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Pain represents a major clinical, social and economic problem, with estimates of its prevalence ranging from 8% to more than 60%, depending on the population. The impact of pain on economies is enormous, with the cost of back pain alone equivalent to more than one-fifth of one country's total health expenditure and 1.5% of its annual gross domestic product, while in another it represents three times the total cost of all types of cancer. However, decision makers have tended to concentrate their attention on one very minor component of the cost burden, namely prescription costs, which, in the case of back pain, represent 1% of the total cost burden. In addition to its economic impact, chronic pain is probably one of the diseases with the greatest negative impact on quality of life. For example, the quality of life for those with migraine had been shown to be at best equal to that for people with arthritis, asthma, diabetes mellitus or depression. The burden that pain imposes on individuals and the enormous costs that society has to bear as a result clearly demonstrate the need for collective thinking in the decision-making process. A broad, strategic perspective--based on evidence relating to effectiveness (including tolerability), efficiency and equity--is required in determining issues relating to the provision of services and resource allocation. In this regard, it is clear that paracetamol (acetaminophen) is effective in securing an analgesic effect; it has a good tolerability profile and is relatively cheap, in terms of both drug acquisition costs and its overall cost profile. Pain management strategies based on collective thinking should therefore place great reliance on paracetamol as an initial therapy in maximising pain relief and minimising cost and the impact of adverse effects.
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PMID:[Pain management: health economics and quality of life considerations]. 1475 90

Laparoscopic adjustable gastric banding (LAGB) is commonly performed for weight reduction in the morbidly obese population. Morbidly obese patients often suffer from many co-morbid conditions including diabetes. Diabetic patients may suffer from symptomatic or asymptomatic gastric dysmotility resulting in intermittent gastric distention. Following gastric banding, in the early postoperative period, patients may be unable to decompress trapped air in the stomach and may develop severe acute distention with associated risk for catastrophic results. We present the case of a diabetic patient who underwent an uneventful LAGB but returned to the hospital with severe abdominal and back pain. Following the diagnosis of acute gastric distention using an abdominal roentgenogram, the stomach was decompressed using a naso-gastric tube. Following initiation of promotility agents, the patient was successfully discharged home without symptoms. A high index of suspicion, prompt diagnosis and appropriate management can prevent complications of acute gastric distention in this patient population.
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PMID:Diagnosis and management of acute gastric distention following laparoscopic adjustable gastric banding. 1518 43

A 56-year-old woman had been treated with stellate ganglion block (SGB) for pigmentation degeneration retinopathy over 6 years. She had no history of diabetes mellitus or immunodeficiency. She complained of high back pain but was afebrile. She was diagnosed as pyogenic osteomyelitis by the MRI findings and hematological examination. Antibiotics was administerd for 3 weeks and inflammatory signs disappeared. We should bear in mind that pyogenic osteomyelitis is very rare but one of the most serious complications with SGB.
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PMID:[A case of pyogenic osteomyelitis of the cervical spine following stellate ganglion block]. 1524 40

Gastroesophageal reflux disease (GERD) is associated with a range of symptoms (typically heartburn, acid regurgitation and dysphagia), which may or may not be accompanied by endoscopically evident esophagitis. A number of studies have demonstrated that health-related quality of life (HRQoL) in reflux disease patients is significantly impaired in comparison to the general population, regardless of the endoscopic findings. Furthermore, this impairment is comparable to or greater than that observed in other chronic conditions, such as diabetes, arthritis or congestive heart failure. Impaired HRQoL in GERD patients is a result of features such as disturbed sleep, reduced vitality, generalized body pain, an impaired sex life and anxiety about the underlying cause of the symptoms. Nocturnal symptoms of reflux disease appear to have a particularly marked impact on HRQoL. The burden of illness imposed by reflux disease on HRQoL also has an impact on productivity, both at and outside work. The impact of reflux disease on productivity is significant and comparable to that caused by headache or back pain. Effective treatment is available for reflux disease, and there is evidence that this can quickly restore HRQoL to levels observed in the general population. However, poor communication between physicians and patients is contributing to unacceptable levels of patient dissatisfaction. Understanding patients' experience of GERD and its treatment through the study of HRQoL is one way to address this problem.
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PMID:Review of the quality of life and burden of illness in gastroesophageal reflux disease. 1538 50

Vertebral deformities and spinal osteoarthritis are common disorders in elderly persons and are associated with back pain, impaired physical functioning, and loss of quality of life. The objectives of this study were to assess the impact of vertebral deformities and osteoarthritis on quality of life in a population-based sample, and to compare this with the impact of six other important chronic diseases on quality of life. The study was performed as a substudy of the Longitudinal Aging Study Amsterdam. Vertebral deformities and osteoarthritis were assessed by spinal radiographs; chronic diseases were assessed by self-report; quality of life was estimated by the SF-12, EQ-5D (EuroQol) and Qualeffo-41 (n = 336). In univariate analyses, severe osteoporosis of the vertebrae significantly worsened the physical component summary scale of the SF-12 and the total score of Qualeffo-41, while osteoarthritis of the spine did not significantly reduce quality of life. The other chronic diseases reduced quality of life, although not all changes reached statistical significance. In multivariate analyses, severe osteoporosis of the vertebrae, cardiac disease, peripheral arterial disease, and diabetes mellitus significantly reduced quality of life. In conclusion, most persons in an elderly population suffer from one or more chronic diseases, and therefore experience loss of quality of life. After adjustment for age, sex, and other chronic diseases, severe osteoporosis of the vertebrae, cardiac disease, peripheral arterial disease, and diabetes mellitus significantly reduced quality of life in the general population.
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PMID:Impact of vertebral deformities, osteoarthritis, and other chronic diseases on quality of life: a population-based study. 1548 May 72

Candesartan cilexetil is the prodrug of candesartan, an angiotensin II receptor antagonist. Candesartan binds selectively and non-competitively to the angiotensin II receptor type 1, thus preventing the actions of angiotensin II. Clinical trials have demonstrated its efficacy at a dose range of 2 to 32 mg once daily in hypertension of all grades, heart failure, in reducing urinary albumin excretion in diabetes mellitus and in coexisting hypertension and renal failure. Pharmacokinetic properties of candesartan cilexetil in elderly patients are not significantly different from those in younger individuals. Hepatic impairment does not change pharmacokinetics of candesartan cilexetil at doses up to 12 mg/day. No dose adjustment is necessary in patients with mild or moderate renal impairment. Tolerability of candesartan cilexetil is not much different from that of placebo. All adverse events are usually of mild to moderate severity and not dose-related. The most common adverse events were headache, upper respiratory tract infection, back pain, and dizziness. The incidence of these adverse effects, as well as of cough, was similar in patients treated with candesartan cilexetil or placebo. The incidence of adverse events in long-term trials was not different from that in short-term trials. Tolerability of candesartan cilexetil does not differ with either age or gender.
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PMID:Candesartan. 1559 74

Researchers have frequently relied on case identification using clinician-based screening as the standard. This study evaluates a self-administered screening questionnaire developed for use in the Veterans Health Study. We compared concordance between elderly patients' reports of selected chronic illnesses and the medical record. The purpose of this study was to determine the feasibility of using a self-report screening questionnaire for case identification in an outcomes study of elderly respondents. Reports of the presence of selected chronic illnesses were compared in a sample of patients (N=402) receiving outpatient care between 2 data sources, patient self-report and medical record, to determine overall concordance in 5 common chronic conditions (hypertension, adult-onset diabetes mellitus, chronic low-back pain, osteoarthritis of the knee, and chronic lung disease). Discordance between the 2 data sources varied by condition. Differences in reporting were small for diabetes and hypertension, intermediate for chronic lung disease, and larger for osteoarthritis of the knee and chronic low-back pain, where the chart did not identify substantial proportions of cases reported in the questionnaire. Use of patient-reported screening questionnaires, which are self-administered, is a valid, cost-efficient method to identify some chronic illnesses. Using medical records alone may result in underestimation of some symptom-based conditions.
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PMID:Concordance between respondent self-reports and medical records for chronic conditions: experience from the Veterans Health Study. 1592 44

The Veterans Health Study (VHS) was designed to produce patient-based measures of health status suitable for monitoring the health of men served by the Veterans Health Administration. This article summarizes the objectives, conceptual framework, and results of 6 substudies of the VHS that were designed to develop disease-focused measures of illness severity, that is, patient-perceived, clinically significant manifestations of disease processes that are associated with decrements in health-related quality of life. Developmental psychometric studies used cross-sectional survey data from the baseline comprehensive evaluations conducted in the VHS. Patients who screened positive for the 6 study medical conditions in the VHS (osteoarthritis of the knee, n = 511; type 2 diabetes, n = 425; chronic lung disease, n = 352; hypertension, n = 996; chronic low-back pain, n = 574; and alcohol-related disorder, n = 175) were administered structured interview modules that assessed symptoms and complications of these chronic diseases. Psychometric analyses were conducted to identify internally coherent and reliable indices, which were validated with respect to their correlations with measures of health-related quality of life (eg, Short Form-36) and the utilization of health services. We constructed 6 indices of illness severity. The severities of osteoarthritis of the knee and chronic lung disease were defined by brief (12 and 6 items, respectively) assessments of symptoms (eg, knee pain and dyspnea). Since diabetes and hypertension are largely asymptomatic, illness severity for these conditions was assessed by ascertaining complications such as angina and vascular disorders. Alcohol-related disorder, which involves both behavioral symptoms and physical complications, was assessed by separate scales for these 2 dimensions of its severity. Chronic low-back pain required a unique solution. Rather than assessing the intensity of back pain, it is more productive to construct a measure that focuses on manifestations of radiculopathy, that is, whether back pain radiated down the leg to below the knee. The 5 symptoms or complication indices and the assessment of radiculopathy in chronic low-back pain were significantly correlated with Short Form-36 scores and intensity of recent use of health services. The 6 measures may complement measures of health-related quality of life in providing more comprehensive assessments of health status in Veterans Affairs patients.
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PMID:Patient-based measures of illness severity in the Veterans Health Study. 1596 20

People with stigmatized illnesses often avoid seeking health care and education. The internet may be a useful health education and outreach tool for this group. This study examined patterns of internet use for health information among those with and without stigmatized illnesses. A national survey of internet users in the USA was conducted. Respondents who self-reported a stigmatized condition-defined as anxiety, depression, herpes, or urinary incontinence-were compared to respondents who reported having at least one other chronic illness, such as cancer, heart problems, diabetes, and back pain. The analytical sample consisted of 7014 respondents. Cross-sectional associations between stigmatized illness and frequency of internet use for information about health care, use of the internet for communication about health, changes in health care utilization after internet use, and satisfaction with the internet were determined. After controlling for a number of potential confounders, those with stigmatized illnesses were significantly more likely to have used the internet for health information, to have communicated with clinicians about their condition using the internet, and to have increased utilization of health care based on information found on the internet, than those with non-stigmatized conditions. Length of time spent online, frequency of internet use, satisfaction with health information found on the internet, and discussion of internet findings with health care providers did not significantly differ between the two groups. Results from this survey suggest that the internet may be a valuable health communication and education tool for populations who are affected by stigmatized illnesses.
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PMID:Internet use and stigmatized illness. 1602 78

As part of its planning process, the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health, periodically evaluates how well it applies its criteria for setting research priorities. For its most recent evaluation, NCCAM compared funding levels in fiscal years 2000 and 2003 for 18 diseases with a substantial public health burden including Alzheimer's disease, arthritis, back pain, cancer, diabetes, coronary heart disease, HIV/AIDS, migraine, and stroke, with 7 measures of disease burden: 1) prevalence, 2) mortality, 3) years of life lost (YLL), 4) years lost to disability (YLD), 5) disability-adjusted life years (DALY's), 6) direct costs of illness (COI), and 7) total COI. There is an increasing relationship between NCCAM research funding and disease burden over the 4-year study period that reflects funding of specific research initiatives. The strength of the individual correlations varied among measures, with the strongest correlations seen with total COI and the weakest seen with mortality. When applied with its other criteria, measures of disease burden aid identification and matching of NCCAM priorities with levels of support.
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PMID:Identifying and pursuing research priorities at the National Center for Complementary and Alternative Medicine. 1605 86


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