People with multimorbidity have reduced functional capacity, lower quality of life, higher mortality rates and use healthcare resources more intensively than healthy people or those with a single chronic condition. Multimorbidity was defined as the coexistence of two or more chronic conditions in the same person. The aim of this study was to explore associations between multimorbidity and use of healthcare services and the impact of socioeconomic status on utilization of hospitalizations and bed days. The study population included all individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. Data on chronic conditions, use of healthcare services and demographics were obtained from Danish national administrative and health registries. Zero-inflated models were used to calculate anticipated annual use of hospitalizations and bed days. The study population comprised 1,397,173 individuals; the prevalence of multimorbidity was 22%. Prevalence was inversely related to educational attainment. For people with multimorbidity, utilization of hospitalizations and bed days increased approximately linearly with the number of chronic conditions. However, a steep increase in utilization of bed days was observed between five and six or more chronic conditions. An educational gradient in hospitalization rates and use of bed days was observed regardless of the number of chronic conditions. Educational attainment was strongly associated with healthcare utilization. Multimorbidity was associated with a significant increase in utilization of all healthcare services in Denmark. In addition, a socioeconomic gradient was observed in utilization of hospitalizations and bed days.

This article aims to alert the medical community and public health authorities to accumulating evidence on health benefits from sun exposure, which suggests that insufficient sun exposure is a significant public health problem. Studies in the past decade indicate that insufficient sun exposure may be responsible for 340,000 deaths in the United States and 480,000 deaths in Europe per year, and an increased incidence of breast cancer, colorectal cancer, hypertension, cardiovascular disease, metabolic syndrome, multiple sclerosis, Alzheimer’s disease, autism, asthma, type 1 diabetes and myopia. Vitamin D has long been considered the principal mediator of beneficial effects of sun exposure. However, oral vitamin D supplementation has not been convincingly shown to prevent the above conditions; thus, serum 25(OH)D as an indicator of vitamin D status may be a proxy for and not a mediator of beneficial effects of sun exposure. New candidate mechanisms include the release of nitric oxide from the skin and direct effects of ultraviolet radiation (UVR) on peripheral blood cells. Collectively, this evidence indicates it would be wise for people living outside the tropics to ensure they expose their skin sufficiently to the sun. To minimize the harms of excessive sun exposure, great care must be taken to avoid sunburn, and sun exposure during high ambient UVR seasons should be obtained incrementally at not more than 5–30 min a day (depending on skin type and UV index), in season-appropriate clothing and with eyes closed or protected by sunglasses that filter UVR.

Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.

Patient-, physician-, and health care system-related barriers of cancer pain management in patients with malignant diseases are a recognized and widely investigated issue. The purpose of this review is to summarize the main findings of empirical research on these barriers in the literature. The most significant patientrelated barriers were patient reluctance to report pain and adhere to treatment recommendations. Besides that, cognitive, affective, and sensory patient-related barriers to cancer pain management with opioid analgesics have been studied using quantitative and qualitative research methods. The Barriers Questionnaire and its shortened and modified versions were the most commonly used instruments in the context of research on patient-related barriers to cancer pain management. The most prominent physicianrelated barriers were insufficient physicians’ knowledge about cancer pain management, inadequate patterns of pain assessment, and inadequate opioid prescription. The methodologies used to conduct the majority of the studies on physician-related barriers were weak. Nevertheless, physician knowledge of pain management guidelines, the quality of pain assessment and opioid prescription have been shown to be obviously better in a few Western countries. Institutional and health care system-related barriers were relevant only in countries with restrictive opioid prescription regulations. The evaluation of the influence of cultural-social-economical background on cancer pain management could probably help to obtain better insight into the problems of unrelieved cancer pain.

Objective: The purpose of this review is to summarize the results of studies on physician-related barriers to cancer pain management with opioid analgesics.Methods: A literature search was conducted in PUBMED, using a combined text word and MeSH heading search strategy. Those articles whose full texts were not available in PUBMED were retrieved from the electronic databases of specific journals.Results: Sixty-five relevant articles, published in the period from 1986 to 2006, were identified. Physicians’ barriers to cancer pain management were studied in questionnaire surveys and in the reviews of drug prescribing documents. The results of the articles found were analyzed with respect to (a) knowledge, beliefs, concerns, problems endorsed or acknowledged by physicians treating cancer pain, (b) physicians’ skills in pain assessment, and (c) adequacy of opioid prescription.Conclusions: This review revealed mostly general and common physician-related barriers to cancer pain management: concerns about side effects to opioids, prescription of not efficient doses of opioids, and very poor prescription for the treatment of side effects from opioids. In the future, the evaluation of the influence of cultural-social-economical background, as well as the differences between the various specialists involved in the care of patients with cancer, should be explored to better understand physicians’ barriers and more effectively address them in interventional and educational programs.