[Indicators of structural quality in palliative care for cancer pain patients in Lower-Saxony]. / Palliativmedizinische Betreuung von Tumorschmerzpatienten in Niedersachsen Indikatoren der Strukturqualität.

INTRODUCTION: Palliative care in Germany fails to reach established standards. To improve this situation the Chamber of Physicians of Lower-Saxony initiated SUPPORT in 1995. Prior to interventions structural quality of care was evaluated, specifically the rate of availability of opioid-prescription-forms and the ability to treat chronic pain (defined as a construct of knowledge, attitudes and skills) were examined. METHODS: The survey was carried out using a standardized questionnaire mailed to a representative stratified sample of 1200 physicians. RESULTS: Out of 865 answering physicians (response rate 72.1%) only 36.9% had their own opioid-prescription-forms. Differentiations regarding to specialty, working place (clinic vs. private practice) and treatment of cancer pain patients during the last three months shows a better result for GPs (84.6%), internists (48.6%), gynecologists (51%) and pain specialists (66.7%). Only 33.1% of respondents claimed knowledge of the WHO-3-step-analgesic-ladder. Again the aforementioned differentiations yield somewhat better results for GPs (49.2%), internists (51.5%), gynecologists (34.7%) and pain specialists (55.6%), however only two thirds of these physicians were able to identify the correct number of steps of the WHO-algorithm. CONCLUSIONS: These results verify an insufficient structural quality in palliative care in Lower-Saxony. In the authors' opinion effective improvements can only be achieved by implementing a parallel strategy:improvement of basic knowledge in pain management with sufficient transfer of this knowledge into practice as well as raising the rate of availability of opioid-prescription-forms,and, on the other hand, establishing local palliative-care-teams with nursing and medical expertise with 24/7 on-demand availability to optimize palliative care.

[Improvement of palliative outpatient treatment of terminally ill cancer patients - SUPPORT as example - The ethically preferable alternative to euthanasia]. / Optimierung der ambulanten palliativmedizinischen Betreuung terminal kranker Tumorpatienten am Beispiel SUPPORT - ethisch zu präferierende nach aktiver Sterbehilfe.

INTRODUCTION: Industrial countries are experiencing substantial increases in cancer prevalence. While advanced cancer therapies resulted in prolonged survival most neoplasms still are incurable. Especially advanced stages of cancer are often accompanied by severe pain and other disabling symptoms. Sufficient pain and symptom control is needed to maintain a decent quality of life for cancer patients. However, expert palliative care for patients suffering from cancer pain is still insufficient. These deficits have encouraged pro-euthanasia pressure groups demanding legitimation of physician-assisted-suicide in Germany. Acting under the guise of promoting patient's autonomy these groups are gaining additional momentum from similar legislation passed in the Netherlands. METHODS: Hospice movement and specialists in palliative medicine reject euthanasia as unethical and instead push for the global development of palliative care services. To address these issues the project SUPPORT was established in the Southern part of Lower-Saxony in 1996 with approval by the local ethics committee and sponsored by the German Ministry of Health. A palliative-care-team (PCT) of nurses and physicians with expert knowledge in palliative medicine supports patients after discharge from hospital by providing state-of-the-art palliative care at home. The PCT is available as a 24/7 standby service and can be called on demand by general practitioners, members of outpatient nursing services as well as by patients and their relatives. By cooperating with the PCT these professional and lay caregivers improve their knowledge and skills regarding pain and symptom control for terminally ill patients. RESULTS: During almost 4 years of practical work more than 50 % of the patients enrolled in the project died at home compared to about 20 % under regular conditions. These data point out quite impressively that due to the PCT-interventions recurrent hospitalisations in a majority of cancer pain patients can be avoided when expert knowledge and help is available at home for patients, their relatives and caregivers whenever needed. CONCLUSION: When sufficiently supported at home by palliative experts the number of patients dying at home is reasonably higher than the rate observed under regular conditions. This would also comply with the wishes of most patients who prefer to die in the privacy of their own home. The project data suggest that the concept of SUPPORT should be capable to improve the current state of palliative medicine in other areas of Germany as well.

[Basics of drug therapy of cancer pain]. / Grundlagen der medikamentösen Tumorschmerztherapie.

Industrial countries experience a significant increase of cancer prevalence. Despite recent advances in the treatment of various types of cancer still most of the patients cannot be cured. Especially the advanced incurable stages of cancer, however, often are accompanied by severe pain. Therefore, the high demand for a sufficient pain management and symptom control seems obvious. Throughout the last decades new drugs and techniques for the management of cancer pain have been developed. Most cancer patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer pain (e.g. WHO-guidelines) are followed consequently. If, nevertheless, intractable pain or ongoing disabling symptoms continue despite proper therapy, every doctor should feel himself obliged to consult an expert in palliative medicine, in order not to tolerate avoidable suffering of his patient.

[Pain therapy in tumor patients and in palliative medicine. 1: Drug therapy]. / Schmerztherapie bei Tumorpatienten und in der Palliativmedizin. Teil 1: Medikamentöse Massnahmen.

Like other industrial countries Germany experiences a significant increase of cancer prevalence. Recent advances in the treatment of various types of cancer resulted in prolonged survivaltimes of patients. Cancer--especially in advanced incurable stages--often is accompanied by severe pain. Therefore, the need for sufficient pain management and symptomcontrol is obvious. Throughout the last decades new drugs and techniques for the management of cancer-pain have been developed. Most cancer-patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer-pain (e.g. WHO-guidelines) are followed consequently. In case of intractable pain or ongoing disabling symptoms despite proper therapy consultation of an expert in palliative medicine should always be considered as well as the option to refer the patient to a specialized pain-management center.

[Pain therapy in tumor patients and in palliative medicine. 2: Invasive measures]. / Schmerztherapie bei Tumorpatienten und in der Palliativmedizin. Teil 2: Invasive Verfahren.

Anesthesiological and neurosurgical methods in the treatment of cancer pain have to be considered as parts of a holistic approach. To treat cancer pain patients appropriately, an interdisciplinary setting is essential. In the eyes of experienced pain specialists as well as physicians in palliative medicine invasive procedures are only of minor importance. Their use has been steadily decreasing while neuromodulatory (e.g. intraspinal opioids) or stimulatory (e.g. TENS, DBS, SCS) methods gained wider acceptance. The only neurolytic procedure which still has some importance is the neurolysis of the celiac ganglion for alleviation of pain in the upper abdomen mostly due to pancreatic cancer. This approach seems to be highly effective and tends to be afflicted with only minor complications. Other neurolytic blocks have shown solely local and temporal efficacy. In their majority they are unprecise and often accompanied by severe complications. Therefore these procedures should be scheduled only after carefully weighing risk versus benefit. Where suitable, the use of neurolytics is replaced by radiofrequency thermocoagulation, to a lesser degree by cryoanalgesia. Both procedures normally do not yield better analgesia but do result in fewer complications. Physicians tend to treat pain as a completely somatic disorder, but chronic pain states are always bio-psycho-social in nature. In order to achieve an effective pain treatment all influencing variables have to be taken into account. Anesthesiological and neurosurgical procedures are only a part of the possible and necessary treatment options. Especially before using one of the invasive methods described here, it seems imperative to involve the patient in the process of decision making more closely than currently practiced.

[Isokinetic strength of lumbar muscles in patients with chronic backache]. / Die isokinetische Kraftleistungsfähigkeit der Rumpfmuskulatur von Patienten mit chronischen Rückenschmerzen.

Lumbar isokinetic strength and the influence of age, bodyweight and testing velocity in patients with chronic low back pain in comparison with persons without pain. Lumbar isokinetic strength parameters of 80 patients with chronic low back pain and 70 persons without pain were compared and the influence of age, bodyweight and testing velocity was evaluated. The patients with chronic low back pain showed less strength than the persons without pain. All parameters of extension discriminated between the two groups whereas only some of the flexion parameters did. The isokinetic strength of the lumbal extension muscles was higher than the strength of the flexion muscles. In patients with chronic low back pain, isokinetic strength of lumbar extension muscles was more reduced than the strength of flexion muscles in comparison with persons without pain. At 90 degrees/sec in comparison to 60 degrees/sec, lower extension forces, higher flexion forces and changed ratios of flexion and extension muscles were measured. Age had an influence only on women. There were no changes in ratios of flexion and extension muscles with increasing age. Bodyweight showed weak correlations with isokinetic flexion forces. The influence of different factors on isokinetic force varies between patients with chronic low back patients and healthy subjects.

[Interrater studies of evaluating the reliability of somatic findings]. / Interrater-Untersuchungen zur Reliabilitätsprüfung somatischer Befunde.

20 patients (11 female, 9 male) without low back pain were included in two interrater studies carried out by three physical therapists. The following variables were investigated: shape of the spine, iliac crest heights, twisting of the pelvis, spine test, length of legs, Patrick sign, Schober test, fingertip-to-floor measurements, flexion and extension of the lumbar spine, straight-leg raising, and length of the iliopsoas and the rectus muscles. Intraclass coefficients for the ordinal variables, and kappa coefficients for the nominal variables were calculated for evaluation of interrater agreement. In both investigations, the Schober sign, lumbar flexion, fingertip-to-floor measurements, straight-leg raising of the left leg, and lengths of both legs were almost perfectly reliable. All other variables exhibited a lower reliability between the three therapists.

Myocardial extraction of bupivacaine in anaesthetized sheep and by hearts of sheep and rats in vitro.

We observed the in vivo kinetics of bupivacaine in the cardiopulmonary system, particularly in the pulmonary artery, the upper part of the descending aorta and the coronary sinus of anaesthetized sheep, each of which received a high dose infusion into the central vein. In some experiments dilution curves were monitored for the non-extracted dye, indocyanine green. Concentrations of bupivacaine were approximately 20% lower in the aorta than in the pulmonary artery. This gradient of bupivacaine was present across the lung for 5-10 min. Concentrations of bupivacaine in the coronary venous plasma were also markedly lower than at the arterial site. Initially more than 50% of the amount of bupivacaine at the arterial site was removed by the heart. Later, the myocardial extraction ratio decreased and plateaued at a value of 0.30-0.40. At this time, concentrations of bupivacaine in the pulmonary artery were approximately 12 micrograms ml-1. Therefore, approximately 0.3-0.6 mg of bupivacaine were extracted per minute by the sheep heart in vivo. On the other hand, isolated perfused rat hearts did not substantially remove bupivacaine (2 micrograms ml-1) from the medium. Approximately one-third of 14C-bupivacaine was retained in slices of rat and sheep myocardial tissue. However, there was no evidence that metabolism played a substantial role in the cardiac kinetics of bupivacaine.

Lumbar range of motion: reliability and validity of the inclinometer technique in the clinical measurement of trunk flexibility.

STUDY DESIGN: This study examines the reliability and validity of measuring lumbar range of motion with an inclinometer. OBJECTIVES: To find out whether a manual determination of the reference points for measuring lumbar range of motion is as reliable as radiologic determination for positioning the inclinometers, lumbar range of motion was determined in degrees by evaluating radiographs and by using the inclinometer technique of Loebl. SUMMARY OF BACKGROUND DATA: Reliability and validity of the inclinometer technique as a clinical measurement of trunk flexibility were investigated. Fifty-four patients participated in the study. METHODS: Lumbar range of motion measurements were taken with and without radiologic control of the T12 and S1 vertebrae as reference points for positioning of the inclinometers. An interrater correlation was done of the inclinometer techniques of a physician and a physiotherapist. Functional radiographs were investigated in a standing position. Lumbar range of motion measurements based on radiographs and those taken using the inclinometer alone were correlated to validate the inclinometer technique. RESULTS: Lumbar range of motion measurements taken with and without radiologic determination showed a very close correlation (r = 0.93; P < 0.001). Flexion alone also demonstrated a close correlation (r = 0.95; P < 0.001), whereas extension showed a somewhat smaller correlation (r = 0.82; P < 0.001). Total lumbar range of motion (r = 0.94; P < 0.001) and flexion (r = 0.88; P < 0.001) were closely related, as indicated by the interrater correlation, whereas extension (r = 0.42; P < 0.05) showed a lesser correlation. Correlation of the measurements taken radiographically and by inclinometer demonstrated an almost linear correlation for measurements of the total lumbar range of motion (r = 0.97; P < 0.001) and flexion (r = 0.98; P < 0.001), whereas extension (r = 0.75; P < 0.001) did not correlate as well. CONCLUSIONS: The noninvasive inclinometer technique proved to be highly reliable and valid, but the measurement technique for extension needs further refinement.

Lumbar range of motion: influence of time of day and individual factors on measurements.

STUDY DESIGN: Influence of time of day and individual factors on the measurements of the lumbar range of motion was investigated. OBJECTIVES: To investigate factors that influence lumbar range of motion. SUMMARY OF BACKGROUND DATA: Twenty-nine patients with chronic low back pain participated in the study. METHODS: The lumbar range of motion was measured by inclinometer technique, Schober sign, modified-Schober sign, and fingertip-to-floor method in the morning, at noon, and in the afternoon. The lumbar range of motion was correlated with patients' gender, age, and body weight. RESULTS: Total lumbar range of motion measured by the inclinometer technique and the modified-Schober sign increased significantly throughout the day from morning to afternoon. Extension lumbar range of motion was shown to be independent of the time of measurement. There were no significant correlations between lumbar range of motion and gender, age, and body weight of the patients. CONCLUSION: For the reliability of a measurement, it is important to investigate lumbar range of motion at the same time of day.

[Diagnosis of magnesium deficiency in intensive care patients]. / Untersuchung zur Diagnose eines Magnesiummangels bei Intensivpatienten.

AIM: Magnesium deficiency was investigated in critically ill patients, comparing measurements of plasma concentrations with the results obtained by the magnesium tolerance test. DESIGN AND METHODS: 20 critically ill patients (5 females, 15 males) between the ages of 27 and 86 were investigated. Magnesium plasma concentrations were determined before the magnesium tolerance test according to Ryzen was performed. For this purpose, magnesium sulfate (0.1 mmol/kg) was infused intravenously over four hours. Renal magnesium excretion was measured in the 24 h urine beginning at the start of the infusion. Magnesium concentrations in plasma and urine were determined using atomic absorption spectrophotometry. MAIN RESULTS: In 12 patients magnesium plasma concentrations were decreased to 0.58-0.79 mmol/l. 6 patients showed values within the normal range of 0.80 to 1.0 mmol/l. In 2 patients the plasma concentration was increased to 1.07 and 1.27 mmol/l. Parenteral magnesium tolerance testing revealed a considerable magnesium deficiency by retention of 65-100% of the loading dose in 14 of the 20 patients. The remaining 6 patients retained 23-48% of the loading dose, thus demonstrating a moderate magnesium deficiency. CONCLUSION: Determination of magnesium plasma concentration appears suitable as an informative preliminary survey, since low values are reliable indicating a magnesium deficiency. However, this study confirms that normal magnesium plasma concentrations do not exclude a considerable magnesium deficiency, which is more sensitively determined by the magnesium tolerance test.

[Interactions between renal and general hemodynamics in fentanyl, droperidol, ketamine, thiopental and in peridural anesthesia--animal studies]. / Wechselwirkung zwischen renaler und allgemeiner Hämodynamik unter Fentanyl, Droperidol, Ketamin, Thiopental sowie unter Periduralanästhesie-tierexperimentelle Untersuchungen.

The main focus of this paper is to show regulative interactions between cardiac index (CI) and renal blood flow (RBF) with various intravenous anaesthetics under steady state conditions. Several experimental series were carried out on dogs with the following anaesthetic doses (as given per hour and per kilogram body weight-h-1 x kg-1): fentanyl 50 micrograms, ketamine 4 and 10 mg, and thiopentone 10 and 20 mg. The basic anaesthesia used was halothane (0.7 vol.%) in N2O/O2 (ratio about 3:1), because renal function, renal autoregulation and responsiveness to renally effective drugs remain nearly unaltered by this anaesthetic procedure. The experimental set-up allowed separate evaluation of effects caused by basic anaesthesia, by intravenous anaesthetic under examination or by the combination of both. All physiological parameters, such as blood gas parameters, plasma electrolytes and intravasal volume were kept in normal range throughout the experiments. Under all anaesthetics studied, RBF reflects the situation of general metabolism especially of cardiac output, as long as sympathetic innervation of the kidneys remains unaltered. Especially the relationship between RBF and CI corresponds with regulative effects in situations without anaesthesia. Within the blood pressure range of autoregulation RBF is greater under ketamine than normal and smaller under fentanyl and etomidate, whereas all other anaesthetics applied show no effect on RBF. Functional "denervation" of the kidney by means of epidural anaesthesia is capable of terminating those effects caused centrally by opioids and transmitted by sympathetic nerves. Diuresis is increased by thiopentone and by ketamine, whereas fentanyl reduces it. The activity of the plasma renin level does not correspond with the degree of renal vascular resistance. The effect of each anaesthetic drug on RBF has principally to be taken as regulative adaptation to altered circulatory conditions. Increasing plasma renin levels are mainly a compensatory reaction following a decline in arterial blood pressure due to anaesthesia induced sympathicolysis. With regard to renal function, the additional use of epidural anaesthesia (functional "denervation" of the kidney) can be recommended especially for highly invasive surgical procedures to antagonize reduction of RBF, which is often induced sympathetically by pain or by commonly used anaesthetic drugs.

[Prevalence of migraine in Germany.]. / Migräneprävalenz in Deutschland.

INTRODUCTION: There are no valid data available for Germany on the prevalence of migraine using the new diagnostic and classification criteria of the International Headache Society (IHS). SAMPLE AND METHODS: Therefore, a survey on migraine prevalence was carried out on a representative sample of 2000 residents aged 16 to 69 years of the states of the former West Germany. The questionnaire incorporated the new criteria of the IHS and the diagnosis of migraine was based on the corresponding classification. RESULTS: Some 23.4% of the sample suffered from headaches, and 3.6% were identified as having migraine according to the IHS classification. The prevalence of migraine was 5.3% in women and 1.7% in men. The highest prevalence of 5.7% was found in the group aged 40-49 years. By extending the 4-72 h IHS attack duration criterion to 2-72 h, the migraine prevalence increased from 3.6% to 4.4%. DISCUSSION: For methodological reasons our study may underestimate the true prevalence of migraine in Germany. Taking our rather "conservative" figures into account, our study reveals, however, that there are more than 2 million migraine sufferers in Germany between 16 and 69 years of age.

Subcutaneous sumatriptan during the migraine aura. Sumatriptan Aura Study Group.

This double-blind, placebo-controlled, multicenter, parallel-group study assessed whether subcutaneous sumatriptan administered during the migraine aura would prolong or modify the aura and prevent or delay development of the headache. One hundred seventy-one patients (88 receiving 6 mg sumatriptan, 83 receiving placebo) treated a single attack of migraine with typical aura at home, by self-injection. The median duration of aura following the first injection was 25 minutes for the sumatriptan group and 30 minutes for the placebo group (NS). The aura symptom profile was similar for the two treatment groups. The proportion of patients who developed a moderate or severe headache within 6 hours after dose administration was similar in the two groups--68% among those receiving sumatriptan and 75% among those receiving placebo (NS). Sumatriptan given during the aura did not prolong or alter the nature of the migraine aura and did not prevent or significantly delay headache development.

Comparison of the determination of magnesium by methylthymol blue spectrophotometry and atomic absorption spectrophotometry.

Plasma samples (n = 155) of 30 patients on an intensive ward were analysed for magnesium simultaneously by atomic absorption spectrophotometry (AAS) and methylthymol blue spectrophotometry. Methylthymol blue spectrophotometry was performed at the bedside, using two different multianalysers, Easy ST 1 and Easy ST 2, Merck, D-Darmstadt. Precision was 12.2% (Easy ST 1) and 17.1% (Easy ST 2), and the average value was 0.89 mmol/l, which was above the expected range (0.72-0.88 mmol/l). Accuracy was 16.25% (Easy ST 1) and 8.75% (Easy ST 2). Analyser 2 was more accurate (8.75% versus 6.25%) but less precise (17.1% versus 12.2%) than analyser 1. Precision of AAS was between the expected values of 0.69 and 0.84 mmol/l. Easy ST and AAS gave significantly different values (p < 0.0001) for 155 measurements. Comparison of AAS and methylthymol blue spectrophotometery showed that methylthymol blue spectrophotometry produced higher values than AAS (mean difference 0.186 mmol/l). Furthermore, analyses of 40 samples of a standardized plasma concentration with methylthymol blue spectrophotometry showed a very low precision (15.3%). Easy ST cannot be assigned for urinary measurements of magnesium. Experimentally measured samples gave unaccountable results.

Exteroceptive suppression of temporalis muscle activity during migraine attack and migraine interval before and after treatment with sumatriptan.

We compared the early (ES1) and late (ES2) exteroceptive suppression (ES) periods of temporalis muscle activity in 18 migraine patients during both the migraine interval and migraine attack and investigated the effect of sumatriptan and placebo on ES parameters. The measurements were performed in a balanced sequence at four different times on each patient, twice during the migraine interval and once in each of two migraine attacks. First ES1 and ES2 were measured (stimulus intensity 20 mA, stimulus duration 0.2 ms, stimulation frequency 2 Hz, averaging of 10 responses), then the medication was given on a double-blind basis with an autoinjector using either 6 mg sumatriptan or a placebo solution. Thirty minutes after application the measurements were repeated. No significant differences were found in early and late exteroceptive suppression latencies and durations between baseline measurements. Treatment did not affect the latencies of ES1 and ES2. While sumatriptan caused a significant increase in ES1 duration (p < or = 0.05) both during the migraine interval and during the migraine attack, placebo showed no significant effect on ES1 duration. Treatment with sumatriptan during the migraine attack was accompanied by a significant increase in the duration of ES2 (p < or = 0.05), but no significant changes in the durations of the late suppression periods were observed under any other conditions. The results do not support the assumption that under the experimental conditions chosen migraine attacks are accompanied by a paroxysmal change in the brain-stem mechanisms involved in the modulation of the ES parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

A new paediatric metabolic monitor.

OBJECTIVE: A paediatric option for the measurement of VO2 and VCO2 (20 to 150 ml/min) has recently been introduced for the adult Deltatrac metabolic monitor (Datex Instrumentarium, Finland) to use in ventilated and spontaneously breathing children. This paper describes a laboratory validation of the paediatric option for ventilated children with regard to the influence of respiratory variables. DESIGN: Respiratory variables were varied within the following ranges: FIO2 0.21-0.8, FIO2-FEO2 (DFO2) 0.01-0.05, FECO2 0.01-0.05, VE 300-6000 ml/min, VT 8-300 ml, RR 10-50/min, P(aw) 10-60 mbar, relative humidity 10% and 60%, and resulted in 107 test situations. SETTING: Gas exchange was simulated by injection of nitrogen and CO2 at a RQ close to 1. PATIENTS OR PARTICIPANTS: Different situations of paediatric patients ventilated in controlled mode were simulated on a gas injection model. INTERVENTIONS: Respiratory and metabolic variables were varied independently to result in a range of 8 to 210 ml/min of VO2 and VCO2. MEASUREMENTS AND RESULTS: Reference measurements were carried out by mass spectrometry and wet gas spirometry. The mean VCO2 difference for all tests ranging from 20 ml/min to 210 ml/min was -2.4% (2SD = +/- 12%). The respective VO2 difference was -3.2% (2SD = +/- 23%). Measurement agreement for VO2 in neonatal respirator treatment (20-50 ml/min) compared to older children (50-210 ml/min) showed a mean difference of -3.9% (2SD = +/- 26%) versus -2.8% (2SD = +/- 20%). The respective differences for VCO2 were -7.1% (2SD = +/- 7%) versus +0.4% (2SD = +/- 10%). The mean difference for VO2 as well as VCO2 indicated a high systematic agreement of both methods. The variability (+/- 2SD) in VCO2 measurement is acceptable for all applications. The overall variability in VO2 measurement (2SD = +/- 23%) can be reduced by exclusion of all tests with a FECO2 and DFO2 below 0.03. This results in a mean difference of -3.2% (2SD = +/- 13.7%). CONCLUSION: Within this limitation the paediatric measurement option seems to introduce a valuable method for clinical application in paediatric intensive care medicine.