Opioid use disorder in chronic non-cancer pain in Germany: a cross sectional study

OBJECTIVES

The DSM-5 diagnosis 'opioid use disorder' (OUD) was established to better describe and detect significant impairment or distress related to opioid use. There is no data on rates of OUD in chronic non-cancer pain (CNCP) in European countries. Therefore, our objective was to screen patients in specialised pain centres for signs of OUD.

DESIGN

Cross-sectional questionnaire study.

SETTING

Four outpatient pain clinics in the area of Bonn, Germany.

PARTICIPANTS

n=204 patients participated in the study (response rate: 87.9%). All adult patients with opioid pain therapy >6 months for CNCP were included. Excluded were patients with malignant disease, patients who could not collect their prescription themselves due to age or multimorbidity and patients on opioid-maintenance therapy.

PRIMARY AND SECONDARY OUTCOME MEASURE

Primary outcome measure was the proportion of patients with mild to severe OUD.

RESULTS

One-fourth (26.5%) of participants were diagnosed with OUD. Moderate to severe disorder was found in 9.3. Young age was the only connected risk factor (OR 0.96 [95% CI 0.94 to 0.99], p: 0.003).

CONCLUSIONS

OUD is a relevant diagnosis in patients on long-term opioid therapy for CNCP in the Bonn area. Careful follow-up by the attending physicians is advisable, especially in patients with moderate or severe disorder.

Challenges in diagnosing dementia in patients with a migrant background - a cross-sectional study among German general practitioners

Background

Diagnosing dementia, a syndrome affecting 35.6 million people worldwide, can be challenging, especially in patients with a migrant background. Language barriers and language-based diagnostic tools, cultural differences in the perception of the syndrome as well as restricted access to healthcare can influence medical care. For the first time in Germany, this study investigates whether German general practitioners (GPs) feel prepared to meet the diagnostic needs of these patient groups and whether there are challenges and support needs.

Methods

A cross-sectional study among a random sample of 982 general practitioners in Germany was conducted from October 2017 to January 2018 (response rate: 34.5%). A self-developed, written, standardised questionnaire was used. Descriptive statistics as well as multiple logistic regression analyses were performed using data of 326 GPs.

Results

Ninety-six percent of GPs reported having experienced barriers at least once. Uncertainties in diagnosing dementia in patients with a migrant background were indicated by 70.9%. There was no significant association between uncertainties in diagnosing dementia and GPs’ sociodemographic characteristics. The most frequently reported barriers were language barriers that affected or prevented diagnostics (89.3%) and information deficits in patients with a migrant background (59.2%). Shameful interaction or lack of acceptance of the syndrome was also common (55.5%). A demand for more information about the topic was expressed by 70.6% of GPs.

Conclusions

Public health measures supporting GPs in their interaction with patients with a migrant background as well as information and services for dementia patients are needed. Efforts to facilitate access to interpreting services and to focus on people with a migrant background in healthcare are necessary.

Trial registration

German Clinical Trials Register: DRKS00012503, date of registration: 05/09/2017 (German Institute of Medical Documentation and Information. German Clinical Trials Register (DRKS) 2017). Clinical register of the study coordination office of the University hospital of Bonn: ID530, date of registration: 05/09/2017 (Universitätsklinikum Bonn. Studienzentrum. UKB-Studienregister 2017).

Wissen und Einstellungen über die saisonale Influenza-Impfung von Hebammenschülerinnen in Nordrhein-Westfalen: Ergebnisse einer Querschnittsstudie

Zielsetzung Erstmalig für Deutschland wurden Einstellungen und Wissensstand von Hebammenschülerinnen bezüglich Impfungen im Allgemeinen, sowie der Influenza-Impfung im Speziellen erfasst.

Methodik Im Rahmen einer Querschnittsstudie wurde zwischen Mai und Juli 2017 eine standardisierte schriftliche Befragung aller Hebammenschülerinnen in Nordrhein-Westfalen durchgeführt. Die Ergebnisse wurden sowohl durch Häufigkeitsanalysen, als auch mittels multipler, logistischer Regression ausgewertet.

Ergebnisse Alle 10 Hebammenschulen in Nordrhein-Westfalen nahmen an der Befragung teil und Fragebögen von 315 Hebammenschülerinnen (Teilnahmerate: 95,7%) konnten ausgewertet werden. Die Effektivität der Impfung gegen saisonale Influenza schätzten 77,8% der Befragten falsch ein, mögliche Nebenwirkungen wurden nur von 35,2% der Befragten korrekt eingeschätzt. Von der Sicherheit einer Impfung während der Schwangerschaft waren 56,2% der Befragten nicht überzeugt. Faktoren, die ein erhöhtes Risiko eines nicht ausreichenden Wissensstands bezüglich Influenza-Impfung bieten, sind ein Lebensalter zwischen 22 und 25 Jahren (adjustiertes Odds ratio (aOR) 1,99 95%-Konfidenzintervall (KI) 1,12–3,52) im Vergleich zu Jüngeren (18–21 Jahre), eine fehlerhafte Einschätzung des Übertragungsrisikos (aOR 3,68 95%-KI 1,85–7,29) sowie ein nicht ausreichendes Wissen über die Influenza-Erkrankung (aOR 1,78 95%-KI 1,04–3,06). Im Gegensatz hierzu zeigten 76,8% der Befragten eine positive Einstellung gegenüber Impfungen im Allgemeinen, 73,3% der Befragten beklagten eine zu geringe Information der Öffentlichkeit über Impfkomplikationen.

Schlussfolgerung Das unzureichende Wissen der Hebammenschülerinnen bezüglich der saisonalen Influenza-Impfung steht einer Erhöhung des Impfschutzes von Hebammen, Schwangeren und somit auch dem Schutz von Neugeborenen entgegen. Aufklärungskampagnen in den Ausbildungsgängen, sowie eine Analyse und Anpassung der Unterrichtsinhalte mit wissenschaftlich validierten Erkenntnissen, erscheinen notwendig. Ferner sollten die Ergebnisse Anlass vorrangig für Betriebsmediziner, Hausärzte und Gynäkologen sein, um Personal in der Hebammenausbildung bzw. -beruf intensiver bezüglich saisonaler Influenza-Impfung zu beraten.

Treatment Options for Gout

BACKGROUND

1-2% of adults in Germany suffer from gout. Gout is one of the few rheumatological diseases that can be cured. It arises through the deposition of uric acid crystals in joints as a result of hyperuricemia. Painful redness and swelling of the affected joints are typical findings. Multiple pertinent guidelines and treatment recommendations have been published, but there is reason to believe that patients with gout are not always treated accordingly.

METHODS

This review is based on relevant publications from the years 2000-2016 that were retrieved by a selective search in the Cochrane and PubMed databases.

RESULTS

In a person with normal renal function, asymptomatic hyperuricemia is not an indication for treatment to lower the serum uric acid level. The drugs of first choice for acute gouty arthritis are nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and colchicine. Treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course; the target uric acid value is <6 mg/dL. Long-term treatment should be initiated only after resolution of the acute attack. For patients with refractory gout, lesinurad (approved in February 2016) in combination with XOI is a new treatment option that can be considered. Comprehensive patient education and counseling is an important component of the treatment of patients with gout. Regular laboratory follow-up is necessary as well.

CONCLUSION

The prevalence of gout is rising around the world. Patients with gout could benefit greatly from consistent implementation of the existing treatment guidelines and recommendations. In the future, controlled trials should be conducted to determine the best time to start treatment and the optimal target level for the serum uric acid concentration in terms of a risk/benefit analysis.

Barriers in general practitioners' dementia diagnostics among people with a migration background in Germany (BaDeMi) - study protocol for a cross-sectional survey

Background

Considering the targeted general practitioner-centred healthcare in Germany, general practitioners (GPs) are in the best possible position to increase awareness of all sorts of dementia, an age-related syndrome with rising relevance in the future. In Germany, a doubling of the number of cases from 1.55 million up to 3 million in 2050 is predicted. Diagnostics can be challenging, especially among patients with a migration background. Complicating factors include: Language-based diagnostic tools, cultural differences in handling the syndrome and its underlying diseases as well as a differing use of the healthcare system. Because of missing research in this field in Germany, the type, frequency and intensity of barriers as well as the way GPs cope with them is unknown. That is why it’s crucial to focus research on diagnostics in total and especially among this population group.

Methods

A cross-sectional study among a random sample of 1000 general practitioners in Germany is conducted in October 2017. A self-administered standardized questionnaire was developed, evaluated and send to the GP practices. A response rate of 30% is expected with one reminder letter. Descriptive statistics as well as, depending on the results, multivariable analyses will be executed. Based on these results and the stated needs, a cluster-randomized intervention study will be constructed to improve healthcare.

Discussion

This study is the first in Germany focusing on how dementia diagnostics in general practice is performed, what problems occur, especially because of a migration background of patients, and how GPs cope with them. Depending on the results, it should emphasize the necessity of dementia diagnostics to be adjusted to the needs of the rising amount of people with a migration background (22.5% in Germany, 2016) like concluded from international studies.

Trial registration

German Clinical Trials Register: DRKS00012503, date of registration: 05.09.2017. Clinical register of the study coordination office of the University hospital of Bonn: ID530, date of registration: 05.09.2017.

Determinants of having no general practitioner in Germany and the influence of a migration background: results of the German health interview and examination survey for adults (DEGS1)

BACKGROUND

It is aspired in the German healthcare system that general practitioners (GPs) act as initial contact for patients and guide through at all steps of medical treatment. This study aims at identifying factors associated with the odds of having no GP within the general population and especially among people with migration background.

METHODS

This cross-sectional analysis was based on the "German Health Interview and Examination Survey for Adults" (DEGS1) conducted by the Robert Koch Institute. Descriptive analyses as well as multiple logistic regression models were performed to analyse the impact of a migration background, age, gender, residential area, socioeconomic status (SES) and other factors on having no GP among 7755 participants.

RESULTS

9.5% of the total study population and 14.8% of people with a migration background had no GP, especially men, adults living in big cities and without chronic diseases. The odds of not having a GP were higher for people with a two-sided migration background (aOR: 1.90, 95% CI: 1.42-2.55). Among the population with a migration background, particularly young adults, men, people living in big cities and having a private health insurance showed higher odds to have no GP.

CONCLUSIONS

It is necessary to investigate the causes of the differing utilization of healthcare of people with a migration background and, if necessary, to take measures for an equal access to healthcare for all population groups. Further research needs to be done to evaluate how to get young people into contact with a GP.

More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners

BACKGROUND

Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations.

OBJECTIVES

This postal survey asked German GPs about their counselling for end-of-life decisions.

METHODS

In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD.

RESULTS

The participation rate was 50.3% (n = 482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21 min for LWs and 16 min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document.

CONCLUSION

The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.

Hyperuricemia and dementia - a case-control study

Background

There is evidence that uric acid may have antioxidant and neuroprotective effects and might therefore alter the risk for neurodegenerative diseases such as dementia. So far, the relation between serum uric acid (SUA) levels or hyperuricemia and dementia remains elusive. Most studies focused on the disease or SUA levels. Effects of anti-hyperuricemic treatment have not been considered yet. This study investigated the association between hyperuricemia and dementia taking into account anti-hyperuricemic treatment.

Methods

We used longitudinal German public health insurance data and analyzed the association between hyperuricemia with and without different treatment options and dementia in a case-control design. Applying logistic regression the analysis was adjusted for several potential confounders including various comorbidities and polypharmacy.

Results

We identified 27,528 cases and 110,112 matched controls of which 22% had a diagnosis of hyperuricemia or gout and 17% received anti-hyperuricemic drugs. For patients with a diagnosis of hyperuricemia we found a slightly reduced risk for dementia (adjusted odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98). The risk reduction was more pronounced for patients treated with anti-hyperuricemic drugs (adjusted OR 0.89, 95% CI 0.85 to 0.94, for regular treatment).

Conclusions

Our results showed a slight reduction for dementia risk in patients with hyperuricemia, both with and without anti-hyperuricemic treatment.

[Survey of physicians on dealing with the topic "Tobacco consumption in patients with lung cancer"]

INTRODUCTION

 About 40 % of the patients are active smokers when diagnosed lung cancer. Half of these patients is the nicotine consumption continues despite the existence of cancer. The overall mortality in these patients is a factor of 3 higher. In addition, the quality of life increases and symptoms such as cough and dyspnoea are reduced.

QUESTION

 How do the treating physicians deal with the tobacco consumption of their patients with lung carcinoma?

METHODS

 A total of 14 physicians from the Bonn University Hospital were interviewed from the departments of pneumology, oncology and thoracic surgery involved in the treatment of the lung carcinoma. The interviews were transcribed and analysed according to the qualitative content analysis Mayring with MAXQDA^® 12.

RESULTS

 The doctors handled the nicotine consumption of their patients very individually. In doing so, the doctors were primarily oriented on the possible life expectancy of the patients. In a curative treatment approach, the doctors presumed a smoking stop in their patients for successful treatment. In the context of a palliative treatment, many doctors no longer wanted the burden of smoking cessation to their patients. Came the desire for a cessation therapy in patients were referred generally to colleagues who were trained in smoking cessation. Obstacles to the independent execution of a smoking cessation were in particular lack of knowledge and short treatment times or high number of patients, especially during the consultation hours.

DISCUSSION

 The doctors were quite convinced of the benefit of a smoking stop in the treatment of the lung carcinoma. Lung cancer patients would benefit if smoking cessation would be even more integrated into the overall therapy. For that one could rely on already established cessation programs and concepts for clinics.

[Prevention of Infections of the Upper Respiratory Tract]

Because of its high prevalence acute respiratory diseases have a significant impact on the population. The focus of this review was the current state of knowledge for the prophylactic efficacy of: zinc, vitamin C, Echinacea preparations, garlic and carrying out physical measures. Furthermore, the benefits of pneumococcal and influenza vaccine were elicited. In the synopsis, the physical measures proved to be the most effective, cost-effective method to prevent infections. The intake of zinc, Echinacea preparations (for example: E. purpurea), vitamin C and garlic showed moderate success in the prevention of infection and must be elicited individually. Pneumococcal and annual influenza vaccines in family practice should be given furthermore accordingly topical STIKO-recommendation. Nevertheless, the prophylactic effect from influenza vaccines on usual cold illnesses is unsettled.

Weniger akute Atemwegsinfekte durch Vitamin-D-Supplementation?

Martineau AR. et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ 2017; 356: i6583

Vitamin D spielt Studien zufolge auch eine Rolle bei der Abwehr pathogener Keime: 25-Hydroxy-Vitamin D (25[OH] Vitamin D) unterstützt z. B. die Synthese antimikrobieller Peptide. Es gibt also eine mögliche Erklärung für die Beobachtung, dass Personen mit niedrigen Vitamin-D-Spiegeln besonders empfindlich gegenüber respiratorischen Infekten sind. Untersuchungen zu einer präventiven Wirkung des Vitamin D verliefen jedoch zum Teil widersprüchlich.

[Acute Gout in Emergency Admissions - Patient Characteristics and Adherence of Care Processes to Current Guidelines]

BACKGROUND

Gout or hyperuricemia are both well known and common diseases. The prevalence of gout is increasing worldwide. Thus, patients with gout are becoming more common. Although there are several published guidelines for the management of gout, actual treatment of gout is inconsistent with these guidelines in many respects. Gout is usually treated by general practitioners (GP) in Germany. The aim of our study was to show which patients present to the emergency department and to record how treatment and clinical diagnostic testing of gout patients is performed in the emergency department of a university hospital in Germany. No such data have been published for Germany.

METHOD

Retrospective analysis of data of patients with ICD Code M10.xx from the emergency department at a university hospital from 05/2013 until 04/2016.

RESULTS

65 patients were treated with acute gout during the study period at the emergency department (age ∅ 53.45 y, 76.9% male, 23.07% female). 42 patients (65%) came outside normal office hours of GPs. In 31 patients, hyperuricemia or gout was known in their medical history, in 22 of these acute gout was known. 48 (73%) of patients came with monoarthritis and therefrom 40 with "classic" gout, such as podagra. 57 (86%) patients were subjected to diagnostic blood analysis and 31 (48%) diagnostic X-ray of the affected joint. We defined the appropriate indications for X-ray in diagnosis of acute gout as: signs of superinfection, prior surgical intervention or uncertain trauma in case history. According to this definition, 67% of the X-rays were performed without the correct indication. Four Patients were given punction of the affected joint to demonstrate monosodium urate monohydrate (MSU) crystals. Twelve patients were admitted as inpatients for surgery and/or antibiotic treatment. 51 (78%) patients received NSAIDs, 7 in combination with steroids and 4 patients received colchicine. Of those patients who received NSAID, 17 had an unknown or impaired renal function. Seven patients received neither pharmacological treatment nor recommendations for further treatment. Ten patients (15%) received a urate-lowering therapy or an existing therapy was increased during acute gout. In 10 patients, a urate-lowering therapy was recommended as further therapy. 63% were given further treatment recommendations such as cryotherapy or diet.

CONCLUSIONS

Acute gout is seldom presented in the emergency room (< 1‰). This confirms the impression that gout is mainly a disease treated in the outpatient setting. As shown in our study, the pharmacological treatment of acute gout was largely consistent with the guideline recommendations; nevertheless observance of renal function before treatment with NSAIDs should be emphasised. Furthermore, we identified overuse of diagnostic procedures. Current guidelines recommend diagnosing acute gout with clinical scores. In conclusion, our study shows that those clinical diagnostic scores should be implemented in clinical practice, in order to avoid unnecessary diagnostic procedures.

Risk of opioid misuse in chronic non-cancer pain in primary care patients - a cross sectional study

BACKGROUND

Efforts to improve treatment of pain using opioids have to adequately take into account their therapeutic shortcomings which involve addictiveness. While there are no signs of an "opioid epidemic" in Germany similar to that in the US, there is little data on the prevalence of prescription opioid misuse and addiction. Therefore, our objective was to screen primary care patients on long-term opioid therapy for signs of misuse of prescription opioids.

METHODS

We recruited 15 GPs practices and asked all patients on long-term opioid therapy (> 6 months) to fill out a questionnaire including the "Current Opioid Misuse Measure" (COMM®), a self-report questionnaire. Patients with a malignant disease were excluded.

RESULTS

N = 91 patients participated in the study (response rate: 75.2%). A third (31.5%) showed a positive COMM® - Score which represents a high risk of aberrant drug behaviour. A positive COMM® - Score showed a statistically significant correlation with a lifetime diagnosis of depression and neck pain.

CONCLUSIONS

While Germany does not face an "opioid eoidemic", addictiveness of opioids should be considered when using them in chronic non-tumor pain. In our study population, almost every third patient was at risk and should therefore be followed up closely. Co-prevalence of depression is a significant issue and should always be screened for in patients with chronic pain, especially thus with aberrant drug behaviour.

Prevalence and comorbidity of osteoporosis- a cross-sectional analysis on 10,660 adults aged 50 years and older in Germany

Background

Knowledge on prevalence of osteoporosis stratifying for socioeconomic background is insufficient in Germany. Little is known in Europe about other diseases that go along with it although these aspects are important for implementing effective public health strategies.

Methods

This cross-sectional analysis was based on the national telephone survey “German Health Update” (GEDA 2012) performed in 2012/2013. GEDA 2012 provides information on self-reported diseases and sociodemographic characteristics for nearly 20,000 adults. Descriptive statistical analysis and multiple logistic regression were used to examine the association between osteoporosis and age, sex, other diseases and education defined by ISCED. Analyses were limited to participants aged 50 years and older.

Results

Overall, 8.7% of the 10,660 participants aged 50+ years had osteoporosis (men 4.7%, women 12.2%). More than 95% of the adults with osteoporosis had at least one coexisting disease. The odds for arthrosis (OR 3.3, 95% CI 2.6-4.1), arthritis (OR 3.0, 95% CI 2.2-4.2), chronic low back pain (OR 2.8, 95% CI 2.3-3.5), depression (OR 2.3, 95% CI 1.7-3.1) and chronic heart failure (OR 2.3, 95% CI 1.6-3.1), respectively, were greater for adults with osteoporosis. Education showed no significant association with osteoporosis.

Conclusions

There was no clear evidence of socioeconomic differences regarding osteoporosis for adults in Germany. However, clinicians need to be aware that multimorbidity is very common in adults with osteoporosis. Health care interventions for osteoporosis could be improved by offering preventive care for other diseases that go along with it. Over- or under-diagnosis in different socioeconomic levels has to be further explored.

Ambulante Notfallversorgung von Pflegeheimbewohner: Ein Status Quo aus pflegerischer Sicht

Ziel der Studie Derzeit sind in Deutschland ca. 2 Mio. Menschen pflegebedürftig, etwa 1/3 davon lebt in Alten- oder Pflegeheimen. Die ambulante Notfallversorgung von Heimbewohnern wird von Hausärzten, dem ärztlichen Bereitschaftsdienst und dem Rettungsdienst sichergestellt. Bisher wurde diese Notfallversorgung nur selten aus Sicht der Pflegenden überprüft. Daher haben wir in unserer Studie untersucht, wie die Pflegekräfte die ärztliche Versorgung bei medizinischen Notfällen empfinden und welche Verbesserungsmöglichkeiten sie sehen.

Methodik Zur Datenerhebung wurden im Jahr 2015/16 leitfadengestützte Interviews mit insgesamt 13 Altenpflegerinnen und einem Altenpfleger im nördlichen Rheinland-Pfalz durchgeführt. Die Interviews wurden digital aufgezeichnet und wörtlich transkribiert. Die Auswertung erfolgte nach der qualitativen Inhaltsanalyse nach Mayring mit MAXQDA® 12.

Ergebnisse Bei einer akuten Verschlechterung des Allgemeinzustandes eines Heimbewohners wird zunächst der zuständige Hausarzt angefordert. Dabei ist es für die Pflegekräfte schwierig, den zuständigen Hausarzt während der laufenden Sprechstunde zu erreichen. Die Qualität der Notfallversorgung ist vor allem von der jeweiligen Praxisstruktur abhängig. Außerhalb der Praxisöffnungszeiten übernimmt der ärztliche Bereitschaftsdienst die Notfallversorgung. Die Dienstärzte kennen die Patienten nicht, was aus Sicht der Pflege für die Bewohner eine Belastung ist, da sie sich immer wieder auf neue Ärzte einstellen müssen. Zum anderen haben die Bereitschaftsärzte lange Anfahrtswege, was zu entsprechenden Verzögerungen, auch im Notfall führt. Einige Pflegekräfte wünschten sich das „alte System“ zurück, bei dem die heimversorgenden Hausärzte auch am Wochenende telefonisch erreichbar waren. Insgesamt bestand der Wunsch nach einer besseren Versorgung der Heimbewohner.

Schlussfolgerung Hausärzte sind für das Pflegepersonal die wichtigsten Ansprechpartner in medizinischen Notfällen. Jedoch sind die meisten Hausärzte nur zeitlich begrenzt erreichbar. Aus Sicht der Pflege wäre es sinnvoll, Anreize für die Hausärzte zu schaffen, für Notfälle auch außerhalb der Praxisöffnungszeiten zur Verfügung zu stehen.

[Beneficial Effect of Medical Cannabis in the Treatment of a Pharmacoresistant Nausea Associated with a Somatoform Disorder in a Patient with Post-Polio Syndrome]

HISTORY AND CLINICAL FINDINGS

 We report a 79-year-old patient with post-polio syndrome (PPS). In the course of this disease, recurrent upper abdominal pain and a therapy-resistant nausea developed without vomiting. In addition, the patient was limited by the combination of muscular weakness, obesity, dietary-treated diabetes and a degenerative spinal cord injury significantly in its mobility and physical capacity.

INVESTIGATIONS AND DIAGNOSIS

 Despite extensive diagnostics, no somatic cause could be found neither for the nausea nor for the upper abdominal pain. Due to the psychological stress within the scope of the PPS, the development of a somatoform autonomic function disorder of the upper gastrointestinal tract may have occurred.

TREATMENT AND COURSE

 Even under combination therapy of antiemetic and pain-modulating drugs, no adequate symptom control could be achieved. In the absence of therapy alternatives and increasing psychological strain the patient was prescribed medical cannabis. Under the therapy there was a relief of the nausea symptoms and decreased pain.

CONCLUSION

 Cannabis is a treatment option for treatment-resistant symptoms as part of a PPS.

Regular Benzodiazepine and Z-Substance Use and Risk of Dementia: An Analysis of German Claims Data

BACKGROUND

While acute detrimental effects of benzodiazepine (BDZ), and BDZ and related z-substance (BDZR) use on cognition and memory are known, the association of BDZR use and risk of dementia in the elderly is controversially discussed. Previous studies on cohort or claims data mostly show an increased risk for dementia with the use of BDZs or BDZRs. For Germany, analyses on large population-based data sets are missing.

OBJECTIVE

To evaluate the association between regular BDZR use and incident any dementia in a large German claims data set.

METHODS

Using longitudinal German public health insurance data from 2004 to 2011 we analyzed the association between regular BDZR use (versus no BDZR use) and incident dementia in a case-control design. We examined patient samples aged≥60 years that were free of dementia at baseline. To address potential protopathic bias we introduced a lag time between BDZR prescription and dementia diagnosis. Odds ratios were calculated applying conditional logistic regression, adjusted for potential confounding factors such as comorbidities and polypharmacy.

RESULTS

The regular use of BDZRs was associated with a significant increased risk of incident dementia for patients aged≥60 years (adjusted odds ratio [OR] 1.21, 95% confidence interval [CI] 1.13-1.29). The association was slightly stronger for long-acting substances than for short-acting ones. A trend for increased risk for dementia with higher exposure was observed.

CONCLUSION

The restricted use of BDZRs may contribute to dementia prevention in the elderly.

Prevalence of multimorbidity in Germany: impact of age and educational level in a cross-sectional study on 19,294 adults

BACKGROUND

Multimorbidity is one of the most important and challenging aspects in public health. Multimorbid people are associated with more hospital admissions, a large number of drug prescriptions and higher risks of mortality. As there is evidence that multimorbidity varies with age and socioeconomic disparity, the main objective aimed at determining age-specific prevalence rates as well as exploring educational differences relating to multimorbidity in Germany.

METHODS

This cross-sectional analysis is based on the national telephone health interview survey "German Health Update" (GEDA2012) conducted between March 2012 and March 2013 with nearly 20,000 adults. GEDA2012 provides information on 17 self-reported health conditions along with sociodemographic characteristics. Multimorbidity was defined as the occurrence of two or more chronic conditions in one individual at the same time. Descriptive statistical analysis was used to examine multimorbidity according to age and education, which was defined by the International Standard Classification of Education (ISCED 1997).

RESULTS

Overall, 39.6% (95% confidence interval (CI) 38.7%-40.6%) of the 19,294 participants were multimorbid and the proportion of adults with multimorbidity increased substantially with age: nearly half (49.2%, 95% CI 46.9%-51.5%) of the adults aged 50-59 years had already two or more chronic health conditions. Prevalence rates of multimorbidity differed considerably between the levels of education. Low-level educated adults aged 40-49 years were more likely to be multimorbid with a prevalence rate of 47.4% (95% CI 44.2%-50.5%) matching those of highly educated men and women aged about ten years older.

CONCLUSIONS

Our findings demonstrate that both, age and education are associated with a higher risk of being multimorbid in Germany. Hence, special emphasis in the development of new approaches in national public health and prevention programs on multimorbidity should be given to low-level educated people aged <65 years.

[Advance Directives in Family Practices: Results of a Survey of GP Patients on their Care Situation]

BACKGROUND

Advance directives (AD) are an important tool for documentation of patients' wishes and are therefore recommended to the elderly as well as patients with chronic diseases. However, there is no standardized procedure in Germany and no guideline for counseling patients who wish to write an AD with or without health care proxy. The aim of this study was to evaluate the care situation concerning the ADs and the role of the primary care physician in drafting the document METHOD: We conducted semi-structured interviews with patients in primary care in North Rhine-Westphalia using a cross-sectional study design.

RESULT

Most of the 154 patients who were interviewed (average age: 58 years; 52% female) suffered from chronic diseases (79%), and about one-third (32%) already had an AD. Fear of "loss of autonomy" was the main reason for preparing an AD. Patients without AD were generally not opposed to the concept and named procrastination (43%) as the main reason for not having prepared one. The chance for preparing an AD increased by the factor 1.08 per life-year (Odds ratio (OR): 1.08; CI: 1.04-1.11). Patients with AD mostly got advice via the internet (22%), their primary care physicians (12%) and relatives (12%). Most patients were satisfied with their AD.

CONCLUSION

The majority of primary care patients do not make use of ADs. The primary care physicians play an important role in counseling and should motivate patients to complete ADs. Here, the establishment of quality standards would be desirable in the future.

Dringende Hausbesuche in Altenheimen – ein Status Quo aus hausärztlicher Sicht

Ziel der Studie Aufgrund des demografischen Wandels nehmen v. a. Hausbesuche in Altenpflegeeinrichtungen zu. Eine besondere Herausforderung an die Logistik der Hausarztpraxen stellen dabei dringende Hausbesuche dar. Bisher gibt es keine Handlungsempfehlungen für die Durchführung von dringenden Hausbesuchen. Daher wurde in dieser Studie untersucht, wie Hausarztpraxen mit Anfragen zu dringenden Heimbesuchen umgehen und welche Verbesserungsmöglichkeiten sich dabei für die ärztliche Notfallversorgung zeigen.

Methodik Es wurden insgesamt 15 Lehrärzte des Instituts für Hausarztmedizin der Universität Bonn mittels leitfadengestützten Interviews zum Thema befragt. Wir werteten die Interviews mit der qualitativen Inhaltsanalyse nach Mayring aus.

Ergebnisse Dringende Hausbesuche werden per Telefon oder per Fax angefordert. Die Hausbesuche werden in der Regel nach der Sprechstunde in der Mittagspause von den Ärzten durchgeführt. Eine Weiterleitung an den Rettungsdienst schildern die Hausärzte als absolute Ausnahme. Angekommen im Heim entstehen Wartezeiten, bis die verantwortliche Pflegekraft Zeit für den gemeinsamen Notfallbesuch hat. Zudem werden deutliche Unterschiede in der Qualifikation der Pflegekräfte und im Umgang mit Notfallsituationen angegeben. Verbesserungsmöglichkeiten sahen die Ärzte daher in der Weiterqualifizierung der Pflegekräfte, in präventiven Hausbesuchen und bei der Einschätzung der Dringlichkeit von Heimbesuchen.

Schlussfolgerung Um die Notfallversorgung in Altenheimen zu verbessern, sollten die von den Hausärzten vorgebrachten Verbesserungsvorschläge in kontrollierten Studien überprüft werden. Zudem könnten durch eine gemeinsame Schulung in der geriatrischen Notfallversorgung die Zusammenarbeit zwischen Hausarztpraxen und Altenpflegeeinrichtungen verstärkt werden.

[Urgency of GP Emergency Visits to Nursing Homes]

 Until now there are no uniform criteria or standards for classification of emergency home visits. Due to demographic changes, especially urgent visits to patients in nursing homes will increase. In the URGENT study, physicians and nurses rated the urgency of emergency visits to nursing home patients before and after the visit. This should help to see how many emergency house calls had been classified as less urgent and how often the assessment of physicians and nurses were in agreement with each other. In a prospective observational study, home visits were analyzed, which were classified as urgent at request by the physicians. After performing home visits, the physicians and the responsible nurse classified again the urgency of the home visit from 0 (not urgent) to 10 (highly urgent). In addition, the times of the home visit requests and the time for carrying out the visits, as well the reasons for the home visits were documented. A total of 75 urgent home visits were documented. The patients were on average 82 years old (65% female). The home visits were done on average 2.5 h after request. In retrospect, the physicians evaluated emergency home visits on average less urgent (5.7±2.7) than the nurses (7.2±2.2). In 20% of emergency home visits (15 cases), physicians and nurses agreed as to their being less urgent (0-5). Our data show that in the absence of a standardized urgent assessment scheme, a significant proportion of home visits is misclassified. In further studies it has to be investigated if a uniform score for urgent assessment could reduce the proportion of incorrect medical response operations so that the efficiency of emergency care for nursing home patients can be improved.

Drug-related celebrity deaths: A cross-sectional study

BACKGROUND

Celebrities are at risk for premature mortality as well as drug-related death. Despite being a vulnerable patient group, celebrities influence people's health behaviours through biological, psychological and social processes. Therefore, celebrity endorsement of the topic could be one way to challenge the current "opioid endemic". Our aim was to better understand the factors surrounding drug-related celebrity deaths by investigating the incidence as well as substances used between 1970 and 2015 using a cross-sectional study design.

METHOD

We searched public databases for drug-related celebrity deaths between 1970 and 2015. They were categorized for sex, profession, age at death, year of death and substances involved. The main outcome measures are descriptive values including number of drug deaths per year and substances involved. Secondary outcome measures are analytical questions to examine whether and which factors influence age at death and year of death (e.g. type of substance use disorder).

RESULTS

We identified 220 celebrities who died a drug-related death with a clear indication of involved substances between 1970 and 2015. The average age at death was 38.6 years; 75% were male. Most celebrities died between the age of 25 and 40. The number of drug-related deaths increased in the 21st century, with a significant increase in the use of prescription opioids. Deaths involving prescription opioids and heroin were associated with a significantly lower mean age at death compared to deaths where these substances were not involved.

CONCLUSIONS

Compared to the 20th century, the total number of celebrities who died from a drug-related death in the 21st century increased, possibly due to an increased involvement of prescription opioids. Negative effects on individual health decisions of celebrity's followers could be the result.

Quinine induced simvastatin toxicity through cytochrome inhibition - a case report

Background

Nocturnal leg cramps are painful, involuntary muscle contractions commonly seen in elderly. While mostly harmless, they can severely impair quality of life and often disrupt sleep. Adverse drug effects may be responsible for a fraction of nocturnal leg cramps but often go unrecognized, resulting in additional prescribing intended to deal with adverse effects that might be better addressed by reduction, substitution, or discontinuation of the offending agent.

Case presentation

An 87 year old female presented as outpatient in family medicine with nocturnal leg cramps which had been present for five years and increasingly burdened her quality of life. She had been using quinine 200 mg once daily for symptomatic relief but the cramps kept returning with increasing intensity. During clinical examination we found neither structural nor neurological or metabolic disorders that explained her symptoms. When doing a medication analysis, we found that she was taking a statin together with quinine. Quinine is a cytochrome P450 isoenzyme 3A4 inhibitor, the very enzyme which is involved in the metabolism of most statins. Therefore the use of both substances simultaneously increases blood levels of the statin thereby increasing the risk of side effects including symptomatic myopathy and myalgia. After discontinuing both medications, the patient was, and remained, symptom free.

Conclusion

This case report describes a possible medication interaction that has rarely been noted in literature.

Individualized versus standardized risk assessment in patients at high risk for adverse drug reactions (IDrug) - study protocol for a pragmatic randomized controlled trial

Background

Elderly patients are particularly vulnerable to adverse drug reactions, especially if they are affected by additional risk factors such as multimorbidity, polypharmacy, impaired renal function and intake of drugs with high risk potential. Apart from these clinical parameters, drug safety and efficacy can be influenced by pharmacogenetic factors. Evidence-based recommendations concerning drug-gene-combinations have been issued by international consortia and in drug labels. However, clinical benefit of providing information on individual patient factors in a comprehensive risk assessment aiming to reduce the occurrence and severity of adverse drug reactions is not evident. Purpose of this randomized controlled trial is to compare the effect of a concise individual risk information leaflet with standard information on risk factors for side effects.

Methods/Design

The trial was designed as a prospective, two-arm, randomized, controlled, multicenter, pragmatic study. 960 elderly, multimorbid outpatients in general medicine are included if they take at least one high risk and one other long-term drug (polymedication). As high risk “index drugs” oral anticoagulants and antiplatelets were chosen because of their specific, objectively assessable side effects. Following randomization, test group patients receive an individualized risk assessment leaflet evaluating their personal data concerning bleeding- and thromboembolic-risk-scores, potential drug-drug-interactions, age, renal function and pharmacogenetic factors. Control group patients obtain a standardized leaflet only containing general information on these criteria. Follow-up period is 9 months for each patient. Primary endpoint is the occurrence of a thromboembolic/bleeding event or death. Secondary endpoints are other adverse drug reactions, hospital admissions, specialist referrals and medication changes due to adverse drug reactions, the patients’ adherence to medication regimen as well as health related quality of life, mortality and resulting costs.

Discussion

Despite extensive evidence of risk factors for adverse drug reactions, there are few prospective trial data about an individualized risk assessment including pharmacogenetic information to increase patient safety. By conducting a health economic analysis, we will evaluate if the application of an individualized drug therapy in daily routine is cost-effective.

Trial registration

German Clinical Trials Register: DRKS00006256, date of registration 09/01/15.

Written survey on recently deceased patients in germany and switzerland: how do general practitioners see their role?

Background

General practitioners (GPs) play an important role in end-of-life care due to their proximity to the patient’s dwelling-place and their contact to relatives and other care providers.

Methods

In order to get a better understanding of the role which the GP sees him- or herself as playing in end-of-life care and which care their dying patients get, we conducted this written survey. It asked questions about the most recently deceased patient of each physician. The questionnaire was sent to 1,201 GPs in southern North Rhine-Westphalia (Germany) and the Canton of Bern (Switzerland).

Results

Response rate was 27.5 % (n = 330). The average age of responding physicians was 54.5 years (range: 34–76; standard derivation: 7.4), 68 % of them were male and 45 % worked alone in their practice. Primary outcome measures of this observational study are the characteristics of recently deceased patients as well as their care and the involvement of other professional caregivers. Almost half of the most recently deceased patients had cancer. Only 3 to 16 % of all deceased suffered from severe levels of pain, nausea, dyspnea or emesis. More than 80 % of the doctors considered themselves to be an indispensable part of their patient’s end-of-life care. Almost 90 % of the doctors were in contact with the patient’s family and 50 % with the responsible nursing service. The majority of the GPs had taken over the coordination of care and cooperation with other attending physicians.

Conclusion

The study confirms the relevance of caring for dying patients in GPs work and provides an important insight into their perception of their own role.

Misuse of Substitution Drugs in the Substitution-Based Therapy

BACKGROUND

The reasons for, and the extent of, misuse of prescribed substitution medication as well as parallel consumption of other drugs during substitution-based therapy have still not been adequately researched in Germany.

METHODS

This study examines the use of substitution medication in German substitution clinics utilizing a nationwide survey with anonymised questionnaires.

RESULTS

The analysis of the 605 questionnaires showed a 30-day consumption prevalence of 8.8% with regard to misuse of substitution substances. The lack of available heroin (38%) and the lack of open spots in treatment programs (21%) were quoted as being the main reasons for the misuse of substitution medication.

CONCLUSION

Although the misuse of substitution medications is considered an important problem, our study showed that the current misuse was prevalent only among a minority of the patients. German regulations focused on the avoidance of misuse might be partially contributing to the problem.