Deficits in pain medication in older adults with chronic pain receiving home care: A cross-sectional study in Germany

OBJECTIVE: To analyze the pattern and appropriateness of pain medications in older adults receiving home care. METHODS: We performed a prospective cross-sectional study in patients ≥65 years old having chronic pain and receiving home care in Berlin, Germany. Data on prescribed pain medications were collected using self-reported information, nursing documents, and medication plans during interviews at home. Pain intensity was determined with the numeric rating scale (NRS) and the Pain Assessment In Advanced dementia (PAINAD) scale. The Pain Medication Appropriateness Scale score (SPMAS) was applied to evaluate inappropriateness (i.e. a score ≤67) of pain medication. RESULTS: Overall 322 patients with a mean age of 82.1 ± 7.4 years (71.4% females) were evaluated. The average pain intensity scores during the last 24 hours were 5.3 ± 2.1 and 2.3 ± 2.3 on NRS and PAINAD scale (range 0-10, respectively). Sixty (18.6%) patients did not receive any pain medication. Among the treated patients, dipyrone was the most frequently prescribed analgesic (71.4%), while 50.8% and 19.1% received systemic treatment with opioids and non-steroidal anti-inflammatory drugs, respectively. The observed median SPMAS was 47.6 (range 0-100) with 58 (18.0%) of patients achieving appropriate values. Half of the patients were treated with scheduled, while 29.9% were only treated with on-demand medications. Cognitive status had no effect on appropriateness of pain treatment. CONCLUSIONS: We observed substantial deficits in dosing patterns and appropriateness of pain medication in older adults with pain receiving home care. This applied to both patients with and without severe cognitive impairment

Multimodal Outcomes in N-of-1 Trials: Combining Unsupervised Learning and Statistical Inference

N-of-1 trials are randomized multi-crossover trials in single participants with the purpose of investigating the possible effects of one or more treatments. Research in the field of N-of-1 trials has primarily focused on scalar outcomes. However, with the increasing use of digital technologies, we propose to adapt this design to multimodal outcomes, such as audio, video, or image data or also sensor measurements, that can easily be collected by the trial participants on their personal mobile devices. We present here a fully automated approach for analyzing multimodal N-of-1 trials by combining unsupervised deep learning models with statistical inference. First, we train an autoencoder on all images across all patients to create a lower-dimensional embedding. In the second step, the embeddings are reduced to a single dimension by projecting on the first principal component, again using all images. Finally, we test on an individual level whether treatment and non-treatment periods differ with respect to the component. We apply our proposed approach to a published series of multimodal N-of-1 trials of 5 participants who tested the effect of creams on acne captured through images over 16 days. We compare several parametric and non-parametric statistical tests, and we also compare the results to an expert analysis that rates the pictures directly with respect to their acne severity and applies a t-test on these scores. The results indicate a treatment effect for one individual in the expert analysis. This effect was replicated with the proposed unsupervised pipeline. In summary, our proposed approach enables the use of novel data types in N-of-1 trials while avoiding the need for manual labels. We anticipate that this can be the basis for further explorations of valid and interpretable approaches and their application in clinical multimodal N-of-1 trials.Comment: 11 pages, 4 figure

Analysis of the quality of pain medication in patients receiving home care considering multimorbidity and polypharmacy in Germany

Hintergrund: Ältere Menschen sind oft von einer hohen Komorbiditätslast betroffen, die im Alter mit Schmerzen assoziiert sein kann. Trotz vielfacher Polypharmazie sind chronische Schmerzpatienten oft mit Schmerzmitteln unterversorgt. Für die ambulante Versorgung Pflegebedürftiger in Deutschland fehlen zuverlässige Daten zur Schmerzsituation sowie zur Angemessenheit der Schmerzmedikation. Ziel dieser Arbeit war es somit, das Schmerzgeschehen älterer Pflegebedürftiger in diesem Setting zu erfassen und deren Pharmakotherapie auszuwerten. Methodik: Im Rahmen der Querschnittstudie ACHE wurden in strukturierten Interviews Daten zum Schmerzgeschehen bei älteren Pflegebedürftigen (Alter ≥ 65 Jahre) mit chronischen Schmerzen (mit oder ohne kognitive Einschränkungen) in der eigenen Häuslichkeit erhoben. Angaben zur Schmerzintensität wurden unter Nutzung des Brief Pain Inventory (BPI-NHR) erfasst. Qualität und Angemessenheit der ärztlichen Schmerzmedikation wurden mittels deutschsprachiger Pain Medication Appropriateness Scale (PMAS) bewertet. Ein PMAS-Score ≤ 67% weist auf eine inadäquate Schmerztherapie hin. Die individuelle Komorbiditätslast wurde mit dem Charlson-Comorbidity-Index (CCI) ermittelt. Unter Berücksichtigung von ärztlich verschriebenen und in der Selbstmedikation bezogenen Arzneistoffen wurde die Gesamtmedikation im Hinblick auf Polypharmazie (≥ 5 Arzneistoffe), klinisch relevanten Arzneimittelinteraktionen sowie Über- und Unterversorgung mit bestimmten Arzneistoffklassen ausgewertet. Ergebnisse: In die ACHE-Studie wurden insgesamt 355 Pflegebedürftige eingeschlossen. Die Pflegebedürftigen (n = 225) berichteten eine hohe Schmerzbelastung mit einer durchschnittlichen Schmerzintensität von 5,3 ± 2,0 in den letzten 24 Stunden. Von 322 Pflegebedürftigen erhielten 58 (18,0%) Pflegebedürftige eine angemessene Schmerzmedikation. Der mediane PMAS-Score lag bei 47,6% (Bereich 0 - 100%). Bei mehr als der Hälfte (55,4%) von 334 Pflegebedürftigen wurde eine moderate bis hohe Komorbiditätslast ermittelt. Der Median für die Anzahl der verschriebenen Arzneistoffe lag bei 9 (Bereich 0 - 25). Insgesamt waren 89,5% von 353 Pflegebedürftigen von Polypharmazie (≥ 5 verschriebene Arzneistoffe) betroffen, während bei 49,3% Multipharmazie (≥ 10 verschriebene Arzneistoffe) vorlag. Bei 15,5% der Pflegebedürftigen wurde eine Überversorgung mit Schleifendiuretika ohne angemessene Indikation festgestellt, während bei 32,3% der Pflegebedürftigen mit Vorhofflimmern eine Unterversorgung mit Antikoagulantien beobachtet wurde. Diskussion: Die vorliegende Arbeit deckt erhebliche Defizite in Qualität und Angemessenheit des pharmakologischen Schmerzmanagements sowie der allgemeinen Pharmakotherapie bei älteren, multimorbiden Pflegebedürftigen (mit oder ohne kognitiven Einschränkungen) bei hoher Schmerzbelastung auf. Es besteht ein dringender Bedarf für interdisziplinäre Versorgungskonzepte in der häuslichen Schmerzversorgung von älteren Pflegebedürftigen.Background: Older adults are often affected by a high burden of comorbidity, which could be associated with pain. Despite high prevalence of polypharmacy, chronic pain patients are often undertreated with analgesics. In Germany, there is a lack of data concerning pain management and appropriateness of pain medication of elderly receiving home care. The aim of this work was to obtain data concerning the pain situation of home care recipients and to assess the overall medication in this setting. Methods: In the framework of the cross-sectional study ACHE, data concerning the pain situation of elderly aged ≥ 65 years with chronic pain (with or without cognitive impairment) were collected during structured interviews. Data on pain intensity was obtained by using the Brief Pain Inventory (BPI-NHR). Quality and appropriateness of prescribed pain medication was assessed by the German Pain Medication Appropriateness Scale (PMAS). A PMAS-score ≤ 67% indicates an inadequate pain therapy. The individual burden of comorbidities was determined with the Charlson-Comorbidity-Index (CCI). Considering prescribed drugs and drugs used in self-medication, the overall medication was evaluated with regard to polypharmacy (≥ 5 drugs), clinically relevant drug-drug interactions as well as over- and undertreatment with certain drug classes. Results: In the ACHE study, a total of 355 patients in need of care were included. An average pain intensity of 5.3 ± 2.0 in the last 24 h were reported (n = 225). Of 322 patients, 58 patients (18.0%) were adequately treated with pain medication. The median PMAS-score was 47.6 % (range 0 - 100%). More than half (55.4%) of 334 patients had moderate to severe comorbidity levels. The median of prescribed medications was 9 (range 0 - 25). Among 353 patients, 89.5% were affected by polypharmacy (≥ 5 prescribed drugs), while in 49.3% of them excessive polypharmacy (≥ 10 prescribed drugs) was detected. Overtreatment with loop diuretics without appropriate indication was determined in 15.5%, while 32.3% of patients with atrial fibrillation were undertreated with anticoagulants. Discussion: The present work indicates substantial deficits in the quality and appropriateness of pharmacotherapy for pain as well as the overall medication of elderly, multimorbid patients (with or without cognitive impairment) affected by chronic pain in home care. Interdisciplinary concepts in the ambulatory care of chronic pain patients are required

Analyzing Population-Level Trials as N-of-1 Trials: an Application to Gait

Studying individual causal effects of health interventions is of interest whenever intervention effects are heterogeneous between study participants. Conducting N-of-1 trials, which are single-person randomized controlled trials, is the gold standard for their analysis. In this study, we propose to re-analyze existing population-level studies as N-of-1 trials as an alternative, and we use gait as a use case for illustration. Gait data were collected from 16 young and healthy participants under fatigued and non-fatigued, as well as under single-task (only walking) and dual-task (walking while performing a cognitive task) conditions. We first computed standard population-level ANOVA models to evaluate differences in gait parameters (stride length and stride time) across conditions. Then, we estimated the effect of the interventions on gait parameters on the individual level through Bayesian linear mixed models, viewing each participant as their own trial, and compared the results. The results illustrated that while few overall population-level effects were visible, individual-level analyses showed nuanced differences between participants. Baseline values of the gait parameters varied largely among all participants, and the changes induced by fatigue and cognitive task performance were also highly heterogeneous, with some individuals showing effects in opposite direction. These differences between population-level and individual-level analyses were more pronounced for the fatigue intervention compared to the cognitive task intervention. Following our empirical analysis, we discuss re-analyzing population studies through the lens of N-of-1 trials more generally and highlight important considerations and requirements. Our work encourages future studies to investigate individual effects using population-level data.Comment: 25 pages, 11 figures, including supplementary material

As escolas do serviço de proteção aos índios em postos Indígenas Kaingang : entre os documentos oficiais e as vozes dos Kófa (1940-1967)

Esta tese tem como tema central a história da educação escolar kaingang durante o período de atuação do Serviço de Proteção aos Índios (SPI) no Rio Grande do Sul. O objetivo da pesquisa foi compreender como a escola instituída a partir da política indigenista do SPI se concretizou entre os kaingang nos Postos Indígenas Nonoai e Guarita entre os anos de 1940 e 1967. Busquei relacionar a proposta de educação escolar pensada pela Diretoria do SPI; a execução do que foi planejado nos gabinetes por parte dos funcionários dos Postos Indígenas; e a forma como a escola foi vivida – e é lembrada hoje – pelas pessoas que conviveram com ela. Assim, a pesquisa contou com a participação direta de 32 kófa (velhos), a quem denomino coautores, por entender que eles são os autores principais das informações orais que compõem a tese. Utilizei-me também de inúmeras fontes escritas produzidas pelo órgão indigenista. Além disso, destaco o papel de outras pessoas kaingang, a quem chamei de colaboradores, pois contribuíram para pensar a pesquisa e foram imprescindíveis para a realização do trabalho de campo. O marco teórico-metodológico do trabalho baseia-se principalmente em escritos de autores indígenas, nos quais me inspirei para: constituir uma perspectiva de relacionalidade com os participantes da pesquisa; estabelecer uma ética de pesquisa adequada ao contexto e modo de conhecer indígena; fazer uma história oral indígena; e definir um método conversacional para as entrevistas. Nesta tese busquei apresentar o maior número de informações sobre a escola do SPI nas comunidades estudadas, na medida em que não existem trabalhos anteriores sobre o tema. A importância do estudo também se justifica por procurar contribuir com o movimento atual de construção da escola indígena específica e diferenciada. O trabalho mostra que a escola do SPI em Nonoai e Guarita teve diversos momentos de descontinuidades e, mesmo quando esteve em funcionamento, constituiu-se em lugar de impermanência, sendo pontual na vida das pessoas e das comunidades. O currículo desta escola tinha como base a alfabetização em língua portuguesa, mas os dados evidenciam que ela pouco ensinou. Embora o uso da língua kaingang em sala de aula não fosse proibido, ela não tinha espaço na formalidade da escola, mas apesar disso, mantinha-se viva e potente entre as crianças. A memória dos kófa sobre seu passado escolar apresenta ambiguidades, mas de modo geral é positiva. O Serviço de Proteção aos Índios foi responsável pela introdução das escolas nas comunidades kaingang do Rio Grande do Sul, mas seu alcance junto aos alunos em Nonoai e Guarita foi limitado em termos de matrícula, frequência, permanência e aprendizagem.This thesis focuses on the history of kaingang education while operating under the Serviço de Proteção aos Índios (SPI) government agency in the state of Rio Grande do Sul, Brazil. It aims to understand how SPI’s indigenous policies informed the school system that developed among the kaingang on the reservations of Nonoai and Guarita between 1940-1967. As such, I examine the relationship involving the educational policies advanced by the SPI, their execution by government staff at the reservations, and how the school was ultimately experienced and remembered by those who lived through it. The research draws on the direct input from 32 kófa (elders), who I consider my “co-authors” given that they are the main authors of the oral histories that constitute the work. In addition, I rely on numerous written sources produced by government staff at the time. Finally, I also draw on various kaingang individuals, who I call my 'collaborators'. These individuals were vital in helping to deepen my thinking about the research, and were also essential to my carrying out the field work. The study’s theoretical framework and methodology is informed by academic work from a number of indigenous authors. It allowed me to use a relational approach with the research participants; establish a research ethics that accounts for both the indigenous context and its specific ways of knowing; apply a conversational method to my interviews; and produce work that emanates directly from oral indigenous history. Given the lack of prior research on the issue, the thesis aims to present the largest possible set of data about indigenous schooling under the SPI at the communities where the study took place. The research is also presented as a contribution to ongoing efforts to develop a bilingual and intercultural indigenous school. Results show that the SPI schools in Nonoai and Guarita had many instances of discontinuity. It also demonstrates that even when they were open, they constituted places of impermanence, playing a particular, and at times limited, role in student's lives and across the wider community. The schools’ curriculum was focused on Portuguese literacy, but the data show little achievement in that respect. While speaking kaingang language was not forbidden in school, it was absent from formal teaching. Even so, the native language remained alive and dominant among students. The memories from the kófa are often ambiguous, but also positive. Although it was responsible for introducing formal education among the kaingang in Rio Grande do Sul, the Serviço de Proteção aos Índios had a limited impact in terms of enrolment, attendance, learning, and avoiding evasion in the reservations of Nonoai and Guarit

A escuta da fala marginalizada em ancestral na voz ascendente

Neste trabalho de conclusão desejo mostrar a importância das narrativas orais e discutir o seu valor, uma vez que elas trazem a paixão que vai além dos documentos oficiais da escrita da História, bem como propor um espaço na academia para a discussão a partir de Poéticas marginalizadas. O vídeo Ancestral na Voz Ascendente, traz a história de mulheres, retratando as sociedades machistas nas quais elas viveram, cada uma a seu tempo e espaço. Nele, estabelece-se um diálogo entre duas formas distintas de narração de histórias (ZUMTHOR, 2005). Uma narrativa é feita por Anita, que está em casa e, de forma espontânea, relembra a história de sua mãe, uma pastora de ovelhas. A outra é constituída por uma performance feita por Gilda, na qual a artista recupera a história de suas antepassadas indígenas: a bisavó retirada da aldeia para ser escravizada em uma fazenda, e a avó vendida para uma família da cidade para exercer atividades domésticas. Pensando numa tradição contínua, passada pela oralidade, busca-se valorizar as vozes subalternizadas das mulheres entrevistadas, registrando suas narrativas como forma de resistência ao poder do colonizador. O conteúdo do vídeo e a sua análise no texto são, além de tudo, questionamentos sobre a forma ocidental de narrar a história e a poesia da humanidade, cujo discurso oficial esquece a parte que cabe aos marginalizados e às mulheres, inscrevendo, geralmente, a perspectiva patriarcal como única. Dessa forma, trata-se de um trabalho sobre e de resistência da mulher e dos subalternizados.En esta monografía deseo mostrar la importancia de las narrativas orales, ya que muestran una pasión que va más allá de los documentos oficiales de la historia escrita. Igualmente propongo un espacio dentro de la academia para discutir su valor a partir de poemas marginalizados. El video ancestral en la voz ascendente, contiene la historia de mujeres retratando las sociedades machistas en las cuales viven, cada una en su tiempo y espacio. En el video se establece un dialogo entre dos formas distintas de narración de historias (ZUMTHOR, 2005): Una de las narraciones es hecha por Anita de manera espontanea recordando la historia de su madre la cual fue una pastora de ovejas. La otra historia está constituida por una performance hecha por Gilda, en la cual se recupera la historia de sus antepasadas indígenas: la bisabuela que fue extirpada de su aldea para convertirse en esclava en una hacienda y la abuela vendida para una familia de la ciudad para transformarse en empleada doméstica. Pensando en una tradición continua, pasada oralmente, se pretende valorizar las voces de las mujeres entrevistadas, registrando sus narraciones como forma de resistencia al poder del colonizador. El contenido del video y su análisis en el texto son, más que todo, cuestionamientos sobre la forma occidental de narrar la historia y poesías humanas, cuyo discurso oficial se olvida de la parte que corresponde a marginales y mujeres, inscribiendo generalmente la perspectiva patriarcal como única. De esta forma se trata de un trabajo sobre y la resistencia de la mujer e de los subalternos

Uso da toxina botulínica como meio terapêutico em medicina dentária : revisão de literatura

Dissertação para obtenção do grau de Mestre no Instituto Universitário Egas MonizEm 1822, Justinus Kerner, um médico, poeta alemão e um dos mais importantes pioneiros no estudo da toxina botulínica, foi o primeiro a publicar uma pesquisa na qual desenvolveu a hipótese de utilizar esta toxina para fins terapêuticos. Atualmente, quase dois séculos após esta observação, as aplicações terapêuticas da toxina botulínica estão em expansão em Medicina Dentária, e constantemente estão a surgir novos estudos sobre este potente e versátil fármaco. A toxina botulínica do tipo A é a toxina biológica mais potente, tem uma difusão limitada no local injetado e sua ação é reversível com o tempo. Estas propriedades farmacológicas favoráveis, juntamente com seus efeitos terapêuticos polivalentes, permitem o uso deste fármaco em diversas aplicações em Medicina Dentária, nomeadamente bruxismo, sialorreia, implantologia e disfunções temporomandibulares tais como dor miofascial, hipertrofia do músculo masséter e luxação da articulação temporomandibular. Apesar de ainda com grau de evidência discutível, os estudos demonstram que os tratamentos com a toxina botulínica, não são considerados como primeira linha, mas apresentam resultados promissores nestas aplicações, quando realizados por um clínico qualificado. No entanto, estes resultados positivos devem ser interpretados com cautela, visto que ainda há muitas questões relacionadas com esta toxina no organismo humano, tal como evidenciado em recentes estudos sobre os potenciais riscos de alterações ósseas mandibulares após aplicações de toxina botulínica nos músculos mastigatórios. Com o intuito de confirmar a real segurança e eficácia do uso terapêutico da toxina botulínica nas diversas aplicações em Medicina Dentária, verifica-se a necessidade da realização de novos estudos baseados em níveis mais elevados de evidência científica. Pretende-se com esta monografia proceder à revisão de literatura científica acerca das atuais aplicações terapêuticas da toxina botulínica na Medicina Dentária.In 1822, Justinus Kerner, a German doctor, poet and one of the most important pioneers in the study of botulinum toxin, was the first to publish a research in which he developed the hypothesis of using this toxin for therapeutic purposes. Today, almost two centuries after this observation, the therapeutic applications of botulinum toxin are expanding in dentistry, and new studies on this powerful and versatile drug are constantly emerging. Botulinum toxin type A is the most potent biological toxin, it has a limited diffusion in the injected place and its action is reversible with time. These favorable pharmacological properties, together with its polyvalent therapeutic effects, allow the use of this drug in various applications in dentistry, including bruxism, sialorrhoea, implantology and temporomandibular dysfunctions such as myofascial pain, hypertrophy of the masseter muscle and dislocation of the temporomandibular joint. Although the degree of evidence is still debatable, the studies show that treatments with botulinum toxin are not considered as first line, but present promising results in these applications, when performed by a qualified clinician. However, these positive results should be interpreted with caution, since there are still many issues related to this toxin in the human body, as evidenced in recent studies on the potential risks of mandibular bone changes following applications of botulinum toxin to masticatory muscles. In order to confirm the real safety and efficacy of the therapeutic use of botulinum toxin in the various applications of dentistry, there is a need for further studies based on higher levels of scientific evidence. The aim of this monograph is to review the scientific literature on the current therapeutic applications of botulinum toxin in dentistry

The impact of guidance counselling on gender segregation: Major choice and persistence in higher education; an experimental study

Gender segregation in higher education is considered one of the main drivers of persistent economic gender inequality. Yet, though there has been considerable research identifying and describing the underlying mechanisms that cause gendered educational choices in higher education, little is known about how gender segregation in higher education could be changed. Accordingly, this article aims to determine the potential of educational interventions during high school to foster gender desegregation in higher education. We focused on two different processes that contribute to gender segregation in majors among higher education graduates: first, the selection into specific majors and, second, the selection out of specific majors. We investigated whether an intensive counselling programme leads to more gender-atypical choices among high-school graduates and examined whether intensive counselling supports several indicators of students' persistence in gender-atypical majors. Based on data from an experimental study of a counselling programme for German high-school students ( N = 625), we estimated the programme's effect with linear probability models and intention-to-treat analysis. Our results show that high-school graduates are more likely to choose a gender-atypical major if they have received intensive counselling. This applies more to men than to women. In addition, the programme improved some persistence indicators for students in gender-atypical majors. Although we found a significant programme effect only for perceived person-major fit and student satisfaction, the coefficients of all aspects of students' persistence show a trend indicating that the programme was beneficial for students in gender-atypical majors. As experimental studies can also be affected by various types of bias, we performed several robustness checks. All analyses indicated stable results. In conclusion, we suggest that intensive counselling programmes have the potential to reduce gender segregation in higher education. More students were motivated to choose a gender-atypical major, and different aspects of student persistence were supported by the programme for students in gender-atypical majors

“Cabelo (crespo e cacheado) pro alto, me levando a saltos” em meio à ressignificação das identidades de mulheres negras em contextos sociais e organizacionais

This article aims to analyze the resignification processes of the black women identities occurring through the so-called transition to natural hair and the way society and organizations have reacted to this resignification. The study contributes to the Organizational Studies field by problematizing identities under construction that pass through various social and organizational spaces that need to be rethought in order to understand this process as much broader than merely aesthetic in the strict sense of this term. The research is qualitative and involved interviews with semistructured scripts with women who have been or are going through the transition to natural hair, whose discursive statements were analyzed through the theoretical-methodological approach of the french discourse analysis. The main results show that the interviewees, when passing through the transition to natural hair, had their identities resignified and such resignification brought relevant changes in their relations in society and in organizations.Este artigo tem coEste artigo tem como objetivo analisar processos de ressignificação de identidades de mulheres negras em sua relação com o processo chamado transição capilar e a maneira como a sociedade e as organizações vêm reagindo a essa ressignificação. O estudo contribui para o campo dos Estudos Organizacionais ao problematizar identidades em construção que transitam por diversos espaços sociais e organizacionais que precisam ser repensados a fim de compreender tal processo como muito mais amplo do que meramente estético, no sentido estrito deste termo. A pesquisa é qualitativa e envolveu a realização de entrevistas com roteiros semiestruturados com mulheres que passaram ou estão passando pela transição capilar, cujos enunciados discursivos foram analisados pela abordagem teórico-metodológica da análise francesa do discurso. Os principais resultados evidenciam que as entrevistadas, ao passarem pela transição capilar, tiveram suas identidades ressignificadas e que essa ressignificação traz relevantes alterações nas suas relações na sociedade e nas organizações