[Management of patients with chronic pain in acute and perioperative medicine : An interdisciplinary challenge]. / Management von Patienten mit chronischen Schmerzen in der Akut- und perioperativen Medizin : Eine interdisziplinäre Herausforderung.

Chronic pain is a frequent comorbidity of patients in hospitals and has an influence on the clinical course and the duration of hospitalization. There is a need to have a better understanding of chronic pain as a comorbidity and it should be considered to a greater extent in understanding diseases, in treatment concepts and hospital structures to ensure a resource-oriented and high-quality care. This begins on admission by identifying pre-existing pain and related risk factors with the medical history and taking these into account in the treatment regimen. A multimodal treatment approach that involves medicinal, educational, psychological and physiotherapeutic expertise is required in these patients. A unimodal approach in the treatment is not effective. A pain physician should be involved in the treatment team as early as possible. Furthermore, psychological joint supervision should be available for these patients as several studies have demonstrated positive perioperative effects of psychological approaches on the treatment in this patient group.

[Cross-sectoral interdisciplinary multimodal pain therapy : Recommendations on structural and process parameters of the ad hoc commission "Interdisciplinary Multimodal Pain Therapy" of the German Pain Society (Deutsche Schmerzgesellschaft e.  V.)]. / Sektorenübergreifende interdisziplinäre multimodale Schmerztherapie : Empfehlungen zu Struktur- und Prozessparametern der Ad-hoc-Kommission "Interdisziplinäre Multimodale Schmerztherapie" der Deutschen Schmerzgesellschaft e. V.

Based on the fundamental concept of the biopsychosocial model, interdisciplinary multimodal pain therapy (IMPT) has developed to one of the most important components in the treatment of patients suffering from chronic pain. The process criteria for IMPT in Germany are described in the German OPS catalogue and IMPT is mainly offered as an inpatient treatment only. This article updates some of the fundamental criteria for IMPT for adult inpatient treatment and the task force defines basic structural and process criteria for the implementation of IMPT for outpatients.

[Physiotherapy and physical therapy in pain management]. / Physiotherapie und physikalische Therapie in der Schmerzmedizin.

Patients attend physiotherapy and physical therapy (PT) due to pain problems and/or functional impairments. Although the main focus for therapists has traditionally been physical examination and treatment of tissue structures and biomechanics, over the last few decades a growing body of research has highlighted the importance of central nervous system processing and psychosocial contributors to pain perception. Treatment with PT aims to reduce disability and suffering by reducing pain and increasing tolerance to movement. In Germany, pain management conducted by physiotherapists is currently undergoing major changes. Firstly, PT education is transitioning from a vocational to a degree level and additionally new concepts for improved multidisciplinary treatment approaches are being developed. However, there still remain substantial differences between therapists working in multidisciplinary pain clinics and those following medical referral in private practices. This article provides information on how national and international impulses have contributed to the development of different concepts of passive therapies and active/functional pain rehabilitation in Germany. In the future PT will need to provide more evidence about efficiency and modes of actions for different treatment options to selectively reason the application to patients with acute, subacute and chronic pain.

[Multimodal pain therapy for treatment of chronic pain syndrome. Consensus paper of the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society on treatment contents]. / Multimodale Schmerztherapie für die Behandlung chronischer Schmerzsyndrome. Ein Konsensuspapier der Ad-hoc-Kommission Multimodale interdisziplinäre Schmerztherapie der Deutschen Schmerzgesellschaft zu den Behandlungsinhalten.

Multimodal pain management is a comprehensive treatment of complex chronic pain syndromes. In addition to medical therapy various other specialized therapeutic interventions based on the biopsychosocial model of pain origin and chronic pain development, are added. During the last few years treatment centers for chronic pain have been established throughout Germany. Multimodal pain management has been included in the official catalogue of the recognized medical procedures for day clinic units as well as for inpatient pain management. In daily practice there is, however, still a lack of clarity and of consistency about the components that multimodal pain management should contain. This is the reason for the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society to propose the following position paper that has been worked out in a multilevel and interdisciplinary consensus process. The paper describes the mandatory treatment measures in the four core disciplines of multimodal pain management, pain medicine, psychotherapy, exercise therapy including physiotherapy and assistant medical professions including nurses.

[Physiotherapy and physical therapies for fibromyalgia syndrome. Systematic review, meta-analysis and guideline]. / Physiotherapie und physikalische Verfahren beim Fibromyalgiesyndrom. Systematische Übersicht, Metaanalyse und Leitlinie.

BACKGROUND: The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: Low-to-moderate intensity aerobic exercise and strength training are strongly recommended. Chiropractic, laser therapy, magnetic field therapy, massage and transcranial current stimulation are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Detection of imidacloprid and metabolites in Northern Leopard frog (Rana pipiens) brains.

Neonicotinoids are a new type of highly water-soluble insecticide used in agricultural practices to eliminate pests. Neonicotinoids bind almost irreversibly to postsynaptic nicotinic acetylcholine receptors in the central nervous system of invertebrates, resulting in overstimulation, paralysis, and death. Imidacloprid, the most commonly used neonicotinoid, is often transported to nearby wetlands through subsurface tile drains and has been identified as a neurotoxin in several aquatic non-target organisms. The aim of the present study was to determine if imidacloprid could cross the blood-brain barrier in adult Northern Leopard frogs (Rana pipiens) following exposure to 0, 0.1, 1, 5, or 10 µg/L for 21 days. Additionally, we quantified the breakdown product of imidacloprid, imidacloprid-olefin, and conducted feeding trials to better understand how imidacloprid affects foraging behavior over time. Exposure groups had 12 to 313 times more imidacloprid in the brain relative to the control and breakdown products showed a dose-response relationship. Moreover, imidacloprid brain concentrations were approximately 14 times higher in the 10 µg/L treatment compared to the water exposure concentration, indicating imidacloprid can bioaccumulate in the amphibian brain. Reaction times to a food stimulus were 1.5 to 3.2 times slower among treatment groups compared to the control. Furthermore, there was a positive relationship between mean response time and log-transformed imidacloprid brain concentration. These results indicate imidacloprid can successfully cross the blood-brain barrier and bioaccumulate in adult amphibians. Our results also provide insights into the relationship between imidacloprid brain concentration and subsequent altered foraging behavior.

[Physicomedical therapy of acute and chronic pain]. / Physikalisch-medizinische Therapie bei akuten und chronischen Schmerzen.

For almost all pain syndromes, whether caused by tumours or not, physicomedical therapies are used as primary or accompanying measures to treat chronic and acute pain. The selection of suitable treatments is, however, often challenging, as there are clear discrepancies between the results of controlled studies on the one hand and the positive results based on individual observations on the other. This article presents an overview of those methods, therapeutic agents, and techniques within the broad range of physicomedical treatments that show a pain-modulating effect and have proven their efficiency for treating acute and chronic pain.

Mouse Strain Impacts Fatty Acid Uptake and Trafficking in Liver, Heart, and Brain: A Comparison of C57BL/6 and Swiss Webster Mice.

C57BL/6 and Swiss Webster mice are used to study lipid metabolism, although differences in fatty acid uptake between these strains have not been reported. Using a steady state kinetic model, [1-(14)C]16:0, [1-(14)C]20:4n-6, or [1-(14)C]22:6n-3 was infused into awake, adult male mice and uptake into liver, heart, and brain determined. The integrated area of [1-(14)C]20:4n-6 in plasma was significantly increased in C57BL/6 mice, but [1-(14)C]16:0 and [1-(14)C]22:6n-3 were not different between groups. In heart, uptake of [1-(14)C]20:4n-6 was increased 1.7-fold in C57BL/6 mice. However, trafficking of [1-(14)C]22:6n-3 into the organic fraction of heart was significantly decreased 33 % in C57BL/6 mice. Although there were limited differences in fatty acid tracer trafficking in liver or brain, [1-(14)C]16:0 incorporation into liver neutral lipids was decreased 18 % in C57BL/6 mice. In heart, the amount of [1-(14)C]16:0 and [1-(14)C]22:6n-3 incorporated into total phospholipids were decreased 45 and 49 %, respectively, in C57BL/6 mice. This was accounted for by a 53 and 37 % decrease in [1-(14)C]16:0 and 44 and 52 % decrease in [1-(14)C]22:6n-3 entering ethanolamine glycerophospholipids and choline glycerophospholipids, respectively. In contrast, there was a significant increase in [1-(14)C]20:4n-6 esterification into all heart phospholipids of C57BL/6 mice. Although changes in uptake were limited to heart, several significant differences were found in fatty acid trafficking into heart, liver, and brain phospholipids. In summary, our data demonstrates differences in tissue fatty acid uptake and trafficking between mouse strains is an important consideration when carrying out fatty acid metabolic studies.

Astrocyte arachidonate and palmitate uptake and metabolism is differentially modulated by dibutyryl-cAMP treatment.

Astrocytes play a vital role in brain lipid metabolism; however the impact of the phenotypic shift in astrocytes to a reactive state on arachidonic acid metabolism is unknown. Therefore, we determined the impact of dibutyryl-cAMP (dBcAMP) treatment on radiolabeled arachidonic acid ([1-(14)C]20:4n-6) and palmitic acid ([1-(14)C]16:0) uptake and metabolism in primary cultured murine cortical astrocytes. In dBcAMP treated astrocytes, total [1-(14)C]20:4n-6 uptake was increased 1.9-fold compared to control, while total [1-(14)C]16:0 uptake was unaffected. Gene expression of long-chain acyl-CoA synthetases (Acsl), acyl-CoA hydrolase (Acot7), fatty acid binding protein(s) (Fabp) and alpha-synuclein (Snca) were determined using qRT-PCR. dBcAMP treatment increased expression of Acsl3 (4.8-fold) and Acsl4 (1.3-fold), which preferentially use [1-(14)C]20:4n-6 and are highly expressed in astrocytes, consistent with the increase in [1-(14)C]20:4n-6 uptake. However, expression of Fabp5 and Fabp7 were significantly reduced by 25% and 45%, respectively. Acot7 (20%) was also reduced, suggesting dBcAMP treatment favors acyl-CoA formation. dBcAMP treatment enhanced [1-(14)C]20:4n-6 (2.2-fold) and [1-(14)C]16:0 (1.6-fold) esterification into total phospholipids, but the greater esterification of [1-(14)C]20:4n-6 is consistent with the observed uptake through increased Acsl, but not Fabp expression. Although total [1-(14)C]16:0 uptake was not affected, there was a dramatic decrease in [1-(14)C]16:0 in the free fatty acid pool as esterification into the phospholipid pool was increased, which is consistent with the increase in Acsl3 and Acsl4 expression. In summary, our data demonstrates that dBcAMP treatment increases [1-(14)C]20:4n-6 uptake in astrocytes and this increase appears to be due to increased expression of Acsl3 and Acsl4 coupled with a reduction in Acot7 expression.

Correlations between karyotype and cytologic findings in multiple myeloma.

In multiple myeloma, correlations between cytogenetic and morphologic findings are hampered by the relatively scarce chromosomal data and the lack of a widely accepted morphologic classification. The aim of the analysis, comprising 111 patients with multiple myeloma, was to study possible correlations between karyotype and a morphologic classification proposed by Bartl et al. Grade of plasma cell infiltration, predominant cell types (Marschalko, small, cleaved, polymorphous, asynchronous, blastic) and grade of malignancy are the basis of this classification. A pathologic karyotype was found in the bone marrow of 39/111 patients (35%). The incidence of chromosomal anomalies closely correlated with the grade of infiltration, plasma cell type and grade of malignancy. Chromosomal anomalies were rarely detected in patients with low infiltration (16%), but they were frequently found in high-grade infiltration (69%). A low incidence was found in Marschalko (25%) or small cell type (15%); the incidence was much higher in cleaved (75%), asynchronous (65%) and basic cell types (71%). An abnormal karyotype was more frequently found in high (71%) than in intermediate (53%) or low (23%)-grade malignant multiple myeloma. The most consistent structural chromosomal aberration found in five patients was translocation t(11;14)(q13;q32). In four of the five patients small, often cleaved plasma cells were the predominant cell types. These reported correlations between morphological and cytogenetic findings must be confirmed by future studies.

Karyotype in multiple myeloma and plasma cell leukaemia.

Between October 1988 and October 1991, 104 patients with multiple myeloma and 6 with plasma cell leukaemia were studied cytogenetically. Abnormal karyotypes were found in bone marrow cells of 33 patients (30%). Most pathological karyotypes were complex with numerous modal and structural anomalies. Numerical anomalies most frequently involved chromosome 11 and structural aberrations occurred most often in chromosomes 1, 11 and 14. The most consistent structural aberration was a 14q+ chromosome (10 patients) resulting from a t(11;14)(q13;q32) in 4 patients and a t(8;14)(q24;q32) in 1 patient. Sequential cytogenetic studies were performed in 15 patients. In 5 of 8 cases with a normal karyotype at diagnosis, chromosomal anomalies were detected when disease progressed. In concomitant cytogenetic/cytological studies it was found that in the majority of patients with normal karyotype the mitoses originated from contaminating normal bone marrow cells. Pathological karyotypes were detected more frequently in pretreated than in untreated patients, in patients with plasma cell leukaemia than in patients with multiple myeloma, in patients with stage III and dense bone marrow infiltration than in patients with stage I. Patients with abnormal karyotype, irrespective if pretreated or not, had a significantly shorter median survival than those with normal karyotype. These findings suggest that karyotype is an independent prognostic factor in multiple myeloma.

Polysomy 13 with concomitant deletion of 13q13-14 involving the retinoblastoma gene and the D13S25 locus in a case of acute myeloid leukemia.

We herein describe a case of acute myeloblastic leukemia (AML), FAB subtype M4, with an unfavorable clinical course and a complex karyotype, including 4-9 copies of chromosome 13. Polysomy 13 was a result of clonal evolution. Fluorescence in situ hybridization (FISH) revealed a cytogenetically unrecognizable deletion within 13q13-14 that included the retinoblastoma gene (RB) and the D13S25 locus in all but one copy of chromosome 13. The only chromosome 13 that did not show a deletion affecting the q13-14 region was translocated to chromosome 7, resulting in a dic(7;13)(q21;p11). In this case, the coexistence of polysomy and a partial deletion within the same chromosome point toward a possible formation of a fusion product with oncogenic potential and its consecutive amplification as a critical alteration in this case.

t(1;19)(q23;p13) in a case of acute monocytic leukemia.

Translocation (1;19)(q23;p13) is considered a specific chromosome aberration in acute lymphoblastic leukemia (ALL). We report a case of M5 acute nonlymphocytic leukemia (ANLL) with t(1;19). In all mitoses studied from peripheral blood (PB) cells, the pathological karyotype 51,XX,t(1;19)(q23;p13),+8, +der(19)t(1;19)(q23;p13), +3mar was detected. No rearrangement of the E2A gene was detected. We believe this case shows that cytogenetically indistinguishable aberrations may be accompanied by quite different molecular events.

Novel Philadelphia variant t(Y;9;22)(q12;q34;q11) in a case of chronic myeloid leukemia.

A novel Philadelphia (Ph) variant translocation, t(Y;9;22)(q12;q34;q11), was detected in a 63-year-old man with a newly diagnosed chronic myeloid leukemia (CML). Reverse transcription polymerase chain reaction (RT-PCR) analysis revealed a b3a2 fusion transcript. Fluorescence in situ hybridization (FISH) utilizing library probes, subtelomeric cosmid probes, and probes hybridizing to the ABL and BCR genes showed a reciprocal three-way translocation involving Yq12, 9q34, and 22q11, and a BCR-ABL fusion signal on der(22). The subtelomeric Yq probe hybridizing centromerically to the IL9 receptor gene and covering the centromeric portion of the SYBL1 gene was found to be translocated to der(9).

ider(9)(q10)t(9;22)(q34;q11) is a recurrent chromosomal abnormality in acute lymphoblastic leukemia and lymphatic blastic phase of chronic myelogenous leukemia.

We report on two cases, one with acute lymphoblastic leukemia and a second with lymphatic blastic phase of Philadelphia chromosome-positive chronic myelogenous leukemia, cytogenetically characterized by ider(9)(q10)t(9;22)(q34;q11). Our findings and the data of the 4 cases previously published indicate that ider(9)(q10)t(9;22)(q34;q11) represents a rare but recurrent chromosomal abnormality occurring in hematological malignancies with lymphoid differentiation, namely acute lymphoblastic leukemia and lymphatic blastic phase of chronic myelogenous leukemia, and most likely evolves from a preexistent der(9) involved in the standard t(9;22).

Cytogenetic Studies in Patients with Acute Myeloid Leukemia Following a Myelodysplastic Syndrome.

Between 1981 and 1988, thirty-nine patients with acute myeloid leukemia (AML) following a de novo myelodysplastic syndrome (n-MDS) were studied cytogenetically. The chromosomal aberration rate was 59%. The anomalies most often found were: complex (four or more) aberrations (n = 6), a 5q- chromosome (n = 6), monosomy 7 or a 7q- chromosome and trisomy 8 as the sole defect (n = 3). Incidence and types of chromosomal aberrations were approximately the same as in myelodysplastic syndromes and in 191 patients with de novo AML studied in our laboratory during the same period. But the cytogenetic pattern in AML post de novo MDS also shared certain similarities with chromosomal findings in 35 patients with secondary, therapy-induced (t) AML/MDS. In both these types of acute leukemia primary changes such as t(8;21), t(15;17) and inv (16) were not found; the frequency of AA-Karyotypes was high (70 and 66%) and the incidence of -5,5q- in AML post de novo MDS was more comparable with that found in t-AML/MDS than in de novo AML. Thus the chromosomal patterns seen in AML post de novo MDS indicate that these leukemias share similarities with both de novo and t-AML not only clinically but also cytogenetically.

Removal of higher molecular weight organic compounds by the granular activated carbon adsorption unit process.

The granular activated carbon adsorption unit process in drinking water treatment typically removes purgeable organic compounds for time periods on the order of a few weeks. Experimental evidence indicates that less volatile compounds of generally higher molecular weight than the purgeable fraction, but still detectable by gas chromatography, are efficiently removed for longer periods. Field data substantiate this. Explanatory mechanisms may include stronger adsorption affinities or biodegradation. Non-gas chromatographable, higher molecular weight materials such as humic acids, as measured by Total Organic Carbon (TOC) or trihalomethane formation potential, revert to lower removal efficiencies. Biodegradation may be responsible for a continued long term removal of a fraction of these materials.

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.