Nociceptive Flexion Reflex Threshold is No Suitable Marker for Diagnosing Opioid-Induced Hyperalgesia.

Background: Opioid induced hyperalgesia (OIH) describes a state of altered pain sensation due to opioid exposure. It often occurs among persons with opioid use disorder receiving substitution therapy. Methods: The purpose of this study was to find out, whether OIH diagnosis could be facilitated by an objective pain indicating marker: the Nociceptive Flexion Reflex (NFR). Forty persons with opioid use disorder, 20 of them maintained on methadone and 20 treated with buprenorphine, as well as a control group of 20 opioid-free subjects, were examined. It was aimed to find out whether and in which way these opioid agonists alter reflex threshold (NFR-T). A cold-pressor test was performed to investigate the prevalence of OIH. Furthermore, electrical stimulation and electromyography analyzation were used for NFR-T measurement. Subjective pain ratings were evaluated with a numeric rating scale. Results: Significantly increased sensitivity to cold pressor pain was found in both maintenance groups when compared to their opioid-free counterparts (p < 0.001). Neither methadone nor buprenorphine showed any effect on NFR-T. This might be explained by the reflex approaching at the wrong location in the central nervous system. Consequently, NFR-T is not a suitable marker for diagnosing OIH. Conclusion: Although methadone and buprenorphine have been proven to cause OIH, no effect on NFR-T was observed. A statistically significant effect could have been observed with a larger number of participants. Further research, with special focus on patients' adjuvant medication, should be conducted in the future, to facilitate diagnosis of OIH and provide appropriate pain management for maintenance patients.

Short-term impact of the COVID-19 pandemic on patients with a chronic pain disorder.

ABSTRACT: The current Covid-19 pandemic has already had a definite impact on the daily life of many people worldwide. It has been proposed that people with preexisting medical conditions will be harder hit by the pandemic and the subsequent measures to contain the spread of the disease. In this questionnaire-based, observational study, we aimed to assess the impact of the pandemic on patients with a chronic pain disorder, who are treated at a tertiary multidisciplinary pain center.Participants rated the impact of the pandemic on their chronic pain disorder using a self-designed questionnaire. Also, participants filled out the regular follow-up questionnaire to assess a chronic pain disorder measuring among other parameters pain intensity, symptoms of depression, anxiety, stress, and pain-related quality of life.Of 136 eligible patients who presented to our pain center between May 5th and July 17th, 112 agreed to participate in the study (82.4%). Eighty two participants (73.2%) reported a deterioration of the pain disorder using the self-designed questionnaire. The more robust parameters of the regular follow-up questionnaire showed no relevant changes compared to data collected before the pandemic. We were not able to detect any demographic and medical parameters that were clinically relevantly associated with a higher impact of the pandemic.We conclude that a chronic pain disorder is a relatively stable disease that does not change significantly due to external factors, like the Covid-19 pandemic, even if the subjective impact is perceived to be high.

Facial and Oral Cross-Contamination of a 3-Year-Old Child With High Concentration Capsaicin: A Case Report.

High-concentration topical capsaicin is used to treat different neuropathic pain states. We present a case in which a 3-year-old child orally ingested capsaicin after touching her mother's arm that had been treated with a high-concentration capsaicin patch 3 hours earlier. The child suffered extreme pain and swelling of the lips and tongue. After the use of cleansing gel, external cooling, and drinking milk, the pain lessened over half an hour and subsided after 2 hours. This report aims to raise awareness for this formerly unreported mode of oral contamination.

Long term reliability of nociceptive withdrawal reflex thresholds.

BACKGROUND: The nociceptive withdrawal reflex (NWR) is a polysynaptic spinal reflex protecting the body from harmful stimuli. Two different methods to assess its' threshold (NWR-T) have been part of clinical trials concerning the evaluation of the nociceptive system in the human body. NWR-T's are gathered by stimulation at the sole of the foot and over the sural pathway. Consequently, EMG analyzes the muscle activity over the biceps femoris and tibialis anterior muscle. Past studies favor stimulation at the sole of the foot. NEW METHOD: The two methods were compared concerning retest-reliability and subjective pain ratings. The retest-reliability was tested over a period of 21 days using an up-down staircase method. Reliability was evaluated with a Bland Altman agreement analysis. Subjective pain ratings were evaluated with a numeric rating scale (NRS). RESULTS: NWR-T assessment was successful for all subjects. The EMG muscle activity had larger reflex amplitudes for measurements of the tibialis anterior muscle. NWR-T values showed greater variability than NRS values. COMPARISON WITH EXISTING METHOD: The retest-reliability over a period of 21 days showed stable NWR-T results for both stimulation sites, but superior reliability was gathered with stimulation at the sole of the foot. Subjects rated stimulation over the sural pathway as more painful. CONCLUSIONS: The NWR-T upholds reliable measurements over a longer period of time and seems to be a stable measure for pain condition. Reliability estimations, EMG recordings, and subject's rating show stimulation at the sole of the foot could be the better choice.

[Self-hypnosis training for in-hospital chronic pain patients : A retrolective observational study]. / "Selbsthypnosetraining" bei chronischen stationären Schmerzpatienten : Eine retrolektive Beobachtungsstudie.

BACKGROUND: Hypnosis is probably one of the oldest therapies known to man. In the last decades modern hypnosis has mainly been used by psychotherapists; however, hypnosis is becoming increasingly more important as a therapeutic method in medicine. Hypnosis can be used for a variety of medical indications. In the literature there is much evidence for the effectiveness of hypnosis. The aim of the present investigation was to demonstrate the effectiveness of hypnosis in inpatient treatment of chronic pain patients and to present a self-hypnosis program, which can be easily integrated into pain therapy. METHODS: From October 2012 to April 2013 all inpatient chronic pain patients were included (group 1: non-hypnosis group, group 2: hypnosis group). Concerning group 2 a standardized protocol for hypnotherapy was integrated in addition to the standardized pain management program. The main goal of hypnotherapy was to integrate a self-hypnosis training so that further implementation in a domestic setting could be guaranteed. By means of standardized test procedures, e. g. Patient Health Questionnaire (PHQ-9), Pain Disability Index (PDI), Generalized Anxiety Disorder (GAD-7) and Numerical Rating Scales (NRS) for pain and general well-being, data were evaluated before and after the pain therapy. RESULTS: The prestandardized and poststandardized test procedures of 30 chronic pain patients were evaluated (17 patients without hypnosis, 13 patients with hypnosis). The main diagnosis according to ICD-10 was "chronic pain disorder" (F45.41) with a MPSS stage III in all patients. The PDI was significantly improved in the hypnosis group (p = 0.019). The other items all showed a trend towards improvement in the hypnosis group (exception GAD-7) but without statistical significance (p > 0.05). DISCUSSION: In a small patient collective, the present investigation was able to show that the integration of modern hypnotherapy into the treatment of chronic pain patients in an inpatient setting can be another useful therapeutic aspect. In particular, the instructions for learning independently seem to be useful due to the limited in-patient time. More research needs to be carried out to support our initial findings.

Is Every Life Worth Saving: Does Religion and Religious Beliefs Influence Paramedic's End-of-Life Decision-making? A Prospective Questionnaire-based Investigation.

BACKGROUND: Paramedics, arriving on emergency cases first, have to make end-of-life decisions almost on a daily basis. Faith shapes attitudes toward the meaning and worth of life itself and therefore influences decision-making. OBJECTIVE: The objective of this study was to detect whether or not religious and spiritual beliefs influence paramedics in their workday life concerning end-of-life decisions, and whether it is legally possible for them to act according to their conscience. METHODS AND DESIGN: This is a literature review of prior surveys on the topic using five key words and questionnaire-based investigation using a self-administered online survey instrument. SETTINGS/PARTICIPANTS: Paramedics all over Germany were given the opportunity to participate in this online questionnaire-based study. MEASUREMENTS: Two databases were searched for prior studies for literature review. Participants were asked about their religiosity, how it affects their work, especially in end-of-life situations, how experienced they are, and whether or not they have any legal latitude to withhold resuscitation. RESULTS: A total of 429 paramedics answered the questionnaire. Religious paramedics would rather hospitalize a patient holding an advance directive than leave him/her at home (P = 0.036) and think death is less a part of life than the nonreligious (P = 0.001). Otherwise, the Spearman's rho correlation was statistically insignificant for all tests regarding resuscitation. CONCLUSIONS: The paramedic's religiosity is not the prime factor in his/her decision-making regarding resuscitation.

Palliative patients under anaesthesiological care: a single-centre retrospective study on incidence, demographics and outcome.

BACKGROUND: While anesthesiologist's involvement in palliative care has been widely researched, extensive data on palliative patients under anesthesiological care in the operating room is missing. This study was performed to assess the incidence, demographics, and outcome of palliative patients under anesthesiological care. METHODS: We conducted a single-center retrospective chart review of all palliative patients under anesthesiological care at a university hospital in 1 year. Patients were classified as palliative if they fulfilled all predefined criteria (a) incurable, life-threatening disease, (b) progression of the disease despite therapy, (c) advanced stage of the disease with limited life-expectancy, (d) receiving or being in need of a specific palliative therapy. Demographics, periprocedural parameters, symptoms at evaluation, and outcome were determined using different medical records. RESULTS: Of 17,580 patients examined, 276 could be classified as palliative patients (1.57%). Most contacts with palliative patients occurred in the operating room (68.5%). In comparison to the non-palliative patients, procedures in palliative patients were significantly more often urgent or emergency procedures (39.1% vs. 27.1%., P < 0.001), and hospital mortality was higher (18.8% vs. 5.0%, P < 0.001). Preprocedural symptoms varied, with pain, gastrointestinal, and nutritional problems being the most prevalent. CONCLUSIONS: Palliative patients are treated by anesthesiologists under varying circumstances. Anesthesiologists need to identify these patients and need to be aware of their characteristics to adequately attend to them during the periprocedural period.

The expenditure of computer-related worktime using clinical decision support systems in chronic pain therapy.

BACKGROUND: Estimate the expenditure of computer-related worktime resulting from the use of clinical decision support systems (CDSS) to prevent adverse drug reactions (ADR) among patients undergoing chronic pain therapy and compare the employed check systems with respect to performance and practicability. METHODS: Data were collected retrospectively from 113 medical records of patients under chronic pain therapy during 2012/2013. Patient-specific medications were checked for potential drug-drug interactions (DDI) using two publicly available CDSS, Apotheken Umschau (AU) and Medscape (MS), and a commercially available CDSS AiDKlinik® (AID). The time needed to analyze patient pharmacotherapy for DDIs was taken with a stopwatch. Measurements included the time needed for running the analysis and printing the results. CDSS were compared with respect to the expenditure of time and usability. Only patient pharmacotherapies with at least two prescribed drugs and fitting the criteria of the corresponding CDSS were analyzed. Additionally, a qualitative evaluation of the used check systems was performed, employing a questionnaire asking five pain physicians to compare and rate the performance and practicability of the three CDSSs. RESULTS: The AU tool took a total of 3:55:45 h with an average of 0:02:32 h for 93 analyzed patient regimens and led to the discovery of 261 DDIs. Using the Medscape interaction checker required a total of 1:28:35 h for 38 patients with an average of 0:01:58 h and a yield of 178 interactions. The CDSS AID required a total of 3:12:27 h for 97 patients with an average time of analysis of 0:01:59 h and the discovery of 170 DDIs. According to the pain physicians the CDSS AID was chosen as the preferred tool. CONCLUSIONS: Applying a CDSS to examine a patients drug regimen for potential DDIs causes an average extra expenditure of work time of 2:09 min, which extends patient treatment time by 25 % on average. Nevertheless, the authors believe that the extra expenditure of time employing a CDSS is outweighed by their benefits, including reduced ADR risks and safer clinical drug management.

Geriatrics in medical students' curricula: questionnaire-based analysis.

BACKGROUND: Demographic development is accompanied by an increasingly aging society. Concerning medical education, the treatment of older people as well as the scientific research and exploration of ageing aspects in the coming years need to be considered. Aim of the study was to ascertain medical students' knowledge, interest, and attitudes regarding older patients and geriatric medicine. METHODS: Each participant completed a self-designed questionnaire. This questionnaire was based on three validated internationally recognised questionnaires ("Facts on Aging Quiz--FAQ", "Expectations Regarding Aging--ERA" and the "Aging Semantic Differential--ASD"). The inquiry and survey were performed at the beginning of the summer term in 2012 at the University of Regensburg Medical School. RESULTS: A total of n = 184/253 (72.7%) students participated in this survey. The results of the FAQ 25+ showed that respondents were able to answer an average of M = 20.4 of 36 questions (56.7%) correctly (Median, Md = 21; SD ±6.1). The personal attitudes and expectations of ageing averaged M = 41.2 points on the Likert-scale that ranged from 0 to 100 (Md = 40.4; SD ±13.7). Respondents' attitudes towards the elderly (ASD 24) averaged M = 3.5 points on the Likert-scale (range 1-7, Md 3.6, SD ±0.8). CONCLUSIONS: In our investigation, medical students' knowledge of ageing was comparable to previous surveys. Attitudes and expectations of ageing were more positive compared to previous studies. Overall, medical students expect markedly high cognitive capacities towards older people that can actively prevent cognitive impairment. However, medical students' personal interest in medicine of ageing and older people seems to be rather slight.

International recommendations for outpatient palliative care and prehospital palliative emergencies - a prospective questionnaire-based investigation.

BACKGROUND: To determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts. METHODS: One hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical . RESULTS: The total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of "Palliative Care Teams" (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and "Do not attempt resuscitation" orders and (4) emergency medical training (physicians and paramedics). CONCLUSIONS: This study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.

Paramedics experiences and expectations concerning advance directives: a prospective, questionnaire-based, bi-centre study.

BACKGROUND: Advance directives and palliative crisis cards are means by which palliative care patients can exert their autonomy in end-of-life decisions. AIM: To examine paramedics' attitudes towards advance directives and end-of-life care. DESIGN: Questionnaire-based investigation using a self-administered survey instrument. SETTING/PARTICIPANTS: Paramedics of two cities (Hamburg and Goettingen, Germany) were included. Participants were questioned as to (1) their attitudes about advance directives, (2) their clinical experiences in connection with end-of-life situations (e.g. resuscitation), (3) their suggestions in regard to advance directives, 'Do not attempt resuscitation' orders and palliative crisis cards. RESULTS: Questionnaires were returned by 728 paramedics (response rate: 81%). The majority of paramedics (71%) had dealt with advance directives and end-of-life decisions in emergency situations. Most participants (84%) found that cardiopulmonary resuscitation in end-of-life patients is not useful and 75% stated that they would withhold cardiopulmonary resuscitation in the case of legal possibility. Participants also mentioned that more extensive discussion of legal aspects concerning advance directives should be included in paramedic training curricula. They suggested that palliative crisis cards should be integrated into end-of-life care. CONCLUSIONS: Decision making in prehospital end-of-life care is a challenge for all paramedics. The present investigation demonstrates that a dialogue bridging emergency medical and palliative care issues is necessary. The paramedics indicated that improved guidelines on end-of-life decisions and the termination of cardiopulmonary resuscitation in palliative care patients may be essential. Participants do not feel adequately trained in end-of-life care and the content of advance directives. Other recent studies have also demonstrated that there is a need for training curricula in end-of-life care for paramedics.

Knowledge levels of pharmaceutical sales representatives in pain therapy: a descriptive questionnaire-based study.

PURPOSE: Pain is a common physiological reaction. The development and sale of medication against pain is a main focus of pharmaceutical companies, with total sales of prescription analgesics amounting to US$50 billion in 2009. In this market, advertising is necessary. One way to market both new and old drugs is through direct physician-to-pharmaceutical sales representative (PSR) contact. PSRs see themselves ideally as equal partners to the physicians they advise, thereby setting high standards for themselves. In this setting, PSRs should therefore have an adequate knowledge of pain therapy. The aim of this study was to evaluate whether these standards can be met by PSRs working in the area of pain medicine in terms of their level of education and knowledge of pain topics. METHODS: We distributed 114 questionnaires that were divided into demographic and knowledge sections. Of these, 90 questionnaires (79%) were returned completed. Since there is no complete list of PSRs working in pain medicine in Germany, we could not draw a representative sample for our study. RESULTS: We collected general demographic data on PSRs as well as on their educational backgrounds. Analysis of the completed questionnaires revealed that there was a high requirement for PSRs to acquire further education in pain therapy. In the knowledge section, PSRs were asked to rate a total of 70 statements on pain therapy as to whether they were true or false. The mean total of correctly rated statements was 48 (69%). CONCLUSIONS: Based on the results, we conclude that most PSRs do not meet their ideal high standards of being equal partners to the specialist physicians they visit. More education is needed to achieve this goal.

Molecular analysis of the SGLT2 gene in patients with renal glucosuria.

The role of SGLT2 (the gene for a renal sodium-dependent glucose transporter) in renal glucosuria was evaluated. Therefore, its genomic sequence and its intron-exon organization were determined, and 23 families with index cases were analyzed for mutations. In 21 families, 21 different SGLT2 mutations were detected. Most of them were private; only a splice mutation was found in 5 families of different ethnic backgrounds, and a 12-bp deletion was found in two German families. Fourteen individuals (including the original patient with 'renal glucosuria type 0') were homozygous or compound heterozygous for an SGLT2 mutation resulting in glucosuria in the range of 14.6 to 202 g/1.73 m(2)/d (81 - 1120 mmol/1.73 m(2)/d). Some, but not all, of their heterozygous family members had an increased glucose excretion of up to 4.4 g/1.73 m(2)/d (24 mmol/1.73 m(2)/d). Likewise, in index cases with glucosuria below 10 g/1.73 m(2)/d (55 mmol/1.73 m(2)/d) an SGLT2 mutation, if present, was always detected in the heterozygous state. We conclude that SGLT2 plays an important role in renal tubular glucose reabsorption. Inheritance of renal glucosuria shows characteristics of a codominant trait with variable penetrance.