Pain Management in Nursing Home Residents: Results from the INCUR Study

OBJECTIVES

Pain is very common among older persons living in nursing home, affecting 45% to 80% of residents, interfering with daily activities and quality of life. Aims of the study are: 1) to measure the analgesics non-prescription in nursing home residents who present pain symptoms; 2) to identify the main determinants of analgesics non-prescription.

DESIGN

Retrospective cross-sectional analysis.

SETTING

Data from an observational study ('Incidence of pNeumonia and related ConseqUences in nursing home Residents' [INCUR] study).

PARTICIPANTS

800 older persons living in 13 French nursing homes. Measurments: Pain symptoms were definied by one of the following criteria: i) Presence of pain affecting the individual's function in the Activities of Daily Living; ii) Presence of daily pain, and/or; iii) Severe pain measured with a visual analogue scale.

RESULTS

Among the patients originally included in the study, 288 (36%) reported pain symptomatology (mean age 86.9 [SD 7.2] years, 220 (76%) participants women). Amongst these, 138 (47.9%) were treated with non-opioid analgesic drugs, 52 (18.1%) with opioids, and 98 (34%) did not receive any analgesic prescription. An adjusted logistic regression analysis found that the strongest determinant of analgesics non-prescription was the number of concomitantly prescribed drugs (p<0.001). Age, education, and frailty were not associated with prescription of analgesic drugs.

CONCLUSIONS

Pain undertreatment is very common among older persons living in nursing homes. The number of prescribed medications represents the most relevant risk factor for the analgesics non-prescription. Our findings document the importance of reviewing prescriptions in nursing home residents.

FRI0238 AUTOLOGOUS FAT GRAFTING IN THE TREATMENT OF FACIAL SCLERODERMA: A SINGLE - CENTRE EXPERIENCE

Background:

Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by progressive cutaneous and internal organ fibrosis. Orofacial manifestations are disabling and treatment options are limited. Fat Tissue Grafting (FTG) can be used for treating facial manifestations of the fibrosis.

Objectives:

In this study, we aimed to assess the safety and efficacy of FGT of our cohort of patients with SSc.

Methods:

We enrolled 20 SSc (18 W, 2 M) patients, from 2016 to 2019, suffering from facial sclerosis and restricted mouth opening capacity. FTG was carried out in accord with modified Colemans’ procedure (1): fat tissue was taken from periumbilical or trochanteric areas and was injected in 8 different points around the mouth. No side effects or adverse reactions have been documented. Evaluations included mouth opening capacity by measuring interincisal distance, oral functionality (MHISS scale) and patient global satisfaction (by Global Health scale).

Results:

A 11 mm (8 - 18mm range) median increase of interincisal distance was reported at month 6 and in 80% of patients at month 12, too (p<0.03). A significant improvement in MHISS scale was also observed (p<003). The patient satisfaction questionnaire showed 95% positive results and 80% of the patient replied affirmatively to the question about the repetition of FTG but only 2 patients required new FTG after 12 months.

Conclusion:

Our results showed that FTG improved mouth opening capacity and that aesthetic and functional results were satisfying to about 90% of the patients; long-term effects of this type of treatment are currently unknown. However, our and litterature data at 12 months follow-up seems to confirm the benefits in long term, despite the filling effect is over.

This study – that’s one of the largest case series described right now (2) - supports the possible therapeutic role of autologous FTG in improving facial scleroderma both in aesthetic and in functional aspects.

References:

[1]Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006; 118: 108S-20S

[2]Fat Grafting for the Treatment of Scleroderma.Strong AL, Rubin JP, Kozlow JH, Cederna PS. Plast Reconstr Surg. 2019 Dec;144(6):1498-1507. doi: 10.1097/PRS.0000000000006291.

Disclosure of Interests:

None declared

Nutritional Considerations in Frail Older Patients with COVID-19

The COVID-19 pandemic is posing an unprecedented challenge to healthcare systems worldwide. Older adults, which frequently present multiple chronic comorbidities, are more susceptible to COVID-19 and experience more likely negative outcomes, in terms of disease severity and mortality. However, chronological age per se may not entirely explain the dramatic scenario described among the frailest and oldest persons. Comorbidities and functional status may indeed play a relevant role. Patients at high risk of adverse clinical outcomes in COVID-19 infection are the same at risk of malnutrition, namely older adults and multimorbid individuals. In fact, COVID-19 can negatively impact on nutritional status, both in patients admitted to the hospital with the most severe manifestations of the infection, as well as in those who experience milder/asymptomatic forms of the disease. Despite being quite difficult in these emergency circumstances, nutritional status needs to be assessed in all COVID-19 patients upon admission and during hospital stay. Early nutritional support should be guaranteed in order to improve several malnutrition-related adverse outcomes. The evaluation of the nutritional status is today even more crucial than in normal times given the delicate status of older patients with COVID-19.

Continuous Transcutaneous Gas Monitoring in Adults on Regular Dialysis Treatment

We tested a transcutaneous (tc) oxygen (O2) and carbon dioxide (COz) sensor in 15 normal adults and in 20 patients on regular dialysis treatment (RDT). We compared the tc gas values (ptcO2, PtcCO2) with the gas tension values in arterial blood samples (PaO2, PaCO2), in normal adults and in RDT-patients at the end of a 30-min test and six times during RDT. During the test, PtcO2 correlated with PaO2 both in normal adults (r 0.72p<0.01) and in RDT patients (r 0.41 p<0.05). PtcCO2 correlated with PaCO2 (r 0.59 in normal adults and r 0.76 in RDT). During 14 acetate dialyses the changes were expressed as %Δ from time 0. %Δ PaO2 was – 12.7 at 60 min, + 4.8 at 240 min; %Δ PtcO2 – 6.0 at 60 min, + 9.7 at 240 min; %Δ PaCO2 – 17.7 at 240 min, – 1.8 1 h later; %Δ PtcCO2 was – 15.8 at 240 min, – 3.2 1 h later. Both in normal adults and in RDT, patients there was a good relationship between PtcCO2 and PaCO2 values. In normal adults the absolute PtcO2 values were always lower than PaO2 (– 14.4± 10 mmHg); in RDT-patients this difference was more pronounced (– 27.6± 15.1) and is probably attributable to the lower Hb levels (6.7± 1.1 vs 12.4± 1.2). During RDT the pattern was the same between tc and gas tension values. The tc-sensor seems to be useful in continuous monitoring, especially in acetate dialysis and/or in patients suspected of developing hypoxemia, but it cannot replace direct blood gas measurements in arterial blood samples.

A New Approach to Blood Pressure and Blood Volume Modulation during Hemodialysis: An Adaptive Fuzzy Control Module

The paper proposes a fuzzy logic based procedure able to control as far as possible the behaviour of the blood pressure of a patient during a dialysis session, allowing him to reach the foreseen dry weight. A PI discrete-time fuzzy control is used in order to compare the controlled variables concerning the (blood pressure and blood volume) to the reference values. Two different reference tables, concerning the pressure and volume errors and rates are introduced, then the proposed control actions are mixed in order to obtain the final value (net ultrafiltration rate). A smooth function of volemia acts on the second control variable, Na concentration in the dialysate. The adaptive control system was simulated on an IBM-PC, rules and terms were expressed by linguistic judgements like: IF “situation”, THEN “action”. A pre-processor converts the rules into the numerical values of the reference tables. The obtained simulation results are satisfactory, the introduction of the Na control allows reaching the target dry weight of the patient with a stable blood pressure.

Estimation of statistical moments for desferrioxamine and its iron and aluminum chelates: contribution to optimisation of therapy in uremic patients

We investigated the best time of administration of desferrioxamine (DFO) with respect to the dialysis session, using the approach of the stochastic dynamic system, integrated with the classical pharmacokinetic models. In the 6 patients studied, the mean arrival times of DFO, aluminoxamine (AlO) and ferrioxamine (FO) were, respectively, 193, 1,350 and 126 min, the mean residence times were 1,048, infinite, 1,190 min, respectively. AlO serum levels reach steady state in a mean time of 7 h and 22 min and remain stable in the interdialytic period. FO achieves a peak at the end of DFO infusion and declines during the interdialytic period. DFO, AlO and FO persist a very long time in the body of the uremic patient, thus the dialysis session should be administered when AlO and FO reach steady state. With a dose of 5-10 mg/kg b.w. of DFO, we propose to start the dialysis 8-12 h after the infusion if the main purpose is to treat Al overload or 2-3 h after the infusion if the main purpose is the treatment of hemosiderosis.

A new approach to blood pressure and blood volume modulation during hemodialysis: an adaptive fuzzy control module

The paper proposes a fuzzy logic based procedure able to control as far as possible the behaviour of the blood pressure of a patient during a dialysis session, allowing him to reach the foreseen dry weight. A PI discrete-time fuzzy control is used in order to compare the controlled variables concerning the (blood pressure and blood volume) to the reference values. Two different reference tables, concerning the pressure and volume errors and rates are introduced, then the proposed control actions are mixed in order to obtain the final value (net ultrafiltration rate). A smooth function of volemia acts on the second control variable, Na concentration in the dialysate. The adaptive control system was simulated on an IBM-PC, rules and terms were expressed by linguistic judgements like: IF "situation", THEN "action". A pre-processor converts the rules into the numerical values of the reference tables. The obtained simulation results are satisfactory, the introduction of the Na control allows reaching the target dry weight of the patient with a stable blood pressure.

The treatment of chronic flexion contractures of the proximal interphalangeal joint

A method of treatment of chronic flexion contractures of the PIP joint is presented, with the results obtained in 19 patients treated between 1989 and 1992 after a follow-up of from 6 to 53 months. The flexion contractures, with an extension deficit which ranged between 70 and 90 degrees, had been present for a period of between 2 months and 24 years. Our treatment program involves the surgical release of the unreducible PIP joint followed by the use of static and/or dynamic splints. Surgery is performed using a midlateral approach; the accessory collateral ligament and the flexor sheath are incised and, after the volar plate and check-rein ligaments have been excised, forced hyperextension is applied. The main collateral ligaments are carefully spared and freed from the condyle if there are any remaining adhesions. In our 19 patients, complete extension of the finger was achieved in 11 cases (57.9%); in the remaining 8 cases (42.1%) the residual extension deficit ranges from 10 to 15 degrees. In our experience this combined surgical and rehabilitative approach had led to consistently good results with minimal complications.

Projection and simulation results of an adaptive fuzzy control module for blood pressure and blood volume during hemodialysis

This paper proposes a fuzzy logic based procedure able to control the behavior of a patient's blood pressure during a dialysis session, allowing him to reach the planned dry weight. A proportional integrative discrete-time fuzzy control is used to subject the controlled variables (blood pressure and blood volume) to the reference values. Two different tables that refer to pressure and volume errors and rates are consulted and the proposed control actions are taken to obtain the final value (net ultrafiltration rate). A saturation-threshold function of volemia acts on the second control variable, Na concentration in the dialysate. The adaptive control system was simulated on an IBM PC, and rules and terms were expressed by linguistic judgments such as: IF "situation," THEN "action." A pre processor converts the rules into the numerical values in the tables. The obtained simulation results are satisfactory, and the introduction of Na control allows achievement of the target dry weight of the patient with a stable blood pressure.

Continuous transcutaneous gas monitoring in adults on regular dialysis treatment

We tested a transcutaneous (tc) oxygen (O2) and carbon dioxide (CO2) sensor in 15 normal adults and in 20 patients on regular dialysis treatment (RDT). We compared the tc gas values (ptcO2, PtcCO2) with the gas tension values in arterial blood samples (PaO2, PaCO2), in normal adults and in RDT-patients at the end of a 30-min test and six times during RDT. During the test, PtcO2 correlated with PaO2 both in normal adults (r 0.72 p less than 0.01) and in RDT patients (r 0.41 p less than 0.05). PtcCO2 correlated with PaCO2 (r 0.59 in normal adults and r 0.76 in RDT). During 14 acetate dialyses the changes were expressed as % delta from time 0. % delta PaO2 was -12.7 at 60 min, + 4.8 at 240 min; % delta PtcO2 -6.0 at 60 min, + 9.7 at 240 min; % delta PaO2 -17.7 at 240 min, -1.8 1 h later; % delta PtcCO2 was -15.8 at 240 min, -3.2 1 h later. Both in normal adults and in RDT, patients there was a good relationship between PtcCO2 and PaCO2 values. In normal adults the absolute PtcO2 values were always lower than PaO2 (-14.4 +/- 10 mmHg); in RDT-patients this difference was more pronounced (-27.6 +/- 15.1) and is probably attributable to the lower Hb levels (6.7 +/- 1.1 vs 12.4 +/- 1.2). During RDT the pattern was the same between tc and gas tension values.(ABSTRACT TRUNCATED AT 250 WORDS)

Acid-base balance during biofiltration

Five patients were shifted from acetate dialysis (AD) to biofiltration (BF); their pre-dialytic acid-base balance (ABB) was re-examined for six months before the start of BF. Samples for ABB were drawn at 0', 30', 60', 120' and 180' during three AD and 1, 2 and 3 hours after them (period A). The same procedure was then repeated two months (period B) and 12 months (period C) after the start of BF. From analysis of the data it is concluded that the correction of AD-acidosis is very rapid during the early two months of BF, but the post-BF ABB may be too alkalotic, with risks if respiratory alkalosis is superimposed. After one year of BF, there were fewer pCO2 falls and pH variations; no more post-BF alkalotic rebounds were observed.

[Carpal tunnel syndrome. 1351 surgical cases]

An analysis was conducted of 1351 cases of carpal tunnel syndrome operated upon in the Department. Plastie and Hand Surgery of the Civil Hospital, Legnano (Italy) between 1966 and 1984. Positive evaluation of efficacy of therapy applied was possible and emphasized the need for diagnosis early enough for operation, the only valid treatment, to be undertaken.

Hyperprolactinemia and sexual disturbances among uremic women on hemodialysis

The investigation of a sample of 99 women on maintenance hemodialysis has shown the presence of sexual disturbances to a great extent: the rate of sexual intercourse and the ability to reach orgasm were significantly lower than in age-matched control women. 80% declared a reduction in their sexual desire and the frequency of intercourse was also lower as compared to the period prior to dialysis. Ageing decreased the sexual activity in both the ill and healthy population, but in uremic patients the sexual activity ended at an earlier age. The patients with hyperprolactinemia reported lower frequencies of intercourse and lower percentages of orgasm than normoprolactinemic ones. The incidence of sexual dysfunction and the role of hyperprolactinemia in this respect were similar to those which are found among male patients on hemodialysis.

Surgical treatment of lesions of the sciatic nerve

The authors discuss their experience in the Division of Plastic and Hand Surgery of the Hospital of Legnano in the treatment of lesions of the sciatic nerve treated by microsurgery and in some cases by nerve grafts. The results obtained were assessed as acceptable in terms of function of the lower limb. Twenty-two cases were followed up, of which 13 had been treated by neurolysis and 9 with nerve grafts. The thigh muscles recovered in all cases, together with muscles innervated by the tibial nerve in 18 cases and the muscles innervated by the peroneal nerve in 13 cases.