The factors determining utilization of health care resources in patients with chronic obstructive pulmonary disease (COPD) are poorly understood. In order to obtain insight into these factors, we studied the utilization of health care resources in 57 stable COPD patients with a forced expiratory volume in one second (FEV1) of 36±9% predicted.Patients were divided into two groups: admitted at least twice in the last year (high medical consumption; n=23) or not admitted in the last year (low medical consumption; n=34). Other variables related to utilization of health care resources studied were: the number of hospital days; the number of out-patient visits to a pulmonary department in the last year; and the average daily dose (ADD) of corticosteroids taken in the last 6 months. The actual cost of utilization of health care resources, however, was not studied. In addition, pulmonary function, serum electrolytes, blood gas values, 6 min walking distance, respiratory and peripheral muscle force, and appraisal of self-care agency (ASA score) were studied.Pulmonary function, serum electrolytes, blood gas values, ASA score and walking distance were not different between the two groups (e.g. FEV1 36±8 vs 36±10% pred). Respiratory muscle forces tended to be lower in the high medical consumption group, this tendency almost reaching statistical significance for maximal expiratory pressure (PE,max) (p=0.08). Peripheral muscle force, however, was clearly reduced in the high medical consumption group (quadriceps force 63±20 vs 82±26% pred; p<0.05). The number of admissions, the number of hospital days, the number of out-patient visits, and ADD were interrelated and also related to ventilatory and peripheral muscle force (r -0.18 to -0.38). This relationship was statistically significant for PE,max, whilst a similar tendency was present for maximal inspiratory pressure (PI,max). In stepwise multiple regression analysis, only quadriceps force was a significant determinant of utilization of health care services.We conclude that utilization of health care services in patients with chronic obstructive pulmonary disease is related to ventilatory and peripheral muscle force. Whether or not reduced muscle force is simply an expression of disease severity remains to be determined.

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In this prospective study we compared the incidence of late acute rejections (LAR) and changes in serumcreatinine over time between compliers and noncompliers with immunosuppressive therapy more than 1 year post transplantation and explored the relative contribution of non-compliance and other risk factors in the occurrence of LAR.One hundred and forty-six adult renal transplant recipients were followed during a 5-year period. Patients were interviewed at the beginning of the study and categorized as non-compliers if they admitted to have skipped immunosuppressive medication on a regular basis during the previous 12 months. The occurrence of LAR during the follow-up period was recorded.We identified 22.6% non-compliers of which 21.2% experienced a late acute rejection compared with 8% in the group of compliers at 5 years postinclusion (p < 0.05). Kaplan-Meier survival analysis showed a decreased rejection free time in non-compliers compared with compliers (p = 0.03). Non-compliant patients had a 3.2 higher risk of LAR (Cox regression analysis, p = 0.005). Non-compliers experienced a higher increase in serum-creatinine over time (Linear Mixed Models, p < 0.001).Non-compliance in renal transplant patients more than 1-year post transplantation is associated with an increased risk for LAR and a higher increase in serumcreatinine during the following 5 years.

The objective was to validate the use of the proposed International Statistical Classification of Diseases and Related Health Problems (10th revision) (ICD-10) criteria for fatigue (P-ICD10) through comparison with the Functional Assessment of Cancer Therapy Fatigue (FACT-F) subscale and three visual analogue scale (VAS) qualities in cancer patients thought to be fatigued. Fatigue was assessed in 834 cancer patients at three clinical centres in Belgium, using P-ICD10, FACT-F, and VAS to assess: level of energy (VAS1), quality of life (VAS2), and ability to perform daily activities (VAS3). Of the 834 interviewed cancer patients, 54% were classified as fatigued by the P-ICD10 criteria. Internal consistency of P-ICD10 was very good (alpha coefficient 0.82). The principal component analysis corroborated good internal consistency with all variables included in the first component; a second component was used to identify psychological fatigue (concentration and short-term memory disabilities). An abridged set of screening tools based on the first three general symptoms of the P-ICD10 is proposed with 100% specificity and 86% specificity, respectively. There was a marked decrease in FACT-F and VAS1 scores in patients diagnosed as fatigued by the P-ICD10 (mean+/-SD, FACT-F 20+/-9 vs 39+/-8, VAS1 34+/-21 vs 61+/-21). A logistic regression model between P-ICD10 criteria diagnosis and FACT-F (VAS1) identified a score of 34 (61) on the FACT-F scale as a proposed cut-off point for the diagnosis of fatigue. The ICD-10 criteria can be recommended as a diagnostic tool, whereas the FACT-F scale and the level of energy 100-mm VAS assess the intensity of fatigue, and are more suitable for follow-up of cancer-related fatigue.

This study evaluated the validity of the dialysis diet and fluid non-adherence questionnaire (DDFQ) as a self-report instrument for clinical practice. The DDFQ was designed to measure non-adherence behaviour with diet and fluid guidelines in patients treated with hospital-based haemodialysis in Flanders (Belgium). In a multicentre cross-sectional study design, 564 patients from 10 dialysis centres in Flanders completed the DDFQ Criterion and construct validity of the instrument were substantiated using correlation techniques between the DDFQ and biochemical and biological ratings of non-adherence. The results of this study suggest that the DDFQ is a valid self-report instrument to assess non-adherence behaviour in haemodialysis patients in Flanders and probably also in other cultures.

The prevalence, intensity, determinants and prevention of pain during bone marrow aspiration (BMA) in adults are not well defined. In the first part of this prospective study (observational phase), 132 adult hematological patients undergoing BMA after local anesthesia scored the procedural pain by means of a visual analogue scale (VAS). Moderate to severe pain was defined as a VAS score exceeding 30 mm. Eighty-six percent reported procedural pain. The VAS score (mean+/-SEM) was 27.2+/-2.1 mm. Thirty-six percent of patients graded the pain as moderate to severe. In a linear regression analysis, VAS score correlated positively with the duration of the procedure (P=0.029) and negatively with the age of the patient (P=0.006). In the second part of the study (interventional phase), 100 patients were randomized to 50 mg tramadol or placebo, given orally at least one hour before BMA. VAS scores during aspiration were significantly lower in tramadol recipients versus placebo recipients (16.5+/-3.0 mm and 28.8+/-3.4 mm, respectively, P=0.003). Pretreatment with tramadol reduced the percentage of patients with at least moderate pain from 40% to 20% (P=0.029). Four tramadol and 3 placebo recipients reported side effects (dizziness or sedation). In conclusion, notwithstanding local anesthesia, the great majority of adult hematological patients experience transient pain during BMA that is of at least moderate intensity in over a third. Pretreatment with tramadol lowers pain intensity significantly and is well tolerated.

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Forty-eight units were enrolled in a descriptive, cross-sectional study to identify strengths and weaknesses of pain management in a German university teaching hospital. Patients had to be > or =18 years old and able to speak German; intensive care, psychiatric, obstetric and pediatric units were excluded. Structured interviews were conducted by an independent researcher not involved in patient care. Patients were asked about prevalence of pain during the interview at rest, on movement, and during the 24 hours before the interview; patients rated pain intensity at rest and on movement as well as the worst pain 24 hours before the interview by using a 10 cm visual analogue scale (VAS). In addition, patients indicated localization, duration, and causes of pain. Chart analysis was carried out to check for pain medication, ICD-10 diagnoses, and demographic data. To evaluate the adequacy of pain management, the Pain Management Index (PMI) was assessed. A total of 561 of the 825 inpatients who were contacted participated in the study. Fifty percent experienced pain during the interview and 63% reported pain during the preceding 24 hours. Fifty-eight percent had moderate or severe pain (VAS > or = 45 mm) and 36% reported severe pain (VAS > or = 65 mm). Thirty-three percent had pain for more than six months. The most prevalent localization of the strongest pain was in the lower extremities (20%). Fifty percent of patients with pain received pain medication. Patients on the surgical wards (P = 0.002) and those having severe pain (P < 0.001) were more likely to get analgesics. However, 30% of those with VAS> or =65 mm received no analgesic and only 24% had adequate medication. A negative PMI, indicating inadequate pain therapy, was found in 44% (246/559) of the sample. Sex and age did not influence pain prevalence, pain intensity, or pain therapy. Pain prevalence and intensity in this German university hospital were high and pain therapy was inadequate in many cases. Pain management needs to be improved by continuous assessment and adequate pain medication.