老年慢性心力衰竭患者服药依从性现状及其影响因素分析

目的 探讨老年慢性心力衰竭(CHF)患者的服药依从性现状及其影响因素.方法 通过合理用药监测系统(PASS)选取河南省人民医院出院的老年CHF患者,采用问卷调查方式评估患者服药依从性、用药信念及对疾病和药物的认识,采用单因素和多因素分析患者服药依从性的影响因素.结果 共发放问卷717份,完成670份.434例(64.8...     

Pain mechanisms in patients with chronic pain

The mechanisms involved in the development of chronic pain are varied and complex. Pain processes are plastic and unrelieved pain may lead to changes in the neural structure involved in pain generation. Nociceptive pain announces the presence of a potentially damaging stimulus that occurs when noxious stimuli activate primary afferent neurons. Neuropathic pain is initiated or caused by a primary lesion or dysfunction in the nervous system resulting from trauma, infection, ischaemia, cancer or other causes such as chemotherapy. The exact mechanisms involved in the pathophysiology of chronic pain are not well understood, but rapid and long-term changes are thought to occur in parts of the central nervous system that are involved in the transmission and modulation of pain following injury. Peripheral and central sensitization of sensory nerve fibres are the primary reasons for hypersensitivity to pain after injury, and mainly occur in inflammatory and neuropathic pain. During these processes the sensation of pain is enhanced as a result of changes in the environment, the nerve fibres and modifications of the functional properties and the genetic programme of primary and secondary afferent neurons. Non-steroidal anti-inflammatory drugs and opioid analgesics are two of the most common classes of drugs used for the treatment of pain. Response to drug treatment shows significant interindividual variability and can lead to side effects. The neurobiological mechanisms that cause pain may account for the different types of pain observed. Identification of these mechanisms may allow us to move from an empirical therapeutic approach to one that it is specifically targeted at the particular mechanisms of the type of pain experienced by an individual patient.     

Evaluating the relationship of methadone concentrations and EDDP formation in chronic pain patients

Methadone is used to treat moderate to severe pain in patients not responsive to non-narcotic analgesics and for maintenance treatment of opioid addiction. Methadone is primarily metabolized by N-demethylation to an inactive metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidene (EDDP) by CYP3A4 and CYP2B6. Establishing expected concentrations for metabolism of methadone to EDDP using urine excretion data may be useful for monitoring "medications" and toxicity. Urine specimens from chronic pain patients were collected during routine clinic visits. Methadone and EDDP were quantified by liquid chromatography-tandem mass spectrometry. Approximately 8,000 subjects who reported taking methadone had creatinine concentrations ≥20 mg/dL, and excreted concentrations of methadone and EDDP above ≥100 ng/mL were selected. The median methadone urine concentration was 3.03 mg/g cr. Ninety-five percent of the population had concentrations between 0.175 and 20.9 mg/g cr. EDDP was, on average, twice the methadone concentration. The wide variance in relationship of methadone to its metabolite was not concentration-dependent. Variability between subjects was larger than variability within subjects. As the urinary pH increased, the proportion of excreted EDDP increased, implying a preferred excretion of EDDP.     

慢病患者药物依从性量表的研究

目的:介绍几种常用的依从性评价量表,为临床以及科研中药物依从性量表的选择提供参考。方法:通过文献研究,总结归纳各种依从性评价问卷的特点。结果:不同量表具有各自的功能特点、适用人群。药物依从性问卷(MAQ)发展最早,条目少,简单易操作,适合初筛;8项Morisky药物依从性量表(MMAS-8)在MAQ的基础上发展而来,比MAQ具有更高的实用性,适用范围广,是现在使用最广泛的量表;适当用药的自我效能量表(SEAMS)侧重于自我效能的评估,但是分值计算较困难,比较耗时;简要药物依从性问卷(BMQ)包含了三方面的评估,包含详细的用药回顾但花费时间长;Hill-Bone量表只针对于高血压患者开发,包含钠的摄入和预约诊疗状况,更适用于黑色人种的高血压患者;药物依从性比率量表(MARS)是适用于慢性精神疾病患者依从性评价的工具,简单易评分。结论:现有的依从性评价工具中,并不存在一种金标准。在各种常用的依从性评价量表中,要根据临床及科研的目的、经济因素、时间因素等选择最适合的量表。     

Analgesic effect of ciramadol in patients with chronic pain

Summary

A double-blind, crossover study was carried out in 15 patients with chronic pain due to cancer to assess the effectiveness of two different doses of a new analgesic, ciramadol, compared with placebo. Patients received single oral doses of the three medications, in random order, on successive days. Assessments of pain intensity and relief were made on a 4-point rating scale at hourly intervals for 4 hours after the dose. The results showed that ciramadol produced significantly more pain relief than did placebo and this analgesic effect increased with the dose administered. Peak activity was observed at about 2 hours, and pain relief was still marked at 4 hours. No side-effects were reported.     

Management of insomnia in patients with chronic pain conditions

The management of insomnia in patients experiencing chronic pain requires careful evaluation, good diagnostic skills, familiarity with cognitive-behavioural interventions and a sound knowledge of pharmacological treatments. Sleep disorders are characterised by a circular interrelationship with chronic pain such that pain leads to sleep disorders and sleep disorders increase the perception of pain. Sleep disorders in individuals with chronic pain remain under-reported, under-diagnosed and under-treated, which may lead--together with the individual's emotional, cognitive and behavioural maladaptive responses--to the frequent development of chronic sleep disorders. The moderately positive relationship between pain severity and sleep complaints, and the specificity of pain-related arousal and mediating variables such as depression, illustrate that insomnia in relation to chronic pain is multifaceted and poorly understood. This may explain the limited success of the available treatments. This article discusses the evaluation of patients with chronic pain and insomnia and the available pharmacological and nonpharmacological interventions to manage the sleep disorder. Non-pharmacological interventions should not be considered as single interventions, but in association with one another. Some non-pharmacological interventions especially the cognitive and behavioural approaches, can be easily implemented in general practice (e.g. stimulus control, sleep restriction, imagery training and progressive muscle relaxation). Hypnotics are routinely prescribed in the medically ill, regardless of their adverse effects; however, their long-term efficacy is not supported by robust evidence. Antidepressants provide an interesting alternative to hypnotics, since they can improve pain perception as well as sleep disorders in selected patients. Sedative antipsychotics can be considered for sleep disturbances in those patients exhibiting psychotic features, or for those with contraindications to benzodiazepines. Low doses of sedative antipsychotics may improve chronic insomnia in the elderly. However, no intervention is likely to be effective unless a good physician-patient relationship is developed.     

慢性乙型肝炎血清HBV DNA水平与血清ALT的关系

目的探讨慢性乙型肝炎病毒(HBV)复制水平与丙氨酸氨基转移酶(ALT)之间的关系。方法对180例慢性乙型肝炎患者血清HBV DNA含量采用荧光标记(AmpliSensor)定量PCR方法检测,并比较HBV DNA含量与ALT的关系。结果慢性乙型肝炎轻度、中度患者HBV DNA含量(105.58±1.92,106.27±2.05)与慢性乙型肝炎重度患者HBV DNA含量(105.73±1.90)相比较差异无统计学意义(P>0.05),且不同HBV DNA水平患者的ALT差异无统计学意义(P>0.05)。结论随着肝损害程度的加重,慢性乙型肝炎患者血清HBV DNA基因含量未发生显著变化,同时血清HBV DNA含量与ALT水平无明显关系。     

Adverse effects associated with non-opioid and opioid treatment in patients with chronic pain

Chronic pain is a debilitating condition that is associated with many common diseases; this places a major burden on the healthcare system. There are currently numerous analgesic agents available for the treatment of chronic pain. In general, the oral non-opioid analgesic, paracetamol, is recommended for the initial treatment of mild to moderate pain. Therapeutic doses of paracetamol do not appear to result in hepatotoxicity, although overdose may lead to acute liver failure. Current data suggest that paracetamol has acceptable gastrointestinal tolerability. Another class of non-opioid analgesic with confirmed efficacy for the treatment of chronic mild to moderate pain are non-steroidal anti-inflammatory drugs (NSAIDs), although this efficacy is offset by the potential of adverse gastrointestinal events. In particular, non-selective NSAIDs, also known as cyclooxygenase (COX) inhibitors, carry an increased risk of serious upper gastrointestinal complications, including ulcers, perforation and bleeding. The introduction of COX-2 inhibitors provided a NSAID-based option with improved gastrointestinal safety, but increased risk of cardiovascular effects. Opioids are powerful analgesic agents used to treat moderate to severe chronic pain. However, treatment with opioids is associated with a number of common adverse effects, including constipation, nausea or vomiting, pruritus, somnolence or cognitive impairment, dry mouth, tolerance or dependence and urinary retention. Although there are multiple strategies in place to manage adverse events that arise from both non-opioid and opioid analgesic therapy, a better understanding of the mechanisms involved in the development of specific drug-related adverse effects is required along with proper prescribing practices and adequate physician/patient education. Balanced against the adverse effects of pain management medications, there is a need to be mindful of the widespread, often serious, adverse consequences of poorly managed pain itself.     

Medication adherence and barriers among low-income,uninsured patients with multiple chronic conditions

BackgroundPoor adherence to long-term therapies is a public health concern that affects all populations. Little is known about the context of adherence in chronic diseases for the uninsured population in the United States.ObjectiveTo evaluate medication adherence and barriers among low-income, uninsured adults recently initiating new therapy for a chronic disease.MethodsA cross-sectional study in two Community Health Centers located in Chatham County, Georgia, was performed between September and December 2015. Patients, randomly selected for inclusion in the study, were eligible if they had been prescribed medication for 2 or more chronic conditions and had recently started a new medication regimen. The Morisky-Green-Levine questionnaire was used to assess adherence. Potential barriers were analyzed using the Multidimensional Model proposed by the World Health Organization—social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors. Multivariate logistic regression models were used to analyze factors associated with non-adherence.ResultsA total of 150 participants were interviewed at 6 months after treatment initiation. Non-adherence was reported by 52% of the participants. Higher adjusted odds of non-adherence were observed in participants who did not receive information about their medications (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.01–5.74), did not regularly visit a primary health-care provider (AOR = 2.74, 95% CI = 1.09–6.88), and had changes in their treatment (AOR = 3.75, 95% CI = 1.62–8.70). Alternatively, adjusted odds of non-adherence were lower for patients who reported using pillboxes (AOR = 0.31, 95% CI = 0.10–0.95), having help from a caregiver (AOR = 0.15, 95% CI = 0.04–0.60), and integrating medication dosing into daily routines (AOR = 0.18, 95% CI = 0.06–0.59).ConclusionsMedication non-adherence was common among low-income, uninsured patients initiating therapy for chronic conditions. Several modifiable barriers highlight opportunities to address medication non-adherence through multidisciplinary interventions.     

团体认知行为心理治疗在慢性疼痛患者中的应用研究

目的评价团体认知行为疗法治疗慢性疼痛患者的疗效。方法对23例团体CBT治疗组患者实行疼痛科常规住院治疗联合团体CBT治疗,对照组仅采取疼痛科常规住院治疗;全部患者在治疗前和出院时进行90项症状清单（SCL-90）及简明疼痛量表（BPI）评分。结果团体CBT治疗组SCL-90躯体化、抑郁、焦虑、精神病性及其他项目分值治疗前后存在显著降低（P〈0.01）,强迫分值下降（P〈0.05）,对照组治疗前后躯体化分值显著下降（P〈0.01）,抑郁及其他项目分值降低（P〈0.05）;治疗组BPI疼痛强度因子减分差值更大,但与对照组相比无统计学差异（P〉0.05）;干扰日常生活因子减分两组存在显著差异,治疗组比对照组更为有效（P〈0.01）。结论团体认知行为心理治疗可改善腹性疼痛患者的精神状态以及对疼痛的适应能力,值得临床推广。     

The effect of mirtazapine in patients with chronic pain and concomitant depression

ABSTRACT

Objective: To evaluate the safety, tolerability and efficacy of mirtazapine in patients with the primary diagnosis of chronic pain and concomitant depression in an open post-marketing surveillance study.

Research design and methods: 594 patients with a primary diagnosis of at least one chronic pain syndrome (minimum duration of 3 months) and the diagnosis of concomitant depression, appropriately made by a neurologist or psychiatrist, were recruited at psychiatric and/or neurological outpatient facilities throughout Germany. The primary efficacy parameter was pain at baseline and endpoint using a patient self-assessment scale. Secondary analyses were performed at baseline, week 1 (day 7 ± 2), week 4 (day 28 ± 4) and at endpoint (day 42 ± 4 or early termination) and included safety and tolerability assessments.

Investigators rated the severity of different potential co-morbidities (including depression) with a four-step rating scale (not present, mild, moderate, severe).

Results: 594 patients were enrolled and treated with mirtazapine (mean daily dose of 34.5 ± 10.4?mg at study endpoint). A statistically significant (?p < 0.0001; one sample sign test) reduction of pain from baseline to endpoint was found for the overall population. The percentage of patients free of pain or with only moderate pain increased significantly, irrespective of patients’ age or pain syndromes. Furthermore, we found a substantial improvement from baseline to endpoint regarding co-morbidities such as sleep disturbance, irritability and exhaustion. The number of adverse events was low (< 7%; n = 37), with fatigue (n = 13) and weight gain (n = 11) occurring most frequently. No previously-unknown side effects occurred. One hundred and six patients (18%) discontinued mirtazapine during the study. The main reason was lack of efficacy (6%, n = 33), which may be a reflection of sub-optimal response to the anti-depressant or analgesic effect of the drug, but no appropriate rating scale was used to clarify this question. Only a small number of patients stopped the drug due to adverse events (3%; n = 15). At study endpoint, the majority of physicians and patients rated the overall efficacy and tolerability of mirtazapine as good or very good. Most patients (80%) continued the therapy after 6 weeks.

Conclusions: Despite the limitations of an open observational study, our findings suggest that mirtazapine is a safe and well-tolerated drug for use in daily clinical practice. It still remains unclear whether the reduction of pain, the enhancement of the depressed mood or the combination of both effects led to these results. Nevertheless, our data point to a potential beneficial effect of mirtazapine in the treatment of patients with pain and concomitant depression. However, more systematic research, including placebo-controlled studies, and further empirical testing are necessary.     

慢性肾脏病非透析患者服药依从性现状及其影响因素研究

目的　了解慢性肾脏病（CKD）非透析患者服药依从性现状,探讨分析其服药依从性的影响因素。方法　采用便利抽样法,选取2020年1月至2021年12月西安市中心医院收治的CKD非透析患者为研究对象。应用一般资料调查表、服药依从性量表、服药信念量表、多维领悟社会支持量表及医院焦虑抑郁量表对患者进行横断面问卷调查,采用单因素分析及多因素logistic回归分析CKD非透析患者服药依从性的影响因素。结果　共纳入342例CKD非透析患者,男性185例,女性157例,年龄（63.6±24.7）岁,服药依从性评分为（6.02±1.54）分,低依从性患者141例（41.23%）、中/高依从性患者201例（58.77%）。多因素分析显示,服药种数、CKD分期、药物不良反应经历、服药信念、社会支持、焦虑及抑郁是CKD非透析患者服药依从性的影响因素（均P<0.05）。结论　CKD非透析患者服药依从性现状不理想,医务人员应根据影响依从性的关键因素有针对性地采取干预措施,以提高其服药依从性、延缓CKD进展。     

The effect of mirtazapine in patients with chronic pain and concomitant depression

OBJECTIVE: To evaluate the safety, tolerability and efficacy of mirtazapine in patients with the primary diagnosis of chronic pain and concomitant depression in an open post-marketing surveillance study. RESEARCH DESIGN AND METHODS: 594 patients with a primary diagnosis of at least one chronic pain syndrome (minimum duration of 3 months) and the diagnosis of concomitant depression, appropriately made by a neurologist or psychiatrist, were recruited at psychiatric and/or neurological outpatient facilities throughout Germany. The primary efficacy parameter was pain at baseline and endpoint using a patient self-assessment scale. Secondary analyses were performed at baseline, week 1 (day 7 +/- 2), week 4 (day 28 +/- 4) and at endpoint (day 42 +/- 4 or early termination) and included safety and tolerability assessments.Investigators rated the severity of different potential co-morbidities (including depression) with a four-step rating scale (not present, mild, moderate, severe). RESULTS: 594 patients were enrolled and treated with mirtazapine (mean daily dose of 34.5 +/- 10.4 mg at study endpoint). A statistically significant (p < 0.0001; one sample sign test) reduction of pain from baseline to endpoint was found for the overall population. The percentage of patients free of pain or with only moderate pain increased significantly, irrespective of patients' age or pain syndromes. Furthermore, we found a substantial improvement from baseline to endpoint regarding co-morbidities such as sleep disturbance, irritability and exhaustion. The number of adverse events was low (<7%; n = 37), with fatigue (n = 13) and weight gain (n = 11) occurring most frequently. No previously-unknown side effects occurred. One hundred and six patients (18%) discontinued mirtazapine during the study. The main reason was lack of efficacy (6%, n = 33), which may be a reflection of sub-optimal response to the anti-depressant or analgesic effect of the drug, but no appropriate rating scale was used to clarify this question. Only a small number of patients stopped the drug due to adverse events (3%; n = 15). At study endpoint, the majority of physicians and patients rated the overall efficacy and tolerability of mirtazapine as good or very good. Most patients (80%) continued the therapy after 6 weeks. CONCLUSIONS: Despite the limitations of an open observational study, our findings suggest that mirtazapine is a safe and well-tolerated drug for use in daily clinical practice. It still remains unclear whether the reduction of pain, the enhancement of the depressed mood or the combination of both effects led to these results. Nevertheless, our data point to a potential beneficial effect of mirtazapine in the treatment of patients with pain and concomitant depression. However, more systematic research, including placebo-controlled studies, and further empirical testing are necessary.     

2型糖尿病患者用药依从性轨迹及其影响因素

目的:探究2型糖尿病患者用药依从轨迹及其影响因素,尤其是人格特质与用药依从的关系。方法:抽取北京市通州区和顺义区4个社区卫生服务中心的2型糖尿病患者作为研究对象,在基线、3个月、6个月、12个月时进行随访。采用中国大五人格量表简式版评估患者的人格特质,采用用药依从量表评估患者用药依从性。构建组基-轨迹模型探究患者的用药依从轨迹,采用重复测量方差分析描述各轨迹变化情况,应用有序多分类Logistic回归探究轨迹的影响因素。结果:共纳入患者671名。用药依从轨迹可分为3组:高-持续型(60.6%),中-增长型(35.3%),低-不变型(4.1%)。重复测量方差分析结果显示,高-持续型和中-增长型不同时间点的用药依从得分差异具有显著性(P=0.007,P<0.001)。有序多分类Logistic回归结果显示,病程(P=0.042,OR=1.053,95%CI:1.002~1.106)、是否为本地医保(P=0.028,OR=4.204,95%CI:1.169~15.120)、神经质得分(P=0.005,OR=0.966,95%CI:0.945~0.988)是2型糖尿病患者用药依从轨迹的影响因素。结论:2型糖尿病患者的用药依从轨迹可以分为3类,病程、是否为本地医保、神经质得分是用药依从轨迹的影响因素。在未来的管理实践中,要多关注病程长的患者,且将人格因素纳入考虑,重点关注神经质特质明显的患者。