[Extended outcome assessment in endonasal sinus surgery]. / Erweiterte Ergebnisanalyse der endonasalen Nasennebenhöhlenchirurgie.

BACKGROUND: Endonasal optically guided surgery has gained wide acceptance for treatment of chronic sinusitis. However, irrespective to the advent of minimally-invasive techniques, standard outcome assessment has not always reflected the increased technical and conceptual efforts. "Psychometric" instruments offer additional information on patients' perceptions of health. We analyzed the practical value of an extended outcome assessment. METHODS: Standardized interviews were carried out with 103 patients pre- and postoperatively applying several psychometrical instruments ("SF-36" and other valid general health-status instruments besides disease-specific questionnaires, providing 124 items/questions altogether). RESULTS: The diverse changes of subtle health status subscores as a rule paralleled each other and were concordant with traditional self-estimated global ratings of the surgical success by the patient. Significant postoperative changes of the "SF-36" questionnaire were especially seen in the subscale "bodily pain" and "level of energy". With few exceptions only, items reflecting any indirect burden of chronic sinusitis revealed less pronounced improvements postoperatively. CONCLUSION: It appears legitimate to question the special benefits of extended psychometric outcome research in comparison to traditional global ratings for daily surgical practice.

[Case report: neonatal hypertension]. / Kasuistik: neonatale arterielle Hypertonie.

BACKGROUND: Neonatal arterial hypertension is rare with an incidence between 0.2 - 3 %. Clinical presentation varies widely and is in some cases dramatic. PATIENT: A 4-day old full-term neonate was admitted to the intensive care unit with severe congestive heart failure and metabolic acidosis. Mechanical ventilation was initiated and dobutamine administered because of poor systolic function. Continuous monitoring of blood pressure revealed severe arterial hypertension (30 to 40 mm Hg above the 95th percentile). Ultrasonography showed an echogenic left kidney with normal perfusion. Laboratory examinations revealed a raised peripheral renin activity, thrombocytopenia, slightly raised d-dimers, a microhematuria and mild proteinuria. After resolution of hypertension under therapy with an ACE-inhibitor, a MAG3 renal scan showed complete absence of renal function on the left side. Renal artery stenosis was excluded by venous transcardial angiography. Under therapy with Captopril, the patient was discharged and followed up for 8 months. He is developing normally with normal serum creatinine (0.4 mg/dl), but low renal function (17 %) of the left side as assessed by DMSA-scan and compensatory right kidney hypertrophy are observed. DISCUSSION: Diagnosis and treatment of neonatal hypertension are discussed with respect to the proposed case. After exclusion of other causes we conclude that a perinatal microangiopathic event may have lead to the renal lesions with malignant renovascular hypertension.

[How reliable is our memory for acute postoperative pain]. / Wie zuverlässig ist unser Gedächtnis für akute postoperative Schmerzen?.Vergleich der retrospektiven Schmerzeinschätzung mit den Aufzeichnungen während postoperativer PCA.

OBJECTIVES: Clinicians use patients' recall of pain as an important source of evidence both in diagnosis and in assessing improvements following treatment. Yet very little is known about the accuracy of these retrospective accounts up to now. METHODS: We examined patients' retrospective evaluations of the pain they experienced at the first postoperative day and related these evaluations to the pain intensity which was recorded in the PCA-report. RESULTS: We found that recall was moderately accurate. Patients mostly overestimated their pain intensity. We could demonstrate that patients who overestimated their pain differed significantly from those who did not. The patients who overestimated showed no significant pain relief over the first three postoperative days. Other influences were the pain intensity of the third day and patients' expectations of the postoperative pain intensity. Our results could be embedded within the theoretical framework of general memory research. CONCLUSIONS: We conclude that real-time evaluations of pain intensity should be recorded additionally to retrospective accounts. Retrospective ratings are important too, because we suggest that the memory of pain more than the experience of pain itself form the basis of patients' future decisions about treatment including their compliance and their satisfaction with pain management.

[Patient-controlled analgesia: psychological predictors of pain experience, analgesic consumption and satisfaction]. / Patientenkontrollierte Analgesie. Psychologische Prädiktoren des postoperativen Schmerzerlebens, des Schmerzmittelverbrauchs und der Patientenzufriedenheit.

INTRODUCTION: The present study examines the relationship between different psychological variables (including anxiety, depression, locus of control, expectations of pain intensity and social support) and postoperative pain, analgesic consumption and satisfaction with the pain management in a study sample of 67 patients. METHODS: Intravenous patient-controlled analgesia was used for postoperative analgesia. Pain intensity was assessed by numerical rating scales and obtained from the PCA-report. On the fourth day after surgery, the patients estimated retrospectively the pain intensity of the first day. RESULTS: The results show that postoperative pain experience correlates significantly with several variables raised preoperatively. The retrospective variables were predicted by psychological measures. There was no relationship to the pain measurements of the PCA-report. CONCLUSIONS: While pain experience could be predicted by stable psychological traits, satisfaction was associated with the state variables, like anxiety and depression. It is precisely satisfaction with the pain therapy that could be improved by special preoperative psychological training and/or general information about the postoperative pain intensity.

Variability of outcome after lumbar disc surgery.

STUDY DESIGN: A prospective, consecutive study of patients' outcome at three subsequent follow-up times after lumbar disc surgery. OBJECTIVES: To evaluate how consistent outcome remained in a group of patients after lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Despite similar results concerning the overall outcome, results in most studies show different prognostic factors for lumbar disc surgery at different follow-up times. A reason for this observation could be that patients shift to a different outcome group during the observation period. METHODS: Before surgery and at the three follow-ups (3, 12, and 28 months after surgery) the Low Back Outcome Score was calculated. Groups with favorable and unfavorable outcome were determined after each follow-up according to the scores. RESULTS: Ninety-eight patients were studied. Forty percent showed an unstable outcome at different follow-up times. For each follow-up, three prognostic factors were determined. No prognostic factor showed significance at all follow-up examinations. CONCLUSIONS: Patients whose outcome after lumbar disc surgery does not remain stable present a major problem in the calculation of prognostic factors.

[Evaluation of postoperative pain therapy with patient-controlled analgesia from the viewpoint of the patient and nursing staff]. / Bewertung der postoperativen Schmerztherapie mittels PCA aus Sicht der Patienten und des Pflegepersonals.

Patient-controlled analgesia has been proven to be an effective technique in postoperative pain management. The aim of our study was to evaluate PCA on general surgery wards. 311 patients and their nurses were questioned about their experiences in using PCA for postoperative pain management. Satisfaction with pain relief judged by both patients and nursing staff, incidence of negative side effects and technical problems were studied. The great majority of patients and nursing staff rated the quality of pain relief as being satisfactory. Incidence of negative side effects was extraordinarily low. There was no respiratory depression observed, technical problems hardly arose. Most of the patients coped very well with operating their PCA-pumps. We conclude that PCA is a safe and effective method in postoperative pain management on surgical wards. Under the condition of regular monitoring of pain intensity, of analgesic consumption, level of sedation and of side effects by trained medical and nursing staff, monitoring of respiration and vigilance is not necessary for the PCA regimen we used.

[Coping and convalescence course after lumbar disk operations]. / Coping und Genesungsverlauf nach lumbaler Bandscheibenoperation.

BACKGROUND: Aim of the present prospective longitudinal study was the statistical foundation and thus further replication of recent findings of Hasenbring [13], who postulated a significant importance of specific, within the psychological pain research long neglected pain coping strategies as risk factors concerning pain chronification: appeals to "stick it out" on the cognitive level and endurance strategies on the behavioural level. METHODS: In contrast to Hasenbring's heterogeneous chronic pain patients sample (first plus repeated surgical or conservative treatment) the present 82 low back pain patients with acute radicular pain and simultaneous lumbar disc prolapse all underwent first time lumbar nucleotomy. Prior to treatment we conducted an extensive psychological and neurological examination. The psychological tests included a general depression scale (Allgemeine Depressionsskala; ADS) and the Kiel Pain Inventory (KPI). Based on these scales a cluster analysis was performed, which allocated patients to four distinct groups resembling the group structure ascertained by Hasenbring [12, 13]: A first group of patients characterized by a positive mood and marked endurance strategies (n=7); another cluster with depressive mood and simultaneous cognitive appeals to stick it out (n=10); a third group of emotionally depressed patients who preferably applied social and physical avoidance strategies in their coping with chronic pain (n=29), plus a last cluster without any psychological risk factors (n=26). RESULTS: As treatment outcome criteria to evaluate the quality of the convalescence process six months later we assessed the pain intensity (11-point self-rating scale), the ability to work, and whether the patients had applied for early retirement or not. Results showed no significant differences in pain intensity between the groups at the 6-month follow up. Concerning the two other outcome variables the two clusters characterized by cognitive or behavioural endurance tendencies turned out to be high risk groups: At the 6-month follow up patients of both groups seemed less likely to return to work. The patients typified by endurance strategies and positive mood had more often applied for early retirement than those patients without psychological risk factors. DISCUSSION: These results corroborate the finding that this subgroup of chronic low back pain patients might indeed carry a bad prognosis and call for further research into this area, especially with regard to rehabilitation potential and facilities of reintegration into working life.

[Evaluation of a group therapy program for anxious children]. / Evaluation eines Trainingsprogramms für ängstliche Kinder.

In this study 14 children with different anxieties attended in small groups a cognitive-behavioral training program. The groups met once a week over a period of ten weeks. Outcome was evaluated with different questionnares for children and parents and interviews at the beginning and the end of training and ten weeks later. The different measures showed a significant reduction of self-reported anxiety. Anxious, avoident and social insecure behaviour was also reduced. Further the negative self-talk of the children changed into more appropriate positive self-talk. As it was not possible to use an appropriate control group, the results can just be seen as hints for the effectivity of a cognitive-behavioral orientated group therapy program for the treatment of various childhood anxieties. Further research under controlled conditions is necessary.

Molecular basis of neurological dysfunction coupled with haemolytic anaemia in human glucose-6-phosphate isomerase (GPI) deficiency.

Glucose-6-phosphate isomerase (GPI) deficiency, an autosomal recessive genetic disorder with the typical manifestation of nonspherocytic haemolytic anaemia, can be associated in some cases with neurological impairment. GPI has been found to be identical to neuroleukin (NLK), which has neurotrophic and lymphokine properties. To focus on the possible effects of GPI mutations on the central nervous system through an effect on neuroleukin activity, we analysed DNA isolated from two patients with severe GPI deficiency, one of them with additional neurological deficits, and their families. The neurologically affected patient (GPI Homburg) is compound heterozygous for a 59 A-->C (H20P) and a 1016 T-->C (L339P) exchange. Owing to the insertion of proline, the H20P and L339P mutations are likely to affect the folding and activity of the enzyme. In the second family studied, the two affected siblings showed no neurological symptoms. The identified mutations are 1166 A-->G (H389R) and 1549 C-->G (L517V), which are located at the subunit interface. We propose that mutations that lead to incorrect folding destroy both catalytic (GPI) and neurotrophic (NLK) activities, thereby leading to the observed clinical symptoms (GPI Homburg). Those alterations at the active site, however, that allow correct folding retain the neurotrophic properties of the molecule (GPI Calden).

Are prognostic factors still what they are expected to be after long-term follow-up?

The aim of this prospective study of 121 patients was to investigate whether or not the predicting factors of lumbar disc surgery become lost over an increased follow-up time. Preoperatively, the patients classified their pain on the visual analogue scale, and general data, case histories, and neurologic findings were recorded. Follow-up examinations were carried out at 3, 12, and 28 months. At the 3-month follow-up examination, six predictive factors were calculated, after 1 year there were only four, and after 28 months only two predictive factors were found. After reviewing these results, it was apparent that the number of prognostic factors diminished over time. To obtain reliable surgery-related results for the prognostic factors in lumbar disc surgery, we believe that the follow-up period should not exceed 1 year.