Psychosocial issues need more attention in COPD self-management education

Abstract

Objective: To find out how regularly the contents of patient education regarded as essential for COPD patients’ self-management are provided by healthcare professionals in specialised healthcare (SHC) and primary healthcare (PHC) in Finland.

Design: A cross-sectional study based on an e-questionnaire with 42 items on the content of self-management education of COPD patients.

Setting: The study sample included all public SHC units with pulmonary outpatient clinics (n?=?29) and nine out of 160 health centres in Finland.

Subjects: 83 doctors and 162 nurses.

Main outcome measures: The respondents’ answers on how regularly they included the contents regarded as essential for COPD patients’ self-management in their education of COPD patients.

Results: COPD patients were educated regularly on medical issues regarding COPD treatment, such as smoking cessation, exercise and pharmacological treatment. However, issues vital for coping with the disease, such as psychological well-being, stress management or fatigue, were often ignored. Patient education in SHC seemed to be more systematic than education in PHC. The education provided by the asthma/COPD nurses (n?=?70) was more systematic than the education provided by the other nurses (n?=?84).

Conclusion: Healthcare professionals’ continuous education should cover not only the medical but also the psychosocial aspects of coping with COPD. The role of doctors and nurses should be considered to ensure that there is no gap in COPD patients’ education. Training asthma/COPD nurses and promoting specialised nurse-led asthma/COPD clinics in primary care could be beneficial while improving practices of patient education that enhance patients’ ability to cope with the disease.

• KEY POINTS

• Issues vital for coping with chronic obstructive pulmonary disease (COPD), such as psychological well-being, stress and fatigue, are irregularly included in self-management education both in primary and specialised healthcare.

• Patient education provided by asthma/COPD nurses is more regular than patient education provided by other nurses.

• The distribution of work between doctors and nurses should be considered to ensure that there is no gap in COPD patients’ education.

     

Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.     

Combined effect of fluoride and 2,3,7,8-tetrachlorodibenzo-<Emphasis Type="Italic">p</Emphasis>-dioxin on mouse dental hard tissue formation in vitro

Fluoride interferes with enamel matrix secretion and mineralization and dentin mineralization. The most toxic dioxin congener, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), also impairs dental hard tissue formation and mineralization in vitro and in vivo. Our aim was to investigate in vitro whether the combined effect of sodium fluoride (NaF) and TCDD on dental hard tissue formation is potentiative. For this purpose, mandibular first and second molar tooth germs of E18 mouse embryos were cultured for 5–12 days with NaF and TCDD alone at various concentrations (2.5, 5, 10, 12.5, 15, and 20 μM and 5, 10, 12.5, and 15 nM, respectively) to determine the highest concentrations, which alone cause no or negligible effects. Morphological changes were studied from the whole tooth photographs and histological tissue sections. The concentrations found were 15 μM for NaF and 10 nM for TCDD. While at these concentrations, the effects of NaF and TCDD alone were barely detectable, the effect of simultaneous exposure on dentin and enamel formation was overt; mineralization of predentin to dentin and enamel matrix secretion and mineralization were impaired. Immunohistochemical analysis revealed that the combined exposure modified amelogenin expression by odontoblasts. Morphology of ameloblasts and the expression of amelogenin indicated that ameloblasts were still secretory. The results show that NaF and TCDD have potentiative, harmful effects on the formation of dental hard tissues. Since children can be exposed to subclinical levels of fluoride and dioxins during early childhood, coincidently with mineralization of the first permanent teeth, this finding may have clinical significance.     

Cognitive/behavioral teratogenetic effects of antiepileptic drugs

The majority of children of mothers with epilepsy are normal, but they are at increased risk for developmental delay. Antiepileptic drugs (AEDs) appear to play a role. Our current knowledge is reviewed, including research design issues and recommendations for future research. In animals, exposure of the immature brain to some AEDs can produce widespread neuronal apoptosis and behavioral deficits. The risks of AEDs in humans are less clear, but recent studies raise concerns, especially for valproate. There is a critical need for well-designed systematic research to improve our understanding of AED effects on the fetal brain.     

Speed and quality in Coronary Artery Bypass Graft (CABG) surgery: is there a connection?

In this paper we study the connection between coronary artery bypass graft (CABG) operation time and quality. Our quality metric was the improvement in health related quality of life (HRQoL) survey score in a sample of 432 patients admitted to Kuopio University Hospital. Patients were interviewed with a structured questionnaire a day before the procedure and the follow-up questionnaires were mailed 6 and 12 months after the surgery. However, the HRQoL metric used did not have high retest reliability. Subsequently, we did not find any connection between CAGB operation times and HRQoL. Likewise, we did not find the speed of the surgeon to have any connection to HRQoL improvement.     

Effect of paracetamol and coxib with or without dexamethasone after laparoscopic cholecystectomy

Background: Pain after laparoscopic cholecystectomy (LCC) is multifactorial. Effective post-operative pain control is necessary in LCC performed as day-case surgery. We studied the efficacy of paracetamol or valdecoxib with or without dexamethasone after LCC.
Methods: One hundred sixty patients were randomized to four groups of 40 patients. Groups 1 and 3 received parecoxib 40 mg intravenously (IV) during surgery and valdecoxib 40 mg × 1 per os (PO) for 7 post-operative days. Groups 2 and 4 received paracetamol 1 g × 4 IV during surgery and 1 g × 4 PO for 7 days. In addition, Groups 3 and 4 were given dexamethasone 10 mg IV intra-operatively. Propofol and remifentanil were used during surgery. The patients were given oxycodone 0.05 mg/kg IV in phase 1 post-anaesthesia care unit (PACU 1) or 0.15 mg/kg PO in phase 2 post-anaesthesia care unit (PACU 2) as needed to keep visual analogue scale <3/10. The patients were supplied with the study drugs for 7 post-operative days.
Results: Pain intensity, nausea and the need of oxycodone in phase 1 PACU were similar in all groups. Dexamethasone reduced the need of oral oxycodone in phase 2 PACU (7.0 ± 1.0 mg vs. 9.1 ± 1.0 mg, P <0.05). Pain intensity was similar in all groups at home. More patients in the parecoxib/valdecoxib groups needed rescue medication on the 1st post-operative day ( P <0.001) than paracetamol-treated patients.
Conclusion: Paracetamol was as effective as parecoxib/valdecoxib for pain after LCC. Dexamethasone decreased the need of oxycodone in phase 2 PACU. The effect of dexamethasone was similar in paracetamol and parecoxib/valdecoxib patients.     

Amitriptyline in the treatment of chemotherapy-induced neuropathic symptoms

Neuropathy is common in patients receiving vinca alkaloids, platinum derivatives, or taxanes. This double-blind, randomized, placebo-controlled study assessed the efficacy of low-dose amitriptyline to relieve chemotherapy-induced symptoms in 44 patients (age 20-65 years) who had neuropathic symptoms (numbness, tingling, pain) with a severity of > or =3/10. They were treated with amitriptyline for eight weeks (10mg/day to start, then dose elevation of 10mg/week up to 50mg/day if tolerated, followed by a stable dose > or =4 weeks). The patients completed a diary twice weekly, noting the intensity of pain, numbness and tingling, global improvement, and adverse effects. Neurological examination was performed at each visit (baseline, four, and eight weeks). The patients assessed both intensity and relief of pain, and overall discomfort. They also completed the Neuropathic Pain Scale and validated measures of anxiety and depression, and quality of life (QoL). The results demonstrated that amitriptyline did not improve sensory neuropathic symptoms, although there was a trend toward global improvement and improved QoL in favor of the amitriptyline group. No statistical significance was reached, probably due to the small number of patients and too low dose of amitriptyline. Amitriptyline was well tolerated.