Michael Hüppe

Severity and specificity of neglect-like symptoms in patients with complex regional pain syndrome (CRPS) compared to chronic limb pain of other origins

Abstract In the literature, the neglect‐like syndrome is described as an additional phenomenon of CRPS. The perception of the affected limb as strange, disordered and not belonging to the body is typical of and characterises this syndrome. Since this phenomenon has never been studied in other pain conditions, we assessed occurrence and extent of neglect‐like symptoms in patients with CRPS of the upper and lower limb (n = 123) and in a control group with chronic limb pain of other origins (n = 117). Our questionnaire for describing the neglect‐like syndrome encompassed five items following Galer and Jensen [Galer BS, Jensen M. Neglect‐like symptoms in complex regional pain syndrome: results of a self‐administered survey. Journal of Pain and Symptom Management 1999;18:213–6], with a six‐point response scale inquiring the extent of respective symptoms. Results show that CRPS‐patients as well as patients with non‐CRPS limb pain exhibit the so‐called neglect‐like syndrome. However, the number of patients confirming such symptoms was significantly higher (OR = 2.87) in the CRPS group, moreover, these patients reported more severe symptoms (F = 17.74; p = 0.001). If the neglect‐like total score is ⩾5, the diagnostic sensitivity is low (21.1%), but the specificity for the diagnosis of CRPS reaches 90.6%. In this study, patients with CRPS of the upper and lower limb were included. The only difference between these two localisations concerning the neglect‐like syndrome was the symptom of ‘involuntary movements’, which occurs significantly more often in affected legs. In conclusion, we recommend to evaluate neglect‐like symptoms and to use them as an additional criterion in the diagnosis of CRPS. High scores of ⩾5 confirm the diagnosis of CRPS, whereas lower scores must not be used for disease classification.

Validation of the German Mainz Pain Staging System in different pain syndromes

Zusammenfassung.Fragestellung: In der vorliegenden Studie wird die Frage untersucht, ob die 3 Chronifizierungsstadien des Mainzer Stadienmodells der Schmerzchronifizierung (MPSS) bei verschiedenen Schmerzdiagnosegruppen mit Unterschieden in den Validitätsindikatoren „Schmerzempfindung“,„schmerzbezogene Beeinträchtigung“,„Depressivität“ und „Lebensqualität“ korrespondieren.Methodik: Der Analyse lagen konsekutiv erhobene Daten aus dem Dokumentationsprogramm QUAST zu Grunde. Validitätsindikatoren waren Selbstbeurteilungsangaben aus Testverfahren des Deutschen Schmerzfragebogens der DGSS. Die zentrale Auswertung erfolgte für Patienten mit der Hauptschmerzdiagnose „Kopfschmerz“, „neuropathischer Schmerz“, „Rückenschmerz“ und „muskuloskelettaler Schmerz“. Für jede der 4 Hauptdiagnosen wurde getrennt überprüft, ob sich die Patienten der 3 Chronifizierungsstadien in den Ausprägungen der psychometrischen Testverfahren unterscheiden und ob sich die 4 Diagnosegruppen untereinander unterscheiden.Ergebnisse: Es wurden 862 Datensätze in die diagnosespezifische Validitätsprüfung aufgenommen. Das Ausmaß der psychosozialen Beeinträchtigung steigt in allen 4 Diagnosegruppen in Abhängigkeit vom Chronifizierungsstadium an. Mit ansteigendem Chronifizierungsstadium steigt zudem der Anteil von Patienten mit Hinweis auf eine klinisch relevante Depression. Dies spricht für die diagnoseübergreifende Validität des MPSS.Schlussfolgerung: Die Befunde belegen für die 4 Diagnosegruppen eine gute Konstruktvalidität des Mainzer Stadienmodells. Da der Anteil der Patienten innerhalb eines Schmerzstadiums diagnoseabhängig ist, sollte auch in zukünftigen Untersuchungen, in denen das Chronifizierungsstadium als unabhängige Variable eingeht, die Auswertung getrennt nach Schmerzdiagnosegruppen erfolgen.Abstract.Objective: Our study was carried out to clarify whether differences in pain intensity,pain-related disability,depression and quality of life change with respect to the stage of chronicity of the Mainz Pain Staging Study (MPSS) in different pain syndromes. Keywords · · · · Methods: All patients with an initial pain clinic consultation from July 2000 to July 2001 and suffering from four major pain syndromes („headache“, „neuropathic pain“, „back pain“ or „muscle and joint pain“) were included. Indicators of validity were several self-rating scales from the German pain questionnaire of the German Chapter of the International Association for the Study of Pain (DGSS). Patient data were collected using QUAST, a database environment specifically developed for documentation and quality assurance in pain therapy. An assessment was made for each of the four major diagnoses to determine whether patients in the three chronicity stages differed in their psychometric test results. In addition,the four diagnosis groups were tested for differences from one another.Results: A total of 862 patient charts with documented pain syndromes and MPSS were extracted and analyzed. The extent of the subjective psychosocial stress and disability increased in all diagnosis groups and was correlated with the chronicity stage. The proportion of patients with an indication of clinically relevant depression (ADS score >23) increased with chronicity regardless of the pain diagnosis. The four main diagnosis groups differed with respect to the chronicity stage according to MPSS (P<0.001), with headache patients being classified predominantly as stage I. Patients with an additional pain diagnosis had a higher chronicity stage (P<0.001).Conclusion: Our results underline the validity of the MPSS for the four diagnosis groups examined; however, pain diagnosis must be controlled in all studies using chronicity stage as an independent variable, e.g., therapy studies. For optimal results physicians must closely follow the test instructions of the MPSS.

Validität des Mainzer Stadienmodells der Schmerzchronifizierung bei unterschiedlichen Schmerzdiagnosen

Zusammenfassung.Fragestellung: In der vorliegenden Studie wird die Frage untersucht, ob die 3 Chronifizierungsstadien des Mainzer Stadienmodells der Schmerzchronifizierung (MPSS) bei verschiedenen Schmerzdiagnosegruppen mit Unterschieden in den Validitätsindikatoren „Schmerzempfindung“,„schmerzbezogene Beeinträchtigung“,„Depressivität“ und „Lebensqualität“ korrespondieren.Methodik: Der Analyse lagen konsekutiv erhobene Daten aus dem Dokumentationsprogramm QUAST zu Grunde. Validitätsindikatoren waren Selbstbeurteilungsangaben aus Testverfahren des Deutschen Schmerzfragebogens der DGSS. Die zentrale Auswertung erfolgte für Patienten mit der Hauptschmerzdiagnose „Kopfschmerz“, „neuropathischer Schmerz“, „Rückenschmerz“ und „muskuloskelettaler Schmerz“. Für jede der 4 Hauptdiagnosen wurde getrennt überprüft, ob sich die Patienten der 3 Chronifizierungsstadien in den Ausprägungen der psychometrischen Testverfahren unterscheiden und ob sich die 4 Diagnosegruppen untereinander unterscheiden.Ergebnisse: Es wurden 862 Datensätze in die diagnosespezifische Validitätsprüfung aufgenommen. Das Ausmaß der psychosozialen Beeinträchtigung steigt in allen 4 Diagnosegruppen in Abhängigkeit vom Chronifizierungsstadium an. Mit ansteigendem Chronifizierungsstadium steigt zudem der Anteil von Patienten mit Hinweis auf eine klinisch relevante Depression. Dies spricht für die diagnoseübergreifende Validität des MPSS.Schlussfolgerung: Die Befunde belegen für die 4 Diagnosegruppen eine gute Konstruktvalidität des Mainzer Stadienmodells. Da der Anteil der Patienten innerhalb eines Schmerzstadiums diagnoseabhängig ist, sollte auch in zukünftigen Untersuchungen, in denen das Chronifizierungsstadium als unabhängige Variable eingeht, die Auswertung getrennt nach Schmerzdiagnosegruppen erfolgen.Abstract.Objective: Our study was carried out to clarify whether differences in pain intensity,pain-related disability,depression and quality of life change with respect to the stage of chronicity of the Mainz Pain Staging Study (MPSS) in different pain syndromes. Keywords · · · · Methods: All patients with an initial pain clinic consultation from July 2000 to July 2001 and suffering from four major pain syndromes („headache“, „neuropathic pain“, „back pain“ or „muscle and joint pain“) were included. Indicators of validity were several self-rating scales from the German pain questionnaire of the German Chapter of the International Association for the Study of Pain (DGSS). Patient data were collected using QUAST, a database environment specifically developed for documentation and quality assurance in pain therapy. An assessment was made for each of the four major diagnoses to determine whether patients in the three chronicity stages differed in their psychometric test results. In addition,the four diagnosis groups were tested for differences from one another.Results: A total of 862 patient charts with documented pain syndromes and MPSS were extracted and analyzed. The extent of the subjective psychosocial stress and disability increased in all diagnosis groups and was correlated with the chronicity stage. The proportion of patients with an indication of clinically relevant depression (ADS score >23) increased with chronicity regardless of the pain diagnosis. The four main diagnosis groups differed with respect to the chronicity stage according to MPSS (P<0.001), with headache patients being classified predominantly as stage I. Patients with an additional pain diagnosis had a higher chronicity stage (P<0.001).Conclusion: Our results underline the validity of the MPSS for the four diagnosis groups examined; however, pain diagnosis must be controlled in all studies using chronicity stage as an independent variable, e.g., therapy studies. For optimal results physicians must closely follow the test instructions of the MPSS.

Quality of life in aortic valve replacement: pulmonary autografts versus mechanical prostheses

OBJECTIVES We sought to determine whether the quality of life (QoL) is different in patients after aortic valve replacement with mechanical prostheses or pulmonary autografts. BACKGROUND Quality of life after mechanical valve replacement may be affected by the risk of thromboembolism and anticoagulation, and after autograft implantation, by the risk of degeneration and re-operation especially of the homograft. METHODS Two groups of 40 patients each--one after the autograft procedure (group I) and one after mechanical valve implantation (group II)--were matched for age, gender and length of follow-up. At latest follow-up, all patients underwent routine echocardiography, the short-form health survey (SF-36) QoL survey and an extensive psychological investigation. RESULTS Patients with an autograft showed better QoL scales, as compared with mechanical valve recipients. The difference was significant for both the physical (72.72+/-20.00 vs. 60.27+/-26.07, p = 0.021) and psychological health sum scores (74.71+/-21.03 vs. 64.71+/-23.49, p = 0.046) and for the subtests of physical functioning (73.72+/-22.44 vs. 62.77+/-25.42, p = 0.049), physical pain (88.39+/-19.13 vs. 73.36+/-27.08, p < or = 0.006), general health perception (64.37+/-17.88 vs. 51.86+/-22.86, p < or = 0.008) and health change (61.89+/-18.94 vs. 50.11+/-24.37, p = 0.02). The QoL variables did not correlate to pressure gradients, ejection fraction and New York Heart Association functional class. Psychometric tests revealed no meaningful differences between the groups. CONCLUSIONS This study provides some evidence that patients with pulmonary autografts have greater benefit in terms of QoL, as compared with recipients of mechanical valve substitutes.

Remifentanil-propofol versus sufentanil-propofol anaesthesia for supratentorial craniotomy: a randomized trial.

Background and objective: Remifentanil has unique pharmacokinetics that might allow faster recovery after neurosurgery. We investigated the effects of a propofol/sufentanil versus a remifentanil/propofol regimen on the primary end-point tracheal extubation time. Methods: In the Neurosurgery Department of a University Hospital, 36 patients awaiting craniotomy for supratentorial tumour resection were randomly assigned to one of two study groups. In the sufentanil/propofol group, anaesthesia was induced with 0.5 μg kg−1 sufentanil and 1-2 mg kg−1 propofol. Propofol infusion and boluses of sufentanil were administered for maintenance. In the remifentanil/propofol group, anaesthesia was started with an infusion of remifentanil (0.2-0.35 μg kg−1 min−1) and a bolus of propofol (1.5-2 mg kg−1). Patients received a propofol infusion and a remifentanil infusion for maintenance of anaesthesia. Recovery times were taken from cessation of the propofol infusion. In addition, data about self-reported nausea and vomiting, pain and analgesic requirements were collected. Results: Patients in the remifentanil/propofol group were extubated earlier (mean times 6.4 (±SD 4.7) versus 14.3 (±9.2) min; P = 0.003). The two groups were similar with respect to postoperative nausea and vomiting, and patient-reported pain scores. Fifty per cent of the remifentanil/propofol patients and 88% of the sufentanil/propofol patients required no analgesics within 1 h after operation (P =0.03). Conclusions: The remifentanil/propofol regimen provided quicker recovery. The two regimens were similar in terms of postoperative nausea and vomiting and patient-reported pain scores, but patients in the remifentanil/propofol group required more analgesics within 1 h postoperatively.

Prevention of medication overuse in patients with migraine

&NA; This multi‐center study compared the therapeutic effect of a cognitive‐behavioral minimal contact program (MCT) to the effect of a brochure (bibliotherapy) for the prevention of medication overuse headache (MOH) in migraine patients. Seven German headache centers recruited 182 migraine patients with high triptan or analgesic intake frequency. Patients were randomly allocated to either the MCT‐group, receiving both an MCT program and an educational brochure or to the biblio‐group receiving only the brochure. All participants continued usual medical treatment. Course of headaches, intake of analgesics or triptans after training, 3 months post‐training as well as 1–2 years (mean 15.7 months) later and psychological variables were defined as outcome variables. A significant decline was observed in the number of headache days (11.0–8.8), migraine days (7.3–5.7) and medication intake days (7.4–6.1) from pre to post in the MCT‐group (p < 0.001 each) and in the biblio‐group (p < 0.001 each). The pre‐to‐post‐improvements were maintained from pre‐ to short‐ and from pre‐ to long‐term follow‐up (p < 0.001 each) in both groups. Both groups improved significantly from pre to post in psychological variables, e.g. pain acceptance: p < 0.001; pain catastrophizing: p < 0.001; functional pain coping: p < 0.001; and pain related internal control beliefs: p < 0.01. Psychological improvements remained stable in both groups at short‐ and long‐term follow‐up. During the study, none of the patients developed an MOH. MCT‐ and bibliotherapy are useful in migraine patients to prevent medication overuse headache or the transition of episodic to chronic headache.

Reliabilität und Validität des Anästhesiologischen Nachbefragungsbogens bei elektiv operierten Patienten

ZusammenfassungFragestellung. Der Anästhesiologische Nachbefragungsbogen für Patienten (ANP) ist ein Selbstbeurteilungsverfahren zur Erfassung von postoperativen Symptome und von Patientenzufriedenheit. Der Fragebogen wurde mit dem Anspruch entwickelt, im klinischen Alltag zur Qualitätssicherung einsetzbar zu sein und dabei ein reliables und valides Messinstrument darzustellen. Diese Testgütekriterien wurden für den ANP untersucht. Methodik. Es füllten 1.112 Patienten ab 18 Jahren (588 Männer, 524 Frauen), die sich einem elektiven chirurgischen Eingriff unterzogen, den ANP postoperativ aus.Aus dem Narkoseprotokoll wurden anästhesiebozogene Daten selektiert.Zur Bestimmung der Retest-Reliabilität füllten 94 Patienten den Fragebogen postoperativ zweimal aus. Ergebnisse. Die Teilnahmebeteiligung entspricht 74,6% der Vollerhebung.Von den 19 Items des ANP haben 16 eine Retest-Reliabilität von rtt>0,70,die übrigen Items liegen über rtt=0,50.Die Reliabilität (innere Konsistenz) der Zufriedenheitsbereiche liegt zwischen rtt=0,76 und rtt=0,91.Frauen geben postoperativ mehr Beschwerden an als Männer und jüngere Patienten (18–49 Jahre) mehr Beschwerden als ältere.Jüngere Patienten sind mit der perioperativen Betreuung weniger zufrieden als ältere,Geschlechtsunterschiede finden sich in den Zufriedenheitsbereichen nicht.Es zeigen sich signifikante und plausible postoperative Symptomunterschiede zwischen Patienten mit Allgemein- und Regionalanästhesie. Patienten nach einer total intravenösen Anästhesie (TIVA) berichten postoperativ weniger Symptome als Patienten nach Inhalationsanästhesie.Aus der Kombination Kombination von Patienten- und Anästhesiemerkmalen lassen sich “Risikogruppen” mit postoperativen Beschwerden vorhersagen. Schlussfolgerungen. Der ANP ist ein zuverlässiges und valides Messinstrument zur differenzierten Erfassung des Patientenbefindens in der postoperativen Phase.AbstractObjective. The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction.The questionnaire consists of two parts.Part 1 assesses the intensity of symptoms regarding the postoperative period in the “recovery-room and the first hours on the ward” (19 items) and the “current state” (17 items).Part 2 assesses patient satisfaction with the anaesthetic care as well as the unspecific perioperative care and postoperative convalescence. The questionnaire was designed to fulfill the criteria of reliability and validity and to serve as a practicable means of auditing the quality of routine clinical practice. Methods. A total of 1,112 patients older than 18 years completed the questionnaire after an elective operation.Additionally data concerning the type of anaesthesia were recorded from the anaesthesia chart.To determine retest-reliability, 94 patients competed the ANP twice postoperatively. Results. The participants of the survey represented 74.6% of the total collective. Out of 19 items 16 had a retest-reliability of rtt>0.70, the 3 other items had a reliabilty of rtt>0.50.Reliability (Cronbachs Alpha) of the patient satisfaction scales was between rtt=0.76 and rtt=0.91.In relation to the period immediately after anaesthesia,women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with perioperative care. Younger patients (18-49 years old) described more postoperative complaints than older patients and a lesser degree of satisfaction with perioperative care.There were plausible differences in postoperative complaints between patients who received general vs. regional anaesthesia.Patients reported less postoperative complaints after TIVA than after volatile anaesthetics.The configuration of patient characteristics and anaesthesia gives indications to “risk groups” who predominantely suffer after anaesthesia. Conclusions. The Anaesthesiological Questionnaire (ANP) is a reliable and valid method for the assessment of postoperative complaints and patient satisfaction.

Elevated IL-6 levels in patients with atypical depression but not in patients with typical depression

Elevated levels of the proinflammatory cytokine Interleukin-6 (IL-6) are among the most consistent findings in patients with major depressive disorder (MDD). Additionally, some evidence suggests that elevated cytokine levels in patients with major depression are responsible for the development of metabolic syndrome in patients suffering from MDD. Therefore, the aim of the study was to examine the concentrations of IL-6 in specific subtypes of MDD and to investigate their relationship to metabolic factors. Twenty-four patients with typical (24) and atypical (eight) major depression according to DSM-IV criteria were studied and compared to 24 normal controls. Blood samples were collected during a stepwise glucose-clamp procedure, and IL-6 concentrations were measured by high sensitivity ELISA. IL-6 levels were elevated in patients suffering from atypical depression but not in patients with typical depression, compared to normal controls. IL-6 correlated significantly with HbA1c, insulin, waist girth, BMI, number of alcoholic drinks per week and C-reactive protein. Our data indicate that high concentrations of IL-6 during the glucose clamp may be limited to the atypical subgroup of patients with MDD.

Patientenkollektiv deutscher schmerztherapeutischer Einrichtungen

BACKGROUND In 1998 the board of the DGSS introduced a computerized documentation system named QUAST (quality assurance in pain therapy) building the foundation for a large, anonymous database that served as a data source for the statistical characterization of clinically relevant profiles of patients in German pain clinics. METHODS A total of 10,054 data files collected between 1998 and 2004, including socio-demographic as well as psychometric and pain parameters were analyzed. RESULTS The main pain diagnoses found in the database sample were back pain (37%), neuropathic pain (21.4%), soft tissue or arthralgia pain (19.5%) and headache (10.6%). The average duration of illness upon presentation at pain clinics was 7 years, nearly 20% contacted it within the first year. Of the sample, 43.8% of the patients were in the second chronicity stage and 39.0% in the third stage of the Mainz Pain Staging System (MPSS). Psychological measurements concerning despression, pain disability and quality of life indicated a great amount of psychological distress. Pronounced differences between main diagnostic groups were observed not only for psychological factors but also for direct pain parameters. CONCLUSIONS The documented data differ from other population-based data collections. In contrast to common belief there are a considerable number of patients who find access to specialized pain therapy institutions at an early stage of their illness. The hitherto regular use of generic, syndrome-overlapping diagnosis and treatment tools should be reconsidered taking into account the differences found between the main pain diagnosis groups. Lastly, this analysis provides current data on the psychological state of chronic pain patients showing a high degree of psychological distress and underlying the need of psychotherapeutic interventions in the treatment of chronic pain patients.

The effect of midazolam on stress levels during simulated emergency medical service transport: a placebo-controlled, dose-response study.

Patients in the emergency medical service (EMS) may have increased endogenous catecholamines because of pain or fear and may benefit from sedation similar to premedication in the hospital. During a simulated EMS scene call, 72 healthy male volunteers were either transported by paramedics from a third-floor apartment through a staircase with subsequent EMS transport with sirens (three stress groups of n = 12; total, n = 36) or asked to sit on a chair for 5 min and lie down on a stretcher for 15 min (three control groups of n = 12; total, n = 36). Catecholamine plasma samples were measured in the respective stress and control groups at baseline and after placebo IV (n = 12) or 25 (n = 12) or 50 (n = 12) &mgr;g/kg of midazolam IV throughout the experiment, respectively. Statistical analysis was performed with analysis of variance;P < 0.05 was considered significant. The Placebo Stress versus Control group, but not the 50 &mgr;g/kg Stress Midazolam group, had both significantly increased epinephrine (73 ± 5 pg/mL versus 45 ± 5 pg/mL;P < 0.001) and norepinephrine (398 ± 34 pg/mL versus 278 ± 23 pg/mL;P < 0.01) plasma levels after staircase transport. After EMS transport, the Placebo Stress versus Control group had significantly increased epinephrine (51 ± 4 pg/mL versus 37 ± 4 pg/mL;P < 0.05) but not norepinephrine (216 ± 24 pg/mL versus 237 ± 18 pg/mL) plasma levels, whereas no significant differences in catecholamine plasma levels occurred between groups after either 25 or 50 &mgr;g/kg of midazolam. In conclusion, simulated EMS patients may be subject to more stress during staircase transport than during transport in an EMS vehicle. Titrating sedation with 25 &mgr;g/kg of midazolam significantly reduced endogenous catecholamines but not heart rate.