Staff and organizational requirements for pain services in hospitals : A recommendation from the German Society for Anaesthesiology and Intensive Care Medicine.

Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.

[Staff and organizational requirements for pain services in hospitals : A recommendation from the German Society for Anaesthesiology and Intensive Care Medicine]. / Personelle und organisatorische Voraussetzungen für Schmerzdienste in Krankenhäusern : Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e. V.

Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.

[Acute pain therapy in German hospitals as competitive factor. Do competition, ownership and case severity influence the practice of acute pain therapy?]. / Akutschmerztherapie in deutschen Krankenhäusern als Wettbewerbsfaktor. Wird die Praxis der Akutschmerztherapie von Wettbewerb, Trägerschaft und Fallschwere beeinflusst?

BACKGROUND: Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management. MATERIAL AND METHODS: A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin). RESULTS: For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI. CONCLUSION: In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

[Postoperative pain management after ambulatory surgery. A survey of anaesthesiologists]. / Postoperative Schmerztherapie nach ambulanten Operationen. Eine Befragung der behandelnden Anästhesisten.

BACKGROUND: Data on practice and quality of postoperative pain treatment by anaesthesiologists after ambulatory surgery are sparse. The current survey enrolled anaesthesiologists in private practice who were responsible for pain therapy after ambulatory surgery. The aim of this investigation was to evaluate the implementation of the German S3 guidelines for acute and postoperative pain therapy in the outpatient setting. PATIENTS AND METHODS: A total of 2,156 anaesthesiologists in private practice received a postal questionnaire which was limited to those anaesthesiologists who were responsible for postoperative pain therapy. The questionnaire included items such as types of surgery, techniques of anaesthesia and analgesic drugs used for pain management during the immediate postoperative phase and for the treatment at home as well as details of pain measurement. RESULTS: Out of 116 responses 108 could be analyzed covering a total of 86,616 patients receiving postoperative pain therapy, 80% of the operations were performed using general anaesthesia and local anaesthesia was additionally used in 9% of the institutions. In the perioperative period 66% of the respondents administered non-steroidal-antiinflammatory drugs (NSAIDs), 62% metamizol (dipyrone), 41% paracetamol (acetaminophen) and 73% opioids. After discharge 81% of the responding anaesthesiologists prescribed NSAIDs, 55% metamizol and 47% opioids for pain relief at home. Only 40% of the respondents measured and documented pain intensity. Nearly all respondents (93%) were satisfied with their pain management after outpatient surgery. CONCLUSIONS: Pain therapy after ambulatory surgery significantly varied with respect to the methods, drugs and measures of quality assurance used by anaesthesiologists in private praxis. This survey demonstrated that the national guidelines of acute pain therapy have only been partially implemented.

[Influence of acupuncture on postoperative pain, nausea and vomiting after visceral surgery : a prospective, randomized comparative study of metamizole and standard treatment]. / Einfluss von Akupunktur auf postoperative Schmerzen, Ubelkeit und Erbrechen nach viszeralen Eingriffen : Eine prospektive, randomisierte Vergleichsstudie mit Metamizol und Standardbehandlung.

BACKGROUND: The objective of this study was to assess repeated needle acupuncture in the treatment of postoperative pain and nausea after visceral surgery. MATERIAL AND METHODS: Sixty-six patients undergoing visceral surgery (hysterectomy, cholecystectomy) were randomly assigned to group A (three sessions of needle acupuncture, n=21), group M (3x1000 mg metamizole, n=20), or group K (control, n=25). All patients received patient-controlled analgesia (PCA) using piritramide. To adjust for nonspecific effects due to physician-patient interaction during acupuncture sessions in group A, patients in groups M and K also received three standardized visits. Primary outcome parameters were defined as pain intensity, analgesic consumption, and frequency of nausea and vomiting in a period up to the morning of the second postoperative day. RESULTS: Patients in group A reported significant less pain, nausea, and vomiting compared to patients in group K. Mean cumulative piritramide consumption was significantly lower in group A (25.0 mg) than in group M (34.5 mg) and group K (55.2 mg). CONCLUSION: Repeated needle acupuncture may be effective in postoperative pain relief and the treatment of nausea and vomiting in the postoperative period. These effects seem not to be due solely to interaction between the acupuncturist and the patient.

Psychoanalysis and the mind-body relation: Psychosomatic perspectives.

Psychosomatic medicine has been historically an important focus for psychoanalytic theorizing. The mind-body relation has special relevance for understanding psychosomatic conditions because psychological and psychodynamic factors are so intimately intertwined with physiological parameters that they cannot for all practical purposes be disentangled. Dualistic impressions of mind and body have given way to more integrated perspectives in which psychic and bodily processes are conceived of as operating within the same conceptual framework. Implications of a more integrated view of the mind-body relation are discussed in relation to emotions and psychosomatic symptoms, development of psychosomatic vulnerabilities, somatization, and alexithymia.

The effects of frequency in pallidal deep brain stimulation for primary dystonia.

The effect of stimulation frequency for pallidal deep brain stimulation in five patients with either generalized or segmental dystonia was evaluated three to twelve months postoperatively via a randomized, double-blind paradigm. The quality of life and the severity of dystonic symptoms improved by approximately 60% and 43% respectively using a frequency of 130 Hz. Compared with 130 Hz a significant further clinical improvement was observed at frequencies of 180 and 250 Hz, which contrasted with a significant deterioration at lower frequencies (5, 50 Hz) compared to 130 Hz.

Neurostimulation of the ventral intermediate thalamic nucleus in inherited myoclonus-dystonia syndrome.

We report on the effects of bilateral neurostimulation of the ventral intermediate thalamic nucleus (VIM) in a patient with medically intractable and progressing inherited myoclonus dystonia syndrome (IMDS). Postoperatively, the patient improved by approximately 80% on the modified version of a myoclonus score without any significant change in the dystonic symptoms. This suggests that neurostimulation of the VIM may be an effective treatment for myoclonus in pharmacologically intractable IMDS.

Striatal dopaminergic metabolism is increased by deep brain stimulation of the subthalamic nucleus in 6-hydroxydopamine lesioned rats.

Deep brain stimulation of the subthalamic nucleus is an established therapeutic strategy for patients with Parkinson's disease. Although the exact mechanisms of action remain unknown, it is noteworthy that dopaminergic medication can be markedly reduced after neurostimulation of the subthalamic nucleus. Previously, we have shown that deep brain stimulation of the subthalamic nucleus is followed by an increase of striatal extracellular dopamine metabolites in naive rats. In the present study we examined the effects of deep brain stimulation on striatal monoamine metabolism in the intrastriatal 6-hydroxydopamine rat model of Parkinson's disease. Deep brain stimulation of the subthalamic nucleus was followed by a delayed increase of extracellular 3,4-dihydroxyphenylacetic and homovanillic whereas dopamine levels were unchanged in stimulated rats and controls. Our results indicate that deep brain stimulation of the subthalamic nucleus affects significantly striatal dopaminergic metabolism in 6-hydroxydopamine lesioned rats.

Pallidal and thalamic neurostimulation in severe tardive dystonia.

A 70 year old woman presented with a 6 year history of medically refractory severe tardive dystonia. After informed consent, a bilateral stereotactic electrode placement targeting the ventral intermediate thalamic nucleus (VIM) and the globus pallidus internus (GPi) was performed. After bilateral stimulation of the GPi, the patient showed a clear and stable improvement of the painful dystonic syndrome within hours. Stimulation of the VIM did not improve the hyperkinetic movements and simultaneous stimulation of both the GPi and the VIM did not result in any additional benefit. The possible pathophysiological mechanisms are discussed.

[Apomorphine therapy versus deep rain stimulation. Clinical and economic aspects in patients with advanced Parkinson disease]. / Apomorphintherapie versus tiefe Hirnstimulation. Klinische und ökonomische Aspekte bei Patienten mit fortgeschrittenem Morbus Parkinson.

Long-term dopaminergic treatment of Parkinson's disease is complicated by the occurrence of dyskinesia and motor fluctuations and is responsible for increasing the costs of treatment. In these patients, continuous subcutaneous therapy with the dopamine agonist apomorphine or deep-brain stimulation represents a promising strategy. While the costs for the treatment with apomorphine are covered by health insurance, separate reimbursement for deep-brain stimulation does not exist in Germany. The case reports (n = 3) presented here emphasize that deep-brain stimulation is less cost-intensive than subcutaneous treatment with apomorphine in selected patients. Even in the first postoperative year costs for medication and hospital stays were reduced by approximately 60%. Moreover, in all three patients, motor complications improved after deep-brain stimulation in comparison to previous subcutaneous application of apomorphine. Thus, to further ensure deep-brain stimulation in parkinsonian patients it is mandatory to find a mode of reimbursement for the institutions concerned.

The influence of pallidal deep brain stimulation on striatal dopaminergic metabolism in the rat.

Deep brain stimulation of the globus pallidus internus has been recently shown to alleviate parkinsonian symptoms and levodopa-induced dyskinesias. However, its exact mechanisms of action are unclear. Pallidal neurones are connected via various pathways to the dopaminergic nigrostriatal system. In the present study we investigated the hypothesis that deep brain stimulation of the entopeduncular nucleus (corresponds to the human internal pallidum) affects striatal dopaminergic metabolism in naive and 6-hydroxydopamine (6-OHDA) lesioned rats using microdialysis. Our results show that stimulation of the entopeduncular nucleus does not significantly affect striatal dopamine metabolism (of dopamine, 3, 4-dihdroxyphenylacetic acid and homovanillic acid) in naive and 6-OHDA-lesioned animals. They contrast with our previous observations that deep brain stimulation of the subthalamic nucleus increases striatal dopamine metabolism suggesting differential effects of these nuclei on striatal dopamine metabolism.

[The effect of selenium and fluorine with respect to caries and toxicity to Osborne-Mendel-rats (author's transl)]. / Die Wirkung von Selen und Fluor auf Osborne-Mendel-Ratten hinsichtlich Kariesbefall und Toxizität

Two experiments carried out with one hundred rats from the Osborne-Mendel-strain were supposed to prove the influence of selenium-containing-drinking-water on caries. The animals were divided into five experimental groups of twenty rats each. Selenium was tested in different doses as an addition to drinking-water in shape of Na2SeO4, as well as in combination with a tooth-paste containing NaF.-Its toxicity was to be determined by the water consumption, the mortality and above all by the body weight of the animals at the end of the test. During the first experiment three groups received Na2SeO4 in doses of 1, 5 and 10 ppm in the drinking water and the cariogenic diet Stephan 580 as food. Two other groups served as control, one receiving the cariogenic diet Stephan 580 and the other one getting the normal breeding diet. The analysis of variance carried out for the assessment of caries and the test of SCHEFFE only show a different attack concerning those groups, receiving the cariogenic diet and the control group fed with the breeding diet Altromin R. Nine of the 40 animals of the groups that had received the selenium doses of 5 and 10 ppm did not survive the experiment. The average value of the water consumption and the body weight of the animals of the selenium group was below the average of the remaining groups, which points out a strong toxicity of Na2SeO4. In regard to the water consumptions, however, one cannot exactly define, whether it is an effect of the selenium of the cariogenic diet. All groups of the second experiment received the cariogenic diet Stephan 580; two of them got Na2SeO4 in doses of 4ppm within their drinking water. The molars of the lower jaws of one of these group were brushed with a tooth-paste containing NaF. The molars of the other group were treated with a paste, serving as a placebo. Two other groups were provided each with the paste containing fluorine and the paste serving as a placebo, but without selenium in their drinking water. Furthermore 20 animals were used as a control group. The analysis of variance showed the widely known protective effect of the fluorine by the statistically significant different distribution of the caries. Comparing those two groups, whose drinking water contained Na2SeO4 with the two other groups whose molars were treated with the paste containing fluorine and the one serving as a placebo respectively, we may conclude, that Na2SeO4 has no influence on the protective effect of the fluorine. A comparison of the group treated with the paste serving as a placebo with the control group shows, that the tooth-brushing obviously has no great effect. In respect to the body weight at the end of the experiment one cannot demonstrate a clear effect using the linear contrast of SCHEFFE, and there also is no infleunce of selenium on the total water consumption, which coincides with the results of the first experiment. The two experiments have shown that Na2SeO4 is toxic in the doses applied...