aorta dilatation (odds ratio 1.10, 95% confidence interval 1.01-1.20, p=0.03). A cut-off value of ≥57.9 g/m² for LVMI had 89% sensitivity and 71% specificity for ascending aorta dilatation.

CONCLUSIONS

Ascending aorta assessment as part of a routine cardiovascular magnetic resonance study after tetralogy of Fallot repair is recommended to screen for future aortic complications, particularly in males and older patients, and those with later repair and larger left ventricles. LVMI assessment has potential as a screening tool for ascending aorta dilatation with future clinical implications.

Is It Possible to "Find Space for Mental Health" in Young People? Effectiveness of a School-Based Mental Health Literacy Promotion Program

Lack of knowledge regarding, and the stigma associated with, mental disorders have been identified as major obstacles for the promotion of mental health and early intervention. The present study aimed to evaluate the effectiveness of a school-based intervention program focused on the promotion of mental health literacy (MHL) in young people (“Finding Space for Mental Health”). A sample of 543 students (22 classes), aged between 12 and 14 years old, participated in the study. Each class of students was randomly assigned to the control group (CG; n = 284; 11 classes) or the experimental group (EG; n = 259; 11 classes). MHL was assessed using the Mental Health Literacy questionnaire (MHLq), which is comprised of three dimensions—Knowledge/Stereotypes, First Aid Skills and Help Seeking, and Self-Help Strategies. The scores on these dimensions can also be combined to give an overall or total score. Participants from the EG attended the MHL promotion program (two sessions, 90 min each) delivered at one-week intervals. Sessions followed an interactive methodology, using group dynamics, music, and videos adapted to the target group. All participants responded to the MHLq at three points in time: pre-intervention assessment (one week prior to the intervention), post-intervention assessment (one week after the intervention) and follow-up assessment (six months after the intervention). The intervention effectiveness and the differential impact of sociodemographic variables on the effectiveness of the program were studied using a Generalized Estimation Equation (GEE). Results revealed that participants from the EG demonstrated, on average, significantly higher improvement in MHL from pre-intervention to follow-up when compared to participants from the CG. Different sociodemographic variables affected the effectiveness of the program on distinct dimensions of the MHLq. Overall, “Finding Space for Mental Health” showed efficacy as a short-term promotion program for improving MHL in schools.

Aortic dilatation after tetralogy of Fallot repair: A ghost from the past or a problem in the future?

INTRODUCTION AND AIMS

Intrinsic aortopathy can lead to dilatation late after tetralogy of Fallot (TOF) repair. Its extent and prevalence are not known. We aimed to assess aortic dimensions and elasticity and to find predictors of aortic dilatation.

METHODS

A total of 126 adults were prospectively included after TOF repair and compared to 63 gender- and age-matched controls. Transthoracic echocardiography was used to assess aortic diameters at the level of the sinuses of Valsalva and ascending aorta and aortic dilatation was defined as z-score >+2. M-mode parameters of the ascending aorta were used to calculate strain, distensibility and stiffness index.

RESULTS

TOF patients (mean age 30±9 years; 52% male) had a complete repair at a median age of five (2-49) years; mean follow-up time since repair was 23±7 years. The prevalence of aortic dilatation at the sinuses of Valsalva and ascending aorta was 29% and 24%, respectively. Compared to controls, TOF patients had a higher ascending aorta z-score, lower strain (6.4% [0.0-61.5] vs. 15.2% [0.0-45.0], p<0.01) and higher stiffness index (7.3 [0.8-23.6] vs. 3.1 [0.9-14.1], p<0.01). On multivariate analysis male gender was strongly associated with sinuses of Valsalva dilatation (odds ratio 6.3, 95% confidence interval 1.5-26.3, p=0.01).

CONCLUSIONS

The prevalence of aortic dilatation late after TOF repair is significant, with a larger and stiffer ascending aorta. Male gender appears to influence aortic root dilatation. This aortopathy requires careful follow-up in order to prevent future complications.

Cutaneous Morbidity Among Inflammatory Bowel Disease Patients: A Cohort Study

BACKGROUND AND AIMS

Patients with inflammatory bowel diseases are prone to cutaneous manifestations. The aim of this study was to investigate their prevalence, type and association to demographic and clinical factors.

METHODS

This was a cross-sectional study. Information relative to patients of a central Portuguese hospital with a definitive diagnosis of an inflammatory bowel disease, who were prospectively recruited, was collected.

RESULTS

The final cohort included 342 patients, 62% of whom had Crohn's disease and 38% had ulcerative colitis. Cutaneous extraintestinal manifestations were present in 44.4% of all patients; this prevalence was lower [14.9%] when excluding cutaneous manifestations secondary to nutrition deficiency or drugs. These skin lesions were classified as granulomatous [0.3%], reactive [4.4%], immunologically associated [10.5%] and secondary to nutritional deficiencies [6.4%] or to bowel-related therapy [29.5%]. Excluding those secondary to nutrition or drugs, cutaneous manifestations were significantly associated with females (odds ratio [OR] 3.210 [1.625-6.340], p = 0.001) and younger patients (OR 0.954 [0.924-0.985], p = 0.004). Additionally, their occurrence was related to patients up to 16 years (OR 13.875 [1.332-144.484], p = 0.028) among the Crohn's disease sub-cohort, whereas in the ulcerative colitis sub-cohort they were more likely to occur in patients with extensive colitis (OR 5.317 [1.552-18.214], p = 0.008).

CONCLUSIONS

Nearly half of the patients analysed had at least one cutaneous extraintestinal manifestation. The fact that certain lesions tend to be more common among patients with defined characteristics should alert the physicians and allow an early diagnosis and, when pertinent, a reference to dermatology.

Liver transplant recipients have a higher prevalence of anal squamous intraepithelial lesions

Background:

Anal squamous intraepithelial lesions (ASIL) are precancerous lesions of anal squamous cell carcinoma, with a higher prevalence in immunosuppressed patients. There are some studies in kidney transplant recipients, but there is no information regarding prevalence in liver transplantation. Our aim was to evaluate the prevalence of ASIL in this setting.

Methods:

Prospective case–control study involving liver transplant recipients without any other known risk factor for ASIL (n=59), which were compared with a healthy control group (n=57). All were submitted to anal cytology and high-resolution anoscopy was performed in those with abnormal results.

Results:

Ten (17%) of liver transplant recipients had abnormal cytological results, seven patients had atypical squamous cells of undetermined significance (ASC-US), one patient had atypical squamous cells that cannot exclude high-grade (ASC-H) and two patients had high-grade squamous intraepithelial lesions (HSIL). In the control group, one patient (2%) had an ASC-US result (P=0.005). Anal squamous intraepithelial lesions were confirmed in 7 out of 10 of liver transplant patients and 0 out of 1 in the controls (P=0.013) by high-resolution anoscopy with biopsies. Current smoking was the only risk factor for abnormal cytology (odds ratio=5.87, 95% confidence intervals=1.22–28.12, P=0.027).

Conclusions:

Liver transplant patients have a higher risk of ASIL. Screening should be considered, especially in smokers.

A Systematic Review and Meta-Analysis of 6-Thioguanine Nucleotide Levels and Clinical Remission in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Thiopurines are widely used in the management of inflammatory bowel diseases. However, their minimum effective dose and dose-response relationship remain undefined, and evidence about their use in clinical practice is mostly heterogeneous. This systematic review and meta-analysis aimed: i] to assess the clinical value of 6-thioguanine nucleotide thresholds; and ii] to compare mean 6-thioguanine nucleotide concentrations between patients in clinical remission vs. those with active disease.

METHODS

A systematic literature search was carried out using four databases. Statistical heterogeneity was assessed with the I2 statistic followed by subgroup and sensitivity analyses. Odds ratios were computed using the random-effects model.

RESULTS

A total of 1384 records were identified in the systematic search, of which 25 were retained for further analysis: 22 were used in the cut-off comparisons and 12 were used in the 6-thioguanine nucleotide mean differences analysis. The global odds ratio for remission in patients with 6-thioguanine nucleotide levels above the predefined thresholds was 3.95 (95% confidence interval [CI], 2.63-5.94; p < 0.001]. When considering the different thresholds individually, the odd ratios were significant for values above 235 pmol/8 × 108 and 250 pmol/8 × 108 red blood cells [2.25 and 4.71, respectively]. Mean 6-thioguanine nucleotide levels were higher among patients in clinical remission, with a pooled difference of 63.37 pmol/8 × 108 red blood cells [95% CI, 31.81-94.93; p < 0.001].

CONCLUSIONS

This study reinforces the link between 6-thioguanine nucleotide levels and clinical remission in inflammatory bowel diseases, also exploring the validity of specific 6-thioguanine nucleotide thresholds to predict clinical outcomes.

Serial Tuberculosis Screening in Inflammatory Bowel Disease Patients Receiving Anti-TNFα Therapy

BACKGROUND AND AIMS

One of the adverse effects of the tumour necrosis factor alpha [[TNFα] monoclonal antibodies for the treatment of immune-mediated inflammatory diseases is a higher propensity for tuberculosis development. The aim of this study was to explore the utility and sensitivity of serial tuberculosis screening during anti-TNFα treatment.

METHODS

A cohort of 46 inflammatory bowel disease patients receiving infliximab was prospectively recruited and followed for 26 months. During this period of time, a tuberculosis skin test and two different interferon ϒ release assays [QFT-GIT and T-SPOT.TB] were applied at 4-6-month intervals.

RESULTS

Overall, 16 patients were diagnosed with latent tuberculosis infection after having at least one test conversion: 12 patients had a positive tuberculosis skin test, seven patients had a positive T-SPOT.TB, and two patients had a positive QFT-GIT. Active tuberculosis was excluded in all; 15 were treated with isoniazid. A comparison between tests showed a moderate accuracy [72% to 85%] but low kappa values [0.063 to 0.377]. Concerning association with demographic and clinical characteristics, test conversion was more common among the male gender and those with a longer disease duration.

CONCLUSIONS

Tuberculosis tests conversions were common in inflammatory bowel disease patients treated with infliximab alone or in association with immunomodulators. In these immunosuppressed individuals, the classical tuberculosis skin test seems to have a higher sensitivity than the modern tests based on the release of interferonϒ.

Clinical performance of an infliximab rapid quantification assay

BACKGROUND

Therapeutic drug monitoring (TDM)-based algorithms can be used to guide infliximab (IFX) adjustments in inflammatory bowel disease (IBD) patients. This study aimed to explore a rapid IFX-quantification test from a clinical perspective.

METHODS

This manuscript describes a prospective cohort study involving 110 ulcerative colitis (UC) patients on the maintenance phase of IFX. IFX trough levels were quantified using a rapid quantification assay and a commonly-used reference kit.

RESULTS

Irrespective of the assay used to measure IFX, its through levels were statistically different between patients with and without endoscopic remission (Mayo endoscopic score = 0), as well as between patients stratified by their faecal calprotectin (FC) levels. Despite the fact that the two methods correlated well with each other [Spearman's rank correlation coefficient = 0.843, p < 0.001; intraclass correlation coefficients = 0.857, 95% confidence interval (CI): 0.791-0.903], there was a discernible systematic variation; values obtained with the reference kit were on average 2.62 units higher than those obtained with the rapid assay. Notwithstanding, 3 µg/ml was shown to be an acceptable cut-off to assess endoscopic status and inflammatory burden levels using both assays. The percentage of patients that had a positive outcome when the IFX concentration measured by the rapid assay ranked above 3 µg/ml was 88% both for a Mayo endoscopic score ⩽ 1 and for an FC concentration <250 µg/g.

CONCLUSIONS

Based on this study, we concluded that using the rapid IFX assessment system with a 3 µg/ml threshold is a reliable alternative to the time-consuming enzyme-linked immunosorbent assays in patients on the maintenance phase of IFX.

Therapeutic drug monitoring of CT-P13: a comparison of four different immunoassays

BACKGROUND

The commercialization of CT-P13, an infliximab (IFX) biosimilar, has the potential to decrease health-related costs and enhance access to biological therapies. This study aimed to address the accuracy and inter-assay agreement of the CT-P13 quantification using four different assays initially developed to assess IFX.

METHODS

The four different methods, one in-house method and three commercially available kits, were used to quantify exogenously-spiked samples and the sera from 185 inflammatory bowel disease (IBD) patients on CT-P13 therapy.

RESULTS

The quantification of the spiked samples unveiled a consistent and accurate behaviour of three of the tested methods, with average percentage recoveries of 90%, 102% and 109%. Results from the clinical samples demonstrated that these three assays were also highly correlated, both concerning Spearman's rank coefficients (range 0.890-0.947) and intraclass correlation coefficients (range 0.907-0.935). There were a few systematic deviations among them, but their impact in the clinical stratification of the patients using different cut-offs was minimal, particularly when these cut-offs were in the 3-4 µg/ml range, for which the strength of agreement (as assessed by the Kappa statistics that ranged from 0.732 to 0.902) was substantial to almost perfect.

CONCLUSIONS

Our results indicate that three of the tested IFX quantification methods can be used to accurately quantify CT-P13 without any adjustments.

Risk factors for the occurrence of epistaxis: Prospective study

OBJECTIVE

Analyse and compare the characteristics of patients with epistaxis admitted to the otolaryngology emergency department with those provided by a control group. Establish a model to identify epistaxis predictive factors.

METHODS

Prospective analysis of 283 consecutive adults, admitted to the otolaryngology emergency department of a tertiary referral centre between 25 January and 25 February 2014. Comparison of gender, age, co-morbidities, usual medication, history of epistaxis or nasal trauma, presence of septal deviation and blood pressure value on admission, between the elements that were admitted to the emergency due to epistaxis (group 1) and a group composed of patients with other symptoms (group 2). Intergroup variations were analyzed using t student and chi-square tests. Multivariate logistic regression and a receiver operating characteristic curve were used to establish a predictive model and test its suitability.

RESULTS

Male gender (OR=2.57, 95% CI 1.1-6.0, p=0.029), older age (OR=1.03, 95% CI 1.0-1.1, p=0.002), existence of peripheral vascular disease (OR=13.47, 95% CI 1.9-95.3, p=0.009), cardiovascular disease (OR=3.91, 95% CI 1.6-9.7, p=0.003) and previous history of epistaxis (OR=5.53, 95% CI 2.5-12.1, p<0.001) were predictors of epistaxis when adjusted for the presence of elevated blood pressure, history of hypertension, cerebrovascular disease and chronic use of anticoagulants or antiplatelet drugs. The model revealed a good applicability (area under the curve of 0.852).

CONCLUSIONS

The only predictive factors of admission to the emergency department due to epistaxis were male gender, older age, peripheral vascular disease, cardiovascular disease and history of epistaxis.

Predicting outcomes of gastric endoscopic submucosal dissection using a Bayesian approach: a step for individualized risk assessment

BACKGROUND AND STUDY AIMS

Efficacy and adverse events probabilities influence decisions regarding the best options to manage patients with gastric superficial lesions. We aimed at developing a Bayesian model to individualize the prediction of outcomes after gastric endoscopic submucosal dissection (ESD).

PATIENTS AND METHODS

Data from 245 gastric ESD were collected, including patient and lesion factors. The two endpoints were curative resection and post-procedural bleeding (PPB). Logistic regression and Bayesian networks were built for each outcome; their predictive value was evaluated in-sample and validated through leave-one-out and cross-validation. Clinical decision support was enhanced by the definition of risk matrices, direct use of Bayesian inference software and by a developed online platform.

RESULTS

ESD was curative in 85.3 % and PPB occurred in 7.7 % of patients. In univariate analysis, male sex, ASA status, carcinoma histology, polypoid or depressed morphology, and lesion size ≥ 20 mm were associated with non-curative resection, while ASA status, antithrombotics and lesion size ≥ 20 mm were associated with PPB. Naïve Bayesian models presented AUROCs of ~80 % in the derivation cohort and ≥ 74 % in cross-validation for both outcomes. Risk matrices were computed, showing that lesions with cancer at biopsies, ≥ 20 mm, proximal or in the middle third, and polypoid are more prone to non-curative resection. PPB risk was < 5 % in lesions < 20 mm in the absence of antithrombotics.

CONCLUSIONS

The derived Bayesian model presented good discriminative power in the prediction of ESD outcomes and can be used to predict individualized probabilities, improving patient information and supporting clinical and management decisions.

Calprotectin and the Magnitude of Antibodies to Infliximab in Clinically-stable Ulcerative Colitis Patients are More Relevant Than Infliximab Trough Levels and Pharmacokinetics for Therapeutic Escalation

Although infliximab (IFX) is an efficient therapy for ulcerative colitis (UC) patients, a considerably high rate of therapeutic failures still occurs. This study aimed at a better understanding of IFX pharmacokinetics and pharmacodynamics among clinically-asymptomatic UC patients. This was a multicentric and prospective study involving 65 UC patients in the maintenance phase of IFX therapy. There were no significant differences between patients with positive and negative clinical, endoscopic and histological outcomes concerning their IFX trough levels (TLs), area under the IFX concentration vs. time curve (AUC), clearance and antibodies to infliximab (ATI) levels. However, the need to undergo therapeutic escalation later in disease development was significantly associated with higher ATI levels (2.62μg/mL vs. 1.15μg/mL, p=0.028). Moreover, and after adjusting for disease severity, the HR (hazard ratio) for therapeutic escalation was significantly decreased for patients with an ATI concentration below 3μg/mL (HR=0.119, p=0.010), and increased for patients with fecal calprotectin (FC) level above 250μg/g (HR=9.309, p=0.018). In clinically-stable UC patients, IFX pharmacokinetic features cannot predict therapeutic response on a short-term basis. However, high levels of ATIs or FC may be indicative of a future therapeutic escalation.

Development and Validation of Risk Matrices for Crohn's Disease Outcomes in Patients Who Underwent Early Therapeutic Interventions

INTRODUCTION

The establishment of prognostic models for Crohn's disease [CD] is highly desirable, as they have the potential to guide physicians in the decision-making process concerning therapeutic choices, thus improving patients' health and quality of life. Our aim was to derive models for disabling CD and reoperation based solely on clinical/demographic data.

METHODS

A multicentric and retrospectively enrolled cohort of CD patients, subject to early surgery or immunosuppression, was analysed in order to build Bayesian network models and risk matrices. The final results were validated internally and with a multicentric and prospectively enrolled cohort.

RESULTS

The derivation cohort included a total of 489 CD patients [64% with disabling disease and 18% who needed reoperation], while the validation cohort included 129 CD patients with similar outcome proportions. The Bayesian models achieved an area under the curve of 78% for disabling disease and 86% for reoperation. Age at diagnosis, perianal disease, disease aggressiveness and early therapeutic decisions were found to be significant factors, and were used to construct user-friendly matrices depicting the probability of each outcome in patients with various combinations of these factors. The matrices exhibit good performance for the most important criteria: disabling disease positive post-test odds = 8.00 [2.72-23.44] and reoperation negative post-test odds = 0.02 [0.00-0.11].

CONCLUSIONS

Clinical and demographical risk factors for disabling CD and reoperation were determined and their impact was quantified by means of risk matrices, which are applicable as bedside clinical tools that can help physicians during therapeutic decisions in early disease management.

Accuracy of Faecal Calprotectin and Neutrophil Gelatinase B-associated Lipocalin in Evaluating Subclinical Inflammation in UlceRaTIVE Colitis-the ACERTIVE study

BACKGROUND AND AIMS

Mucosal healing and histological remission are different targets for patients with ulcerative colitis, but both rely on an invasive endoscopic procedure. This study aimed to assess faecal calprotectin and neutrophil gelatinase B-associated lipocalin as biomarkers for disease activity in asymptomatic ulcerative colitis patients.

METHODS

This was a multicentric cross-sectional study including 371 patients, who were classified according to their endoscopic and histological scores. These results were evaluated alongside the faecal levels of both biomarkers.

RESULTS

Macroscopic lesions [i.e. endoscopic Mayo score ≥1] were present in 28% of the patients, and 9% had active disease according to fht Ulcerative Colitis Endoscopic Index of Severity. Moreover, 21% presented with histological inflammation according to the Geboes index, whereas 15% and 5% presented with focal and diffuse basal plasmacytosis, respectively. The faecal levels of calprotectin and neutrophil gelatinase B-associated lipocalin were statistically higher for patients with endoscopic lesions and histological activity. A receiver operating characteristic-based analysis revealed that both biomarkers were able to indicate mucosal healing and histological remission with an acceptable probability, and cut-off levels of 150-250 μg/g for faecal calprotectin and 12 μg/g for neutrophil gelatinase B-associated lipocalin were proposed.

CONCLUSIONS

Faecal calprotectin and neutrophil gelatinase B-associated lipocalin levels are a valuable addition for assessment of disease activity in asymptomatic ulcerative colitis patients. Biological levels of the analysed biomarkers below the proposed thresholds can rule out the presence of macroscopic and microscopic lesions with a probability of 75-93%. However, caution should be applied whenever interpreting positive results, as these biomarkers present consistently low positive predictive values.

The risk of disabling, surgery and reoperation in Crohn's disease - A decision tree-based approach to prognosis

Introduction

Crohn’s disease (CD) is a chronic inflammatory bowel disease known to carry a high risk of disabling and many times requiring surgical interventions. This article describes a decision-tree based approach that defines the CD patients’ risk or undergoing disabling events, surgical interventions and reoperations, based on clinical and demographic variables.

Materials and methods

This multicentric study involved 1547 CD patients retrospectively enrolled and divided into two cohorts: a derivation one (80%) and a validation one (20%). Decision trees were built upon applying the CHAIRT algorithm for the selection of variables.

Results

Three-level decision trees were built for the risk of disabling and reoperation, whereas the risk of surgery was described in a two-level one. A receiver operating characteristic (ROC) analysis was performed, and the area under the curves (AUC) Was higher than 70% for all outcomes. The defined risk cut-off values show usefulness for the assessed outcomes: risk levels above 75% for disabling had an odds test positivity of 4.06 [3.50–4.71], whereas risk levels below 34% and 19% excluded surgery and reoperation with an odds test negativity of 0.15 [0.09–0.25] and 0.50 [0.24–1.01], respectively. Overall, patients with B2 or B3 phenotype had a higher proportion of disabling disease and surgery, while patients with later introduction of pharmacological therapeutic (1 months after initial surgery) had a higher proportion of reoperation.

Conclusions

The decision-tree based approach used in this study, with demographic and clinical variables, has shown to be a valid and useful approach to depict such risks of disabling, surgery and reoperation.

The impact of the patient post-intensive care syndrome components upon caregiver burden

OBJECTIVE

To evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden.

DESIGN

A prospective observational study was conducted over 26 months (January 2013-February 2015).

SETTING

Medical-surgical ICU and follow-up consultation in Portugal.

PATIENTS OR PARTICIPANTS

Patients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study.

MAIN VARIABLES OF INTEREST

In ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder).

RESULTS

A total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden. Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008). When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden.

CONCLUSIONS

The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

Predictive factors of small bowel patency in Crohn's disease patients

BACKGROUND

Patency capsule was developed to avoid small bowel video capsule endoscopy retention, namely in patients with Crohn's disease.

AIMS

To evaluate the predictive factors of small bowel patency in Crohn's disease patients.

PATIENTS AND METHODS

Retrospective analysis including 151 Crohn's disease patients submitted to patency capsule (Agile® Patency Capsule) from 2011 to 2012. Patients that excreted the intact patency capsule were classified as having a patent small bowel (without patency capsule retention), other patients were considered to have negative patency of the small bowel (patency capsule retention).

RESULTS

Patients had a mean age of 41±14 years, 54% were female and 25% had been previously submitted to surgery. Stricturing disease was seen in 20% of cases and penetrating disease in 16% of cases. Left-sided colonic lesions and ileal strictures were observed at colonoscopy in 13% and 9% of patients, respectively. In our sample, 28% of patients had negative patency of the small bowel (patency capsule retention). In multivariate analysis, independent factors that were associated with negative patency of the small bowel in Crohn's disease patients were stricturing (OR 10.16, p < 0.001) and penetrating phenotypes (OR 11.73, p = 0.001), left-sided colonic lesions (OR 3.77, p = 0.038), ileal stricture (OR 9.76, p = 0.003); previous intestinal surgery was found to be protective (OR 0.16, p = 0.006).

CONCLUSIONS

Stricturing or penetrating disease, ileal strictures, no previous surgery and left-sided colonic lesions were the factors associated with negative small bowel patency in Crohn's disease patients.

Portuguese Version of the Pain Beliefs and Perceptions Inventory: A Multicenter Validation Study

BACKGROUND

We aimed to perform the translation, cultural adaptation, and validation of the Pain Beliefs and Perceptions Inventory (PBPI) for the European Portuguese language and chronic pain population.

METHODS

This is a longitudinal multicenter validation study. A Portuguese version of the PBPI (PBPI-P) was created through a process of translation, back translation, and expert panel evaluation. The PBPI-P was administered to a total of 122 patients from 13 chronic pain clinics in Portugal, at baseline and after 7 days. Internal consistency and test-retest reliability were assessed by Cronbach's alpha (α) and intraclass correlation coefficient (ICC). Construct (convergent and discriminant) validity was assessed based on a set of previously developed theoretical hypotheses about interrelations between the PBPI-P and other measures. Exploratory and confirmatory factor analyses were performed to test the theoretical structure of the PBPI-P.

RESULTS

The internal consistency and test-retest reliability coefficients for each respective subscale were α = 0.620 and ICC = 0.801 for mystery; α = 0.744 and ICC = 0.841 for permanence; α = 0.778 and ICC = 0.791 for constancy; and α = 0.764 and ICC = 0.881 for self-blame. Exploratory and confirmatory factor analysis revealed a four-factor structure (performance, constancy, self-blame, and mystery) that explained 63% of the variance. The construct validity of the PBPI-P was shown to be adequate, with more than 90% of the previously defined hypotheses regarding interrelations with other measures confirmed.

CONCLUSION

The PBPI-P has been shown to be adequate and to have excellent reliability, internal consistency, and validity. It may contribute to a better pain assessment and is suitable for research and clinical use.

Detection of anti-infliximab antibodies is impacted by antibody titer, infliximab level and IgG4 antibodies: a systematic comparison of three different assays

BACKGROUND

There is scant information on the accuracy of different assays used to measure anti-infliximab antibodies (ADAs), especially in the presence of detectable infliximab (IFX). We thus aimed to evaluate and compare three different assays for the detection of IFX and ADAs and to clarify the impact of the presence of circulating IFX on the accuracy of the ADA assays.

METHODS

Blood samples from 79 ulcerative colitis (UC) patients treated with infliximab were assessed for IFX levels and ADAs using three different assays: an in-house assay and two commercial kits, Immundiagnostik and Theradiag. Sera samples with ADAs and undetectable levels of IFX were spiked with exogenous IFX and analyzed for ADAs.

RESULTS

The three assays showed 81-96% agreement for the measured IFX level. However, the in-house assay and Immundiagnostik assays detected ADAs in 34 out of 79 samples, whereas Theradiag only detected ADAs in 24 samples. Samples negative for ADAs with Theradiag, but ADA-positive in both the in-house and Immundiagnostik assays, were positive for IFX or IgG4 ADAs. In spiking experiments, a low concentration of exogenous IFX (5 µg/ml) hampered ADA detection with Theradiag in sera samples with ADA levels of between 3 and 10 µg/ml. In the Immundiagnostik assay detection interference was only observed at concentrations of exogenous IFX higher than 30 µg/ml. However, in samples with high levels of ADAs (>25 µg/ml) interference was only observed at IFX concentrations higher than 100 µg/ml in all three assays. Binary (IFX/ADA) stratification of the results showed that IFX+/ADA- and IFX-/ADAs+ were less influenced by the assay results than the double-positive (IFX+/ADAs+) and double-negative (IFX-/ADAs-) combination.

CONCLUSIONS

All three methodologies are equally suitable for measuring IFX levels. However, erroneous therapeutic decisions may occur when patients show double-negative (IFX-/ADAs-) or double-positive (IFX+/ADAs+) status, since agreement between assays is significantly lower in these circumstances.

Proactive therapeutic drug monitoring of infliximab: a comparative study of a new point-of-care quantitative test with two established ELISA assays

BACKGROUND

Therapeutic drug monitoring is a powerful strategy known to improve the clinical outcomes and to optimise the healthcare resources in the treatment of autoimmune diseases. Currently, most of the methods commercially available for the quantification of infliximab (IFX) are ELISA-based, with a turnaround time of approximately 8 h, and delaying the target dosage adjustment to the following infusion.

AIM

To validate the first point-of-care IFX quantification device available in the market - the Quantum Blue Infliximab assay (Buhlmann, Schonenbuch, Switzerland) - by comparing it with two well-established methods.

METHODS

The three methods were used to assay the IFX concentration of spiked samples and of the serum of 299 inflammatory bowel diseases (IBD) patients undergoing IFX therapy.

RESULTS

The point-of-care assay had an average IFX recovery of 92%, being the most precise among the tested methods. The Intraclass Correlation Coefficients of the point-of-care IFX assay vs. the two ELISA-based established methods were 0.889 and 0.939. Moreover, the accuracy of the point-of-care IFX compared with each of the two reference methods was 77% and 83%, and the kappa statistics revealed a substantial agreement (0.648 and 0.738).

CONCLUSIONS

The Quantum Blue IFX assay can successfully replace the commonly used ELISA-based IFX quantification kits. This point-of-care IFX assay is able to deliver the results within 15 min makes it ideal for an immediate target concentration adjusted dosing. Moreover, it is a user-friendly desktop device that does not require specific laboratory facilities or highly specialised personnel.

Acute and chronic malnutrition and their predictors in children aged 0-5 years in São Tomé: a cross-sectional, population-based study

OBJECTIVE

Undernutrition is an important cause of morbidity and mortality in infants and children worldwide. The aim of this study was to evaluate the nutritional status and their predictors in children from 0 to 5 years of age in São Tomé.

STUDY DESIGN

A cross-sectional study was conducted in São Tomé Island.

METHODS

A total of 1285 individuals were enrolled between January and May 2011. Children were measured, and height for age (HAZ), weight for height (WHZ) and body mass index (BAZ) Z-score were computed. Global acute undernutrition is defined as weight for height <-1 Z-score (wasting < -2 Z-scores) and global chronic undernutrition as length/height for age <-1 Z-score (stunting < -2 Z-scores). Relevant information was collected from individual health bulletins, namely gestational age and birth weight, as well as weight at 6, 12, 18 and 24 months for all individual above these ages. Mothers were invited to answer a specific questionnaire.

RESULTS

A high percentage of global acute undernutrition (30.9% in <24 months and 21.9% in ≥24 months) and global chronic undernutrition (32.5% in <24 months and 41.1% in ≥24 months) was observed. Appropriate birth weight for gestational age (AGA) is significantly associated with lower odds for both acute (OR 0.485 [95% CI 0.299-0.785]) and chronic undernutrition (OR 0.427 [95% CI 0.270-0.675]) in children >12 months. Weight gain above 0.67 Z-score in the first semester of life was strongly related to lower odds for both acute (OR 0.109 [95% CI 0.040-0.291]) and chronic undernutrition (OR 0.379 [95% CI 0.187-0.770]) in children >12 months of age. Similarly, mother's education seems to protect against acute (>12 months: OR 0.448 [95% CI 0.244-0.825]; >24 months: OR 0.186 [95% CI 0.064-0.540]) and chronic undernutrition (>12 months: OR 0.389 [95% CI 0.232-0.653]; >24 months: OR 0.324 [95% CI 0.171-0.625]). All logistic regressions were adjusted for all children (gender, age, gestational age, birth weight, breastfeeding, begin consumption alcohol), mothers (age, height, body mass index, educational level, number of previous pregnancies, smoking during pregnancy, alcohol consumption during pregnancy) and household (number of siblings and persons at home) variables included in the protocol.

CONCLUSIONS

Birth weight, nutritional status, and the mother's education and weight gain particularly in the first year of life were important factors protecting against undernutrition during infancy and childhood. These results emphasize the importance of women's nutrition and of adequate birth weight and particularly weight gain during the first year of life in order to prevent wasting and stunting in childhood.

Needs in Nursing Homes and Their Relation with Cognitive and Functional Decline, Behavioral and Psychological Symptoms

Unmet needs are becoming acknowledged as better predictors of the worst prognostic outcomes than common measures of functional or cognitive decline. Their accurate assessment is a pivotal component of effective care delivery, particularly in institutionalized care where little is known about the needs of its residents, many of whom suffer from dementia and show complex needs. The aims of this study were to describe the needs of an institutionalized sample and to analyze its relationship with demographic and clinical characteristics. A cross-sectional study was conducted with a sample from three nursing homes. All residents were assessed with a comprehensive protocol that included Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), Neuropsychiatric Inventory (NPI) and Adults and Older Adults Functional Inventory (IAFAI). To identify needs, the Camberwell Assessment of Need for the Elderly (CANE) was used. The final sample included 175 residents with a mean age of 81 standard deviation (SD = 10) years. From these, 58.7% presented cognitive deficit (MMSE) and 45.2% depressive symptoms (GDS). Statistically significant negative correlations were found between MMSE score and met (r s = -0.425), unmet (r s = -0.369) and global needs (r s = -0.565). Data also showed significant correlations between depressive symptoms and unmet (r s = 0.683) and global needs (r s = 0.407), and between behavioral and psychological symptoms (BPSD) and unmet (r s = 0.181) and global needs (r s = 0.254). Finally, significant correlations between functional impairment and met (r s = 0.642), unmet (r s = 0.505) and global needs (r s = 0.796) were also found. These results suggest that in this sample, more unmet needs are associated with the worst outcomes measured. This is consistent with previous findings and seems to demonstrate that the needs of those institutionalized elderly remain under-diagnosed and untreated.

The economic impact of chronic pain: a nationwide population-based cost-of-illness study in Portugal

In addition to its high frequency and relevant individual and social impact, chronic pain (CP) has been shown to be a major contributor to increased healthcare utilisation, reduced labour productivity, and consequently large direct and indirect costs. In the context of a larger nationwide study, we aimed to assess the total annual direct and indirect costs associated with CP in Portugal. A population-based study was conducted in a representative sample of the Portuguese adult population. The 5,094 participants were selected using random digit dialling and contacted by computer-assisted telephone interviews. Questionnaires included the brief pain inventory and pain disability index. Estimates were adequately weighted for the population. From all CP subjects identified, a subsample (n = 562) accepted to participate in this economic study. Mean total annualised costs per CP subject of €1,883.30 were observed, amounting to €4,611.69 million nationally, with 42.7% direct and 57.3% indirect costs, and corresponding to 2.71% of the Portuguese annual GDP in 2010. Only socio-demographic variables were significantly and independently associated with CP costs, and not CP severity, raising the possibility of existing inequalities in the distribution of healthcare in Portugal. The high economic impact of CP in Portugal was comprehensively demonstrated. Given the high indirect costs observed, restricting healthcare services is not a rational response to these high societal costs; instead improving the quality of CP prevention and management is recommended.

Clinical predictors of colectomy in patients with ulcerative colitis: systematic review and meta-analysis of cohort studies

INTRODUCTION

Colectomy is a major event that may significantly affect the outcome of ulcerative colitis (UC) in terms of both quality of life and mortality. This paper aims to identify clinical prognostic factors that may be significantly associated with this event.

METHODS

PubMed, ISI Web of Knowledge and Scopus were searched to identify studies investigating the association between clinical factors in adult patients with UC and studied events.The clinical factors evaluated in this meta-analysis were gender, smoking habits, disease extent,use of corticosteroids, and episodes of hospitalization.

RESULTS

Of the 3753 initially selected papers, 20 were included. The analysis showed a significantly lower risk of colectomy for female patients (odds ratio [OR] 0.78 [95% CI 0.68, 0.90]) and for smoking patients (OR 0.55 [0.33, 0.91]), and a higher risk for patients with extensive disease (OR 3.68 [2.39,5.69]), for patients who took corticosteroids at least once (OR 2.10 [1.05, 4.22]), and for patients who were hospitalized (OR 4.13 [3.23, 5.27]).

CONCLUSION

Gender, smoking habits, disease extent, need for corticosteroids, and hospitalization were all significantly associated with UC prognosis. These results may clarify the relative influences of these and other prognostic factors in the natural course of the disease and therefore help improve the management approach, thus improving the follow-up of patients.

Effects of local anesthetic on the time between analgesic boluses and the duration of labor in patient-controlled epidural analgesia: prospective study of two ultra-low dose regimens of ropivacaine and sufentanil

BACKGROUND

Patient-controlled epidural analgesia with low concentrations of anesthetics is effective in reducing labor pain. The aim of this study was to assess and compare two ultra-low dose regimens of ropivacaine and sufentanil (0.1% ropivacaine plus 0.5 μg.ml-1 sufentanil vs. 0.06% ropivacaine plus 0.5 μg.ml-1 sufentanil) on the intervals between boluses and the duration of labor.

MATERIAL AND METHODS

In this non-randomized prospective study, conducted between January and July 2010, two groups of parturients received patient-controlled epidural analgesia: Group I (n = 58; 1 mg.ml-1 ropivacaine + 0.5 μg.ml-1 sufentanil) and Group II (n = 57; 0.6 mg.ml-1 ropivacaine + 0.5 μg.ml-1 sufentanil). Rescue doses of ropivacaine at the concentration of the assigned group without sufentanil were administered as necessary. Pain, local anesthetic requirements, neuraxial blockade characteristics, labor and neonatal outcomes, and maternal satisfaction were recorded.

RESULTS

The ropivacaine dose was greater in Group I (9.5 [7.7-12.7] mg.h-1 vs. 6.1 [5.1-9.8 mg.h-1], p < 0.001). A time increase between each bolus was observed in Group I (beta = 32.61 min, 95% CI [25.39; 39.82], p < 0.001), whereas a time decrease was observed in Group II (beta = -1.40 min, 95% CI [-2.44; -0.36], p = 0.009). The duration of the second stage of labor in Group I was significantly longer than that in Group II (78 min vs. 65 min, p < 0.001).

CONCLUSIONS

Parturients receiving 0.06% ropivacaine exhibited less evidence of cumulative effects and exhibited faster second stage progression than those who received 0.1% ropivacaine.

Audiometric Outcome Comparison between Titanium Prosthesis and Molded Autologous Material

Objective

To evaluate and compare the audiometric outcomes of ossicular reconstruction with titanium prosthesis and autologous material.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Subjects and Methods

Audiometric results of consecutive patients who performed ossiculoplasty with titanium prosthesis (n = 43) or autologous material (n = 48), from October 2008 to December 2011, were reviewed retrospectively and compared. The association between air-bone gain and age, ossiculoplasty material (autologous or titanium), preoperative diagnosis (chronic otitis media without cholesteatoma, cholesteatoma, or conductive hearing loss with intact tympanic membrane), and type of surgery (tympanoplasty, canal wall-down mastoidectomy, or canal wall-up mastoidectomy) was explored using regression analysis.

Results

Preoperative audiometric evaluation did not show differences between titanium and autologous groups in air-bone gap and pure-tone average. A postoperative decrease of 11.0 dB in air-bone gap and 12.4 dB in pure-tone average was observed in titanium ossiculoplasty compared with a reduction of 4.0 dB in air-bone gap and 5.1 dB in pure-tone average when autologous reconstruction was used. Mann-Whitney test revealed superior results in the titanium group compared with autologous reconstruction patients in air-bone gap ( P = .02) and pure-tone average ( P = .02). However, no statistically significant associations were observed after multivariate linear regression analysis of air-bone gap gain when adjusted for age, ossiculoplasty material, type of surgery, and preoperative diagnosis. One titanium prosthesis extrusion occurred during follow-up (2%).

Conclusion

Audiometric results achieved by titanium prosthesis are promising, but significant differences compared with autologous ossiculoplasty were not present.

Epidemiology of chronic pain: a population-based nationwide study on its prevalence, characteristics and associated disability in Portugal

A cross-sectional nationwide epidemiological study was performed in a random sample of the Portuguese adult population, aiming to describe the prevalence and impact of chronic pain (CP). The 5,094 participants were selected by random digit dialing, between January 2007 and March 2008, and estimates were adequately weighted for the population. Prevalence of CP was 36.7% (95% confidence interval [CI] [35.3-38.2]), based on the definition of the International Association for the Study of Pain. Recurrent or continuous pain was present in 85% of those with CP, and moderate-to-severe intensity and disability were present in 68 and 35%, respectively. Highest CP prevalence was observed among the elderly, retired, unemployed, and less educated. Highest disability was found in relation with family/home responsibilities, recreational activities, occupation/work, and sleep/rest; 13% reported a diagnosis of depression and 49% reported interference in their job. The main factors associated with disability were sex, pain intensity, and depression or depressive symptoms. CP is highly prevalent, causes high personal and social burden, and affects particularly the most vulnerable subgroups. Portugal, depending on CP definition, could be placed in the lower prevalence group in Europe. Improvement in pain intensity management and special attention to affective components of CP are recommended.

PERSPECTIVE

In this cross-sectional nationwide epidemiological study, we showed that chronic pain is a significant problem that is present in 37% of the Portuguese adult general population, is associated with high personal, family, and social burden, and affects in particular the most vulnerable subgroups of the population.

Hemorrhagic ascites associated with endometriosis. A case report

BACKGROUND

Endometriosis associated with massive, bloody ascites is an unusual occurrence. This report draws attention to this condition as a complication of endometriosis, with the description of a case and a review of 31 others.

CASE

A 41-year-old, black nulligravida with massive, bloody ascites and a pelvic mass underwent laparotomy, and an intraoperative microscopic examination ruled out malignancy. The histologic report was compatible with endometriosis. The patient was treated with a GnRH analog, with progressive reduction of ascitic fluid and full remission after six months.

CONCLUSION

Bloody ascites should be considered a complication of endometriosis, especially in nulliparous women of childbearing age with abdominal distention, a pelvic mass, dysmenorrhea, abdominal pain, weight loss and eventual pleural effusion, suggesting a diagnosis of ovarian malignancy.

Action of alpha-methyldopa on human umbilical circulation in vitro

To determine the possible effects of alpha-methyldopa on the motility of human umbilical artery, a total of 53 arterial segments were perfused with different concentrations of the drug as follows: 38 segments with 125, 250 and 500 ng/ml of the drug, 9 segments with 500 ng/ml alpha-methyldopa in combination with 10(-7) M yohimbine, and 6 segments with 10(-7) M yohimbine alone. alpha-Methyldopa had a vasoconstrictor effect at all doses employed, with a clear dose-effect correlation (p less than 0.01). The vasoconstrictor effect of 500 ng/ml alpha-methyldopa was fully inhibited in the presence of 10(-7) M yohimbine. These results suggest that alpha 2-adrenergic receptors are present in the umbilical circulation and that alpha-methyldopa may play a role in the control of this circulation.