[Psychological assessment and psychotherapy for chronic pain in the elderly]. / Psychologische Diagnostik und Psychotherapie bei chronischen Schmerzen im Alter.

Systematic reviews of psychosocial assessment and effectiveness of psychotherapy for chronic pain syndromes in older patients are rare. However, it is of particular importance to consider the psychosocial aspects of elderly people with chronic pain. This narrative review describes recommended German-language assessments of the psychosocial dimensions of pain and summarizes existing studies of psychological therapy approaches for chronic pain in old age. Effective psychometric instruments are available for the assessment of cognitive function, pain-specific attitudes, depression, fear of falling, interpersonal processes and social activities, pain management, pain acceptance, disability, psychological well-being, and quality of life. Further experience with the use of these instruments with cognitively impaired or geriatric patients is required. The efficacy of age-adapted cognitive behavioral therapy and multimodal therapy for older patients has been documented. However, there is often a lack of supporting documentation about important result parameters (e.g., quality of life, functioning in everyday life, or pain acceptance). Overall, chronic pain in elderly people requires a biopsychosocial-spiritual model of pain. More attention should be given in research and daily practice to religiosity/spirituality as a possible means of coping, while mindfulness- and acceptance-based therapies should be further explored.

[Health care professionals' attitudes and beliefs towards older back pain patients. Analysis of the assessment methods and research gaps]. / Einstellungen und Überzeugungen von Behandlern bei älteren Patienten mit Rückenschmerzen. Eine Analyse der Erhebungsinstrumente und Forschungslücken.

In recent years, the influence of doctors' and therapists' attitudes and beliefs for the treatment of chronic low back pain patients has been increasingly investigated. Attitudes and beliefs of health care providers have been identified as important contributors for an activity based, guideline-oriented therapeutic approach and different questionnaires were developed to evaluate this interaction. Recent reviews discuss the quality of those questionnaires as well as the impact of attitudes towards therapeutic choices and activity recommendations by health care professionals. This article summarizes these results and illuminates transferability of existing questionnaires to older patients with back pain. A literature review shows that most studies were conducted with physiotherapists and general practitioners. At present the most thoroughly investigated tool for its psychometric validity is the Pain Attitudes and Beliefs Scale (PABS). The PABS could be a suitable instrument for examinations regarding therapist attitudes towards older pain patients by using more age-neutral wording. Concluding from the literature, an additional methodological assessment tool could be the utilization of case vignettes. However, those case vignettes, which had been used in studies in England, should be translated and culturally adapted before its application in Germany. Overall, it must be assumed that attitudes and beliefs of clinicians are also important in the care of older patients in pain. With regards to activity recommendations, ageism and the special situation of older people should also be taken into account including possible risk of falling, multimorbidity, polypharmacy, and cognitive impairment. These topics should all be considered in adapted or newly developed questionnaires for the evaluation of attitudes and beliefs of health care providers regarding back pain in older persons.

[Coping resources in a sample of chronic low back pain patients. Evaluation of the questionnaire for back pain]. / Fragebogen zu Bewältigungsressourcen bei Rückenschmerzen. Evaluierung an einer Stichprobe chronischer Kreuzschmerzpatienten.

BACKGROUND: The coping resources questionnaire for back pain (FBR) uses 12 items to measure the perceived helpfulness of different coping resources (CRs, social emotional support, practical help, knowledge, movement and relaxation, leisure and pleasure, spirituality and cognitive strategies). The aim of the study was to evaluate the instrument in a clinical patient sample assessed in a primary care setting. SAMPLE AND METHODS: The study was a secondary evaluation of empirical data from a large cohort study in general practices. The 58 participating primary care practices recruited patients who reported chronic back pain in the consultation. Besides the FBR and a pain sketch, the patients completed scales measuring depression, anxiety, resilience, sociodemographic factors and pain characteristics. To allow computing of retested parameters the FBR was sent to some of the original participants again after 6 months (90% response rate). We calculated consistency and retest reliability coefficients as well as correlations between the FBR subscales and depression, anxiety and resilience scores to account for validity. By means of a cluster analysis groups with different resource profiles were formed. Results. RESULTS: For the study 609 complete FBR baseline data sets could be used for statistical analysis. The internal consistency scores ranged fromα=0.58 to α=0.78 and retest reliability scores were between rTT=0.41 and rTT=0.63. Correlation with depression, fear and resilience ranged from r=-0.38 to r=0.42. The cluster analysis resulted in four groups with relatively homogenous intragroup profiles (high CRs, low spirituality, medium CRs, low CRs). The four groups differed significantly in fear and depression (the more inefficient the resources the higher the difference) as well as in resilience (the more inefficient the lower the difference). The group with low CRs also reported permanent pain with no relief. The groups did not otherwise differ. CONCLUSIONS: The FBR is an economic instrument that is suitable for practical use e.g. in primary care practices to identify strengths and deficits in the CRs of chronic pain patients that can then be specified in face to face consultation. However, due to the rather low reliability, the use of subscales for profile differentiation and follow-up measurement in individual diagnoses is limited.

Defining oligometastatic pancreatic cancer: a systematic review and critical synthesis of consensus.

BACKGROUND: Small retrospective series suggest that local consolidative treatment (LCT) may improve survival in oligometastatic pancreatic ductal adenocarcinoma (PDAC). However, no uniform definition of oligometastatic disease (OMD) in PDAC exists; this impedes meaningful conclusions. PATIENTS AND METHODS: A systematic literature search using PubMed, Web of Science, and Cochrane CENTRAL registries for studies and protocols reporting on definitions and/or LCT of OMD in PDAC was performed. The primary endpoint was the definition of OMD. Levels of agreement were categorized as consensus (≥75% agreement between studies), fair agreement (50%-74%), and absent/poor agreement (<50%). RESULTS: After screening of 5374 abstracts, the full text of 218 studies was assessed, of which 76 were included in the qualitative synthesis. The majority of studies were retrospective (n = 66, 87%), two were prospective studies and eight were study protocols. Studies investigated mostly liver (n = 38, 51%) and lung metastases (n = 15, 20%). Across studies, less than one-half (n = 32, 42%) reported a definition of OMD, while 44 (58%) did not. Involvement was limited to a single organ (consensus). Additional criteria for defining OMD were the number of lesions (consensus), metastatic site (poor agreement), metastatic size (poor agreement), treatment possibilities (poor agreement), and biomarker response (poor agreement). Liver OMD could involve three or fewer lesions (consensus) and synchronous disease (fair agreement), while lung metastases could involve two or fewer lesions and metachronous disease (consensus). The large majority of studies were at a high risk of bias or did not include any control groups. CONCLUSION: Definitions of OMD were not used or varied widely between studies hampering across-study comparability and highlighting an unmet need for a consensus. The present study is part of a multistep process that aims to develop an interdisciplinary consensus on OMD in pancreatic cancer.

[Pain assessment in elderly nursing home residents: methods paper for the S3-guideline development]. / Schmerzassessment bei älteren Menschen in der vollstationären Altenhilfe : Methodenpapier zur S3-Leitlinie.

In Germany, there is currently no guideline for pain assessment in elderly people. Pain management in nursing home residents is, however, legally required. For this particular group, especially for people with dementia, suitable interdisciplinary orientations for health care are lacking in Germany. The working group "Pain and Age" of the German Pain Society ("Deutschen Schmerzgesellschaft") in conjunction with the German Centre for Neurodegenerative Diseases ("Deutschen Zentrum für Neurodegenerative Erkrankungen"), Witten, has embarked on the development of interdisciplinary S3-Guideline for "Pain Assessment in Elderly People in Nursing Homes", based on the methodology suggested by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V."), the German Agency for Quality in Medicine ("Ärztliche Zentrum für Qualität in der Medizin"), and that described in the DELBI ("Deutschen Leitlinien-Bewertungsinstrument"). Delegates of the 38 scientific societies and interest groups currently participating can contribute to the contents on three different levels. The present article outlines the methods for developing the guideline.

[Pain and fear of movement in the elderly : the need for an interdisciplinary approach]. / Schmerz und Bewegungsangst im Alter : Notwendigkeit zur interdisziplinären Herangehensweise.

According to evidence-based guidelines a physically activating therapy approach in older chronic pain patients is necessary for the preservation of autonomy. Often the elderly are not easy to motivate for this because of inappropriate attitudes, low self-efficacy, fear of pain and fear of falling. The latter might be more important for self-induced restriction of activity in older pain patients than fear avoidance beliefs known from pain research. The fear of caregivers concerning pain and falls can also lead to physical restrictions in the elderly. The underlying diseases and drug effects have to be borne in mind in exercise-oriented therapy. It seems necessary to design special therapy elements for all national care sectors using age-specific motivation strategies and to assure an interdisciplinary cooperation.

The use of stable isotopes ((13)C/(12)C and (15)N/(14)N) to trace exposure to oil sands processed material in the Alberta oil sands region.

Various oil sands reclamation strategies incorporate oil sands processed material (OSPM) such as mature fine tailings (MFT), engineered tailings (consolidated tailings, CT), and tailings pond water (TPW) into reclamation components that need to develop into viable aquatic ecosystems. The OSPM will contain elevated salinity and organics such as naphthenic acids (NA) and polycyclic aromatic compounds (PAC) that can be chronically toxic to aquatic organisms depending upon levels and age. Due to the complexity of the chemical mixtures, analysis of these compounds in exposed organisms can be challenging. In this study, the stable carbon and nitrogen isotope signatures of selected invertebrates from various types of oil sands reclamation sites were analyzed to determine whether stable isotopes can be used to trace the exposure of aquatic organisms to organic constituents of OSPM. In a series of experimental reclamation ponds of similar age and size, there were trends of (13)C depletion and (15)N enrichment for benthic invertebrates along a gradient of increased levels of MFT and/or TPW. A survey of 16 sites revealed high delta(15)N values for invertebrates in aquatic systems containing MFT and CT (gypsum-treated mixes of MFT and tailings sand), which was attributed to the presence of NH(4)(+), a process by-product in OSPM. Findings of this study indicate a potential for the use of stable nitrogen isotopes to define exposure of biota to OSPM during environmental effects monitoring programs both in surface waters and in cases where groundwater seepage containing oil sands processed water enters surface receiving environments in the region.

Activating therapy modalities in older individuals with chronic non-specific low back pain: a systematic review.

BACKGROUND: Although there are many special exercise-based therapy approaches for the working population suffering chronic low back pain, similar programmes for older individuals are rare. OBJECTIVES: To summarise all evaluated physical therapy approaches, and assess the effects on older people with chronic low back pain. DATA SOURCES: Medline, CINAHL, Cochrane, Embase, PEDro, PsychINFO and Psyndex. STUDY SELECTION/ELIGIBILITY: Age≥65 years, subacute or chronic non-specific low back pain of ≥6weeks' duration, and a physical therapy approach. STUDY APPRAISAL AND SYNTHESIS METHODS: Study selection, data extraction, and assessment of methodological quality and clinical relevance were performed independently by two reviewers. As there were only a few controlled trials and wide heterogeneity in observation periods and outcome measures, pooling of data was not feasible. Therefore, the results are presented descriptively. RESULTS: In total, nine studies were included; six related to mixed physiotherapy modalities, one related to strength training, and two related to endurance training. Low-quality evidence suggests that physical therapy modalities are associated with a small-to-moderate reduction in pain and a small improvement in function. LIMITATIONS: The results must be interpreted with caution due to poor methodological quality. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Few studies have been performed in this highly relevant and growing age group. It is not possible to recommend one particular modality or programme; as such, prescriptions should reflect patients' preferences and local conditions. Further research of higher methodological quality is needed urgently.

A rapid, semi-automated counting procedure for enumeration of antibody-forming cells in gel and nucleated cells in suspension.

A commercially available bacterial colony counter has been modified to permit rapid, highly accurate, semi-automated enumeration of antibody-producing plaque forming cells in semi-solid support medium as well as enumeration of nucleated cells in suspension on a standard hemacytometer chamber. This apparatus should therefore serve as an enormous time-conserving accessory to most modern laboratories involved in immunological research.

Determination of thresholds for detection of cerebellar blood flow deficits in brain SPECT images.

UNLABELLED: Two observer studies were performed to determine the threshold (i.e., ratio of the counts in a lesion area to the counts in the corresponding contralateral region) at which two experienced observers diagnosed blood flow deficits in the cerebellum in 99mTc-HMPAO SPECT scans to be clinically significant, and investigate the effect of the intensity mapping scale on the detectability of lesions. METHODS: Lesions representing blood flow deficits varying from no decrease to a 12.5% decrease were simulated in 300 patient images. The first study, a receiver-operator characteristics (ROC) experiment, used two observers to compare the detectability of lesions with three intensity mapping scales: two pseudocolor scales, and a linear gray scale. A second "threshold-criterion" study was done to estimate the threshold at which observers determine deficits to be clinically significant. RESULTS: In the ROC study, the observers were more accurate in detecting lesions displayed in pseudocolor than in gray scale. In the threshold-criterion study, the threshold at which observers assessed clinically significant deficits was found to range between 0.900 and 0.950 (corresponding to a 5%-10% decrease in counts), depending on the observer, and the intensity mapping scale. For both observers, the detection threshold was higher (i.e., closer to 1.0) with the pseudocolor scale than with the gray scale. CONCLUSION: The definition of a threshold value for use in quantitative techniques is dependent on both the observer and the intensity mapping scale. Observers were more accurate with the pseudocolor scales.

Bilateral retrovesical testes: an unusual location for impalpable undescended testes.

Although the majority of impalpable undescended testes lie in an intracanalicular location, a significant number are also found to be intraabdominal. The expected location of intraabdominal testes is a line joining the renal hilum and the internal inguinal ring. We describe a case of an adult patient in whom impalpable undescended testes were located in a retrovesical location. This case highlights the importance of performing a thorough inspection of the entire abdomen and pelvis if the impalpable testis is not found in an expected location.

Liver resection by ultrasonic dissection and intraoperative ultrasonography.

Ultrasonic dissection (USD) and intraoperative ultrasonography (IOUS) have shown encouraging results in a retrospective analysis of 109 patients with benign or malignant liver disease. Of 109 patients assessed between 1980 and 1993, 84 were resected: 27 by finger fracture technique (FFT) and 57 by USD. Hospital mortality was 4.8% (4/84) and 30-day mortality was 6.0% (5/84). Overall morbidity was 48.8% (41/84) and liver related morbidity (hepatic bleeding, sepsis, and bile leak) was 34.5% (29/84); of the 29 patients, 5 required re-operation. Liver complications occurred in 12/27 (44.4%) in the FFT group as opposed to 17/57 (29.8%) in the USD group. The incidence of postoperative hepatic bleeding was significantly less by USD than by FFT (p = 0.03). As well, intraoperative blood loss (p = 0.01) number of intraoperative blood units used (p = 0.002), and postoperative length of stay (p = 0.009) have been significantly reduced by USD. IOUS was used on 64 patients. Not only has it improved the sensitivity (99%) and specificity (98%) for detection of hepatic neoplasms, it has also helped increase the precision and accuracy of anatomical tumour localization. As a result, 11/64 patients (17.2%) had their preoperative plans changed: 8 were abandoned and 3 were revised. In summary, USD has significantly reduced intraoperative blood loss and hence reduced the number of intraoperative transfusions, incidence of postoperative complications and postoperative length of stay. IOUS should be routinely employed in patients undergoing liver resection since it provides critical information that could obviate oncologically useless resections.

Periurethral injection of collagen in the treatment of urinary stress incontinence: ultrasonographic appearance.

OBJECTIVE: To describe the ultrasonographic appearance of collagen injected periurethrally to treat urinary stress incontinence. PATIENTS AND METHODS: Transvesical and transvaginal ultrasonography (US) was performed 26 times in 23 patients 3 to 36 months after periurethral injection of collagen to treat symptomatic urinary stress incontinence. The patients ranged in age from 23 to 86 (median 54) years. The appearance, location and volume of the collagen were recorded. Clinical data were also obtained. RESULTS: Transvesical US demonstrated the collagen in 17 of the patients, whereas transvaginal US demonstrated the collagen in all of them. The collagen collections appeared as circumscribed masses at the bladder base and showed various levels of echogenicity with both techniques. However, in patients with more than one deposit of collagen, the collections had similar echogenicity, and echogenicity increased over time in the two patients who underwent serial imaging. In 21 of the patients, the collagen collections were located posterior or lateral to the urethra, and these patients recorded complete or moderate resolution of incontinence. In two of the patients the collections were exophytic, projecting into the bladder lumen; these patients experienced little improvement in their continence. CONCLUSIONS: US provides a rapid, noninvasive method of assessing collagen after periurethral injection. Transvaginal US is the best method of visualizing such collections.

Magnetic resonance imaging after intraurethral collagen injected for stress urinary incontinence.

PURPOSE: Magnetic resonance imaging (MRI) was performed to evaluate the results of intraurethral collagen injected stress urinary incontinence. MATERIALS AND METHODS: A total of 32 women underwent MRI of the pelvis at a median of 12 months after the last injection. The appearance, volume and position of the intraurethral collagen were assessed by 1 radiologist blinded to the outcome, and these findings were compared to clinical data to identify predictive features of success. RESULTS: Intraurethral collagen was easily imaged by MRI and appeared as a hyperintense focus within the wall of the urethra. Neither volume nor position of retained intraurethral collagen was predictive of clinical outcome (p= 0.80 and p= 0.32, respectively). The volume of injected intraurethral collagen strongly correlated with the retained volume in clinically successful and failed cases (Pearson's r= 0.64 and r= 0.90, respectively). No evidence of local or remote pathological conditions resulting from intraurethral collagen injection was identified. CONCLUSIONS: The position and volume of intraurethral collagen were not predictive of clinical outcome. While MRI is not recommended fro routine investigation, it is an excellent research modality for assessing the fate of intraurethral collagen injection.

Role of intraoperative ultrasonography in hepatic surgery: a preliminary report.

Twenty-four patients who underwent ultrasonography during hepatic surgery in the 22 months from October 1989 to July 1991 were studied prospectively to determine the value, if any, of intraoperative ultrasonography. For 6 (25%) of the 24 patients the operative plan was altered because of the ultrasonographic findings. In one of them resection was extended from a left lateral segmentectomy or sectorectomy to a left hemihepatectomy. In the other five patients the planned liver procedure was abandoned. Two of these five patients were cirrhotic--in one of them an additional metastasis was seen, and in the other there was tumour invasion of the portal vein. Of the three noncirrhotic patients, one had tumour invasion of the right hepatic vein, and the other two patients had additional metastases in the caudate lobe (Couinaud segment 1). Ultrasonography was found to be useful in 25% of patients who underwent this investigation during hepatic surgery--it avoided liver resections that would have failed because of advanced malignant disease.

Peripancreatic retroperitoneal gas mimicking necrotizing pancreatitis after laparoscopic cholecystectomy.

The computed tomographic image of gas in the pancreas and peripancreatic retroperitoneum is strongly suggestive of necrotizing pancreatitis. The authors describe an 81-year-old woman who, 7 days after laparoscopic cholecystectomy, presented with retroperitoneal gas but did not have the clinical or biochemical features of necrotizing pancreatitis. Resolution of her low-grade fever and of the radiologic findings with conservative treatment and the absence of other causes for pneumoretroperitoneum suggest that the gas observed was related to the laparoscopic cholecystectomy.

Value of standardized gestational age charts for fetuses of first-generation Oriental immigrants to Canada.

OBJECTIVE: to ascertain if standard gestational age charts can be used to accurately predict the gestational age of fetuses of first-generation Oriental immigrants to Canada. PATIENTS AND METHODS: Over a 3-year period, all patients presenting for obstetric ultrasound examinations were invited to participate in the study. The authors recorded biparietal diameter, head circumference, femur length and abdominal circumference for 139 fetuses in the second and third trimesters. A study performed in the first trimester was used as the baseline for gestational age. The data for 126 of the fetuses were complete, and these data were used for the analysis. RESULTS: For 77 of the fetuses, both parents were Oriental, and for 49, one or both parents were not Oriental; the latter constituted the control group. A total of 1008 individual measurements were obtained, and of these, all but 14 fell within two standard deviations of the norm, according to standard gestational age charts. Of the abnormal measurements, seven were obtained from five fetuses with Oriental parents, and seven were obtained from six fetuses in the control group. The difference between the two groups in the proportion of measurements falling either above or below two standard deviations from the norm was not statistically significant (Fisher's exact test, p = 0.41694). CONCLUSION: The authors conclude that standard gestational age charts can be used to determine gestational age in first-generation Oriental immigrants to Canada.

The role of intraoperative ultrasonography in planning the resection of hepatic neoplasms.

OBJECTIVE: Both intraoperative ultrasonography (US) and computed tomography with arterial portography (CTAP) may be used in planning segment-oriented liver resection in patients with primary or secondary hepatic neoplasms. This study was conducted to determine if intraoperative US findings substantially alter surgical plans based on CTAP findings alone. PATIENTS AND METHODS: Patients with potentially resectable hepatic lesions were considered for the study; judgement as to whether a lesion was resectable was based on a clinical evaluation and CTAP. Over the period Apr. 4, 1991, to Oct. 1, 1993, 24 consecutive patients with hepatic lesions were examined; of these, 22 (13 men and 9 women with a mean age of 60.1 years) underwent US during resection, 1 did not undergo surgery and 1 was found at surgery to have carcinomatosis. The true nature of the lesions was verified pathologically or by follow-up imaging and assays for carcinoembryonic antigen. RESULTS: The surgical plan based on CTAP findings alone was altered by the intraoperative US findings in 9 (41%) of the 22 patients. A total of 60 intrahepatic abnormalities were evaluated: 49 malignant lesions and 11 artifacts. The specificity (100%) and negative predictive value (73.3%) for intraoperative US were significantly greater than for CTAP (specificity of 9.1% and negative predictive value of 14.1%). CONCLUSION: In a substantial proportion of patients undergoing hepatic resection, intraoperative US alters the surgical plan based on CTAP and provides additional specificity in the evaluation of liver lesions. This method of imaging is therefore justified for patients undergoing liver resection.

Radiographic features of hepatocellular carcinoma and their relation to prognosis in Canada.

To determine the radiographic features of hepatocellular carcinoma (HCC) as seen in Canada and their relation to prognosis, multiple imaging studies for 40 patients with histologically proven HCC were reviewed. The patients, 34 men and 6 women ranging in age from 43 to 86 years, were selected from a larger database on the basis of the availability of ultrasound (US) images and at least one other imaging study. The patients had been examined between 1981 and 1991 at a tertiary-care hospital. In 35 of the 40 cases (88%) HCC had been detected by US assessment, the criterion for complete analysis, but in one of those cases the lesion was not observed in the initial scans. HCC was detected by computed tomography (CT) in the 27 cases in which that technique had been used. Cirrhosis was present in 27 of the 35 patients (77%) for which a complete analysis was performed. Median survival after diagnosis for all 40 patients was 14.1 weeks. Seven radiographic features were analysed for prognostic value by univariate and multivariate (Cox) regression analysis. However, the regression analysis indicated no relation between survival and tumour size, the nature of the tumour (diffuse and infiltrative or discrete), vascular involvement, encapsulation, extrahepatic spread, tumour location or echogenicity. No radiographic feature, including tumour size, correlated with the serum level of alpha-fetoprotein, which was elevated in 23 of the 32 cases (72%) in which it had been determined. These results confirm the variable radiographic appearance of HCC but differ in other respects from those reported previously, particularly those for studies performed outside North America.(ABSTRACT TRUNCATED AT 250 WORDS)

Differentiation of adrenal masses with MR imaging: comparison of techniques.

PURPOSE: To determine the efficacy of various magnetic resonance (MR) imaging sequences for the differentiation of adrenal masses. MATERIALS AND METHODS: Fifty-three adrenal masses in 46 patients (adenomas, metastases, myelolipomas, hemorrhages, and pheochromocytomas) were evaluated by means of T1-, T2-, and T2*-weighted sequences, calculated T2 values, chemical shift imaging techniques, and dynamic contrast material-enhanced imaging. The Student t test and receiver operating characteristic analysis were used to evaluate the differences in the groups of masses. RESULTS: Analysis of the chemical shift-induced signal intensity of the adrenal masses and the T2*-weighted sequence enabled differentiation of adenomas, metastases, and pheochromocytomas. Adenomas and pheochromocytomas were also differentiated by means of a heavily T2-weighted sequence. Signal intensity values for all masses overlapped. CONCLUSION: Although a chemical shift imaging technique and a T2*-weighted sequence helped correctly differentiate among the groups of adrenal masses, the degree of overlap suggests that it is still difficult to evaluate disease in individual patients.