Is there any gender-specific impact in the treatment of patients with basal cell carcinoma in the head and neck region?

Background: There are no current studies concerning gender-specific impact on the treatment of BCCs. We performed a retrospective analysis with the aim of showing that selection of treatment by physician and patients' evaluation concerning quality of life and aesthetic outcome has a gender-specific impact. Methods: Overall, 47 patients treated by excision of BCC from the head and neck region at our department from 2015 to 2020 were included. Defects were closed via flap, split-thickness skin graft. or primary closure. Pain, scar quality, patient satisfaction and quality of life were ascertained by the Skin Cancer Index (SCI), the Basal and Squamous Cell Carcinoma Quality of Life (BaSQoL) questionnaire, Patient and Observer Scar Assessment Scale (POSASv2.0EN) and Vancouver Scar Scale (VSS). Results: Women received significantly more flaps than split-thickness skin grafts (p = 0.025). The coverage method was independent of surgeons' gender.Patient's POSAS were higher in women (p = 0.087), and observer's POSAS (p = 0.229) and VSS (p = 0.7) showed no significant difference between genders.SCI and BaSQoL scores showed that women are significantly more critical than men after BCC treatment (SCI p = 0; BaSQoL p = 0.022). Furthermore, dermatological follow-up frequency was significantly higher in women (p = 0.035). Conclusion: We determined the gender-specific impacts on the treatment of patients with BCCs regarding methods of closure, post-interventional dermatological follow-ups, quality of life, scar quality, and overall patient satisfaction. No difference in scar quality was found when assessed by physicians.

[Treatment for chronic back pain? : Active multimodal, interdisciplinary pain therapy vs. physiotherapy-physical therapy for chronic back pain]. / Behandlung bei chronischen Rückenschmerzen? : Aktive multimodale, interdisziplinäre Schmerztherapie vs. physiotherapeutisch-physikalische Therapie bei chronischen Rückenschmerzen.

BACKGROUND: In industrialized countries, chronic back pain is referred to as the "number one common disease". OBJECTIVES: Are there any indications of different outcomes of chronic back pain patients when treated with a multimodal, interdisciplinary pain therapy (MMSTh) compared to physiotherapy-physical therapy? MATERIALS AND METHODS: Entrance and final examination by means of survey, questionnaires and physical tests in the intervention and control group, evaluation and comparison of the results. RESULTS: The intervention group showed very significant improvements in all tests. In contrast, the control group achieved only partial improvements in physical parameters and quality of life. This resulted in clear group differences in favor of the MMSTh. In terms of patient satisfaction, the control group showed a better result than the intervention group. CONCLUSIONS: Treatment with MMSTh is superior to standard physiotherapy-physical. Due to the extensive, proven positive effect on many pain-causing and pain-preserving factors, multimodal pain centers should be used more frequently in chronic back pain patients.

[Comparative Cost Effectiveness of Clostridium Histolyticum Collagenase (Xiapex®) and Partial Fasciectomy for the Treatment of Dupuytren's Contracture in Austria]. / Kosteneffektivität der Behandlung von Patienten mit Dupuytren-Kontraktur mit mikrobieller Collagenase Clostridium histolyticum (Xiapex®) im Vergleich zur partiellen Fasziektomie in Österreich.

INTRODUCTION: Since Dupuytren's contracture is a common disorder, the costs for its surgical treatment impose a considerable burden on the healthcare system. For the first time in the German-speaking area, this study aimed to provide a comparative cost-effectiveness analysis for partial fasciectomy vs. treatment with Clostridium histolyticum collagenase (CCH). METHODS: A retrospective monocentric study of the period from 2012 to 2014 comprised 40 patients with previously untreated Dupuytren's contracture of one finger. 20 outpatients received one CCH treatment (Group 1), while 20 inpatients underwent partial fasciectomy (Group 2). The direct pre-interventional treatment and post-interventional costs were compared. RESULTS: The direct post-interventional and postoperative results were comparable. Group 1 (CCH) showed a mean reduction in contracture of 96.4%; in Group 2 (partial fasciectomy), this was 97.7%. There were fewer complications in Group 1 than in Group 2. Mean treatment costs in Group 1 were € 1 458.60 and in Group 2, € 5 315.20. CONCLUSION: Treatment with CCH is more cost effective than with partial fasciectomy. This is due to greater costs for personnel, time and surgical material, as well as the treatment of the more frequent complications in Group 2. Despite the limited comparability, our findings are consistent with the present international literature.

[Pain in hospital: Assessing the pain situation in Austrian patients]. / Schmerz im Krankenhaus: Erfassung der Schmerzsituation österreichischer Patienten.

BACKGROUND: In a survey of all adult inpatients at the Wilhelminen Hospital in Vienna and the Klagenfurt Clinic on Lake Wörthersee, data on pain prevalence, the most frequent sites of pain, pain intensity, pain type, effect of pain on patients, pain evaluation on the various wards, pain precipitating factors, and patient satisfaction were collected. MATERIALS AND METHODS: All inpatients > 18 years were questioned using a questionnaire developed by the investigators at the Department for Anesthesia, Intensive Care, and Pain Medicine at the Wilhelminen Hospital. RESULTS: A pain prevalence of 45.7% was found at the Wilhelminen Hospital and of 40.8% at the Klagenfurt Clinic. Women reported pain significantly more often than men. No significant difference was found between surgical and conservative treatment wards in terms of pain prevalence. Patients on conservative treatment wards reported significantly higher current pain intensity than those in surgical departments. The most common areas of pain were joints and bones. A score >3 in the ID pain questionnaire was reached by 8.8% (Wilhelminen Hospital) and 4.0% (Klagenfurt Clinic) of participants. Pain influenced mood, mobility, and nighttime sleep, and was intensified by the daily clinical routine. CONCLUSION: Overall, it was demonstrated that the majority of patients at both hospitals were satisfied with the pain management. However, pain management in conservative treatment disciplines must not be neglected. More intense current pain, a worse quality of life, and a trend toward lower patient satisfaction indicate that analgesic treatment in nonsurgical disciplines should be optimized.

[Pain measurement in cognitively impaired patients with the Doloshort scale]. / Schmerzmessung bei kognitiv beeinträchtigten Patienten mit der Doloshort-Skala.

BACKGROUND: Until recently the measurement of pain in cognitively impaired patients represented a neglected field in the diagnostics and treatment of pain. Investigations indicate a prevalence of pain in nursing home residents of between 45 % and 80 %. MATERIAL AND METHODS: This study investigated the reliability of the German translation of the Doloshort scale and compared it with the visual analog scale (VS). The aim of this study was to determine the practical applicability of this scale in the clinical routine and to calculate the intrarater reliability (retest) and interrater reliability. RESULTS: The interrater and intrarater reliability of the Doloshort scale was between 0.949 and 0.970. There was a highly significant correlation between the values of the Doloshort scale and the VAS. CONCLUSION: The Doloshort scale is a well suited measurement instrument for the evaluation of pain in cognitively impaired patients. Because of the short form only simple instructions are necessary and it has a high acceptance with users.

[Quality of postoperative pain therapy in Austria: national survey of all departments of anesthesiology]. / Qualität der postoperativen Schmerztherapie in Österreich : Bundesweite Umfrage unter allen anästhesiologischen Abteilungen.

BACKGROUND: Despite increasingly sophisticated concepts of perioperative pain therapy, such as increased use of combined regional anesthesia techniques, the renaissance of ketamine and dipyrone or the use of oral opioids, no significant improvement has been achieved in postoperative pain therapy since 1995. About 300,000 of the approximately 700,000 patients undergoing major surgery each year in Austria experience moderate to severe postoperative pain. The aim of this study was therefore to assess the nationwide status of perioperative acute pain management in postoperative recovery rooms and surgical wards in order to identify potential areas for improvement. METHODS: In 2006 the directors of all Austrian anesthesiology departments (n=125, 100%) were contacted and asked to give detailed information on the status of acute pain management of each individual hospital in Austria using a standardized questionnaire. Data of each individual department were derived from quality control and self-assessment of each department. No patients were questioned. The return rate was 96% (n=120) due to intensive personal contact in cases of missing data. RESULTS: In this nationwide survey 120 anesthesiology departments participated together accounting for a total of 757,895 operations per year. Of the patients 63.6% were informed preoperatively on the available regimens of acute pain management. In 81% of patients perioperative pain therapy consisted of a multimodal therapeutic approach, 58.6% of the departments used international guidelines and 39.7% worked with international guidelines adapted to local requirements. In 88% of patients a detailed prescription for postoperative pain therapy was available when transferred to the surgical ward. Surgical wards were equipped with routine pain therapy protocols in 28% another 20% of wards had special pain therapy protocols for individual operations. In 22% of cases pain assessment was repeated 3-4 times per day and in 33.9% postoperative pain was assessed only once twice per day. Pain assessments were recorded in the patient charts in 60.7% of cases. If changes to the pain therapy regimen were required anesthesiologists were involved in only 14.3% of cases. In addition an acute pain service was available only in 39.2% of Austrian anesthesiology departments. CONCLUSIONS: Although the multimodal approach to acute pain therapy is widely used and standardized therapeutic regimens are well established in the majority of anesthesiology and surgical wards, there still remains room for improvement. Pain assessment is generally barely adequate and written documentation of pain assessment is missing almost completely. In addition, almost two thirds of hospitals in Austria are still lacking an acute pain service.

[Clonidine for remifentanil-induced hyperalgesia: a double-blind randomized, placebo-controlled study of clonidine under intra-operative use of remifentanil in elective surgery of the shoulder]. / Clonidin bei Remifentanil-induzierter Hyperalgesie: Doppelblinde randomisierte, placebokontrollierte Studie mit Clonidin unter intraoperativer Analgesie mit Remifentanil bei Schultereingriffen.

BACKGROUND: In the postoperative period, α2-adrenergic agonists have an opioid sparing effect. In a previous, experimental study, it was also shown that clonidine attenuates remifentanil-induced hyperalgesia. In this study, we examined under clinical conditions whether early administration of a single dose of clonidine can inhibit remifentanil-induced hyperalgesia in patients undergoing elective surgery of the shoulder and with continuous intraoperative use of remifentanil. PATIENTS AND METHODS: In this study 40 patients received double-blind and randomized either 150 µg clonidine or placebo intravenously before skin incision. Anaesthesia was maintained with propofol and remifentanil (0.23 ± 0.09 µg/kg body weight/min) and morphine (0.1 mg/kg body weight) was administered 20 min before incision closure. Postoperatively, the patients were given a patient-controlled analgesia pump (PCA) with morphine. RESULTS: Overall morphine consumption as well as overall assessment of pain with the visual analogue scale in the first 24 h postoperatively did not differ significantly between the groups. Isolated pain scores at 12 h and 24 h were significantly enhanced in the clonidine group (p<0.05). CONCLUSION: An early single dose of 150 µg of clonidine did not reduce the postoperative morphine consumption and pain scores in patients undergoing elective surgery of the shoulder with remifentanil/propofol-based anaesthesia. After the effect of clonidine has presumably subsided the pain can even increase, therefore further studies with repetitive doses of clonidine should be carried out.

Blockade of intra-articular adrenergic receptors increases analgesic demands for pain relief after knee surgery.

Activation of opioid receptors on peripheral sensory nerve terminals by opioid peptides that are produced and released from immune cells can result in inhibition of inflammatory pain. This study tests the hypothesis that postoperative pain is attenuated endogenously through a local sympathetic neurotransmitter-activated release of opioids in patients undergoing knee surgery. We examined the expression of opioid peptides and adrenergic receptors in cells infiltrating inflamed synovial tissue and we hypothesized that intra-articular (i.a.) administration of the adrenergic receptor antagonist labetalol will increase postoperative analgesic consumption and/or pain intensity in these patients. In a double-blind, randomized manner, 75 patients undergoing therapeutic knee arthroscopy received i.a. placebo (20 ml saline) or labetalol (2.5 or 5 mg in 20 ml saline) at the end of surgery. Postoperative pain intensity was assessed by visual analog and verbal rating scales at rest and on exertion, and by the consumption of morphine via patient-controlled analgesia. Synovial biopsies were taken during the operation for double-immunofluorescence confocal microscopy studies. Alpha(1)- and beta(2)-adrenergic receptors were co-expressed in opioid peptide-containing cells. No significant difference was seen in pain scores, but patients receiving 2.5 mg labetalol requested significantly higher amounts of morphine. These findings are consistent with the notion that surgical stress induces sympathetically activated release of endogenous opioids from inflammatory cells and subsequent analgesia via activation of peripheral opioid receptors.

[Analgesic efficacy of TENS therapy in patients with gonarthrosis. A prospective, randomised, placebo-controlled, double-blind study]. / Analgetische Effizienz von transkutaner elektrischer Nervenstimulation (TENS-Therapie) bei Patienten mit Gonarthrose. Eine prospektive, randomisierte, placebokontrollierte, doppelblinde Studie.

BACKGROUND: The goal of the study was to substantiate the influence of TENS on pain development and medication needs of patients with proven gonarthrosis and chronic pain. The study included a 3-week stimulation period and 2-week observation period after the end of stimulation. MATERIALS AND METHODS: Patients (at least 20 per group) were assigned to either an active treatment group or placebo group in a randomised, double-blind, placebo-controlled trial. For the active treatment group the TENS therapy device with HAN stimulation (alternating phase of stimulation) was used (TENStem eco).Total length of time: 30 min at least two times a day. The length of therapy was 3 weeks (therapy), followed by an observation period of 2 weeks (follow-up). The total length of the study was 5 weeks, whereby at the beginning and at the end of weeks 1, 3 and 5 the SF-36, WOMAC score and Lysholm score were documented; the pain score was documented daily. RESULTS: There are no significant demographic differences between the groups. In the active treatment group there was clear relief in pain intensity in the morning, midday and evening over the 3-week period of therapy. The Lysholm score in the active treatment group was 53.4 at the beginning, 90 after 1 week, 94.5 after the third week and 91 by the fifth week (significant difference). There were no side effects. CONCLUSION: TENS therapy with HAN stimulation resulted in pain relief in patients with gonarthrosis during the therapy period with TENS, but the pain relief did not last beyond the end of the TENS therapy. There was an improvement in the Lysholm score and the WOMAC score during the therapy. This improvement remained over the following 2-week period of observation without further TENS therapy. TENS therapy is a simple and effective method to treat gonarthrosis with very few side effects.

[Quality of life and pain in hospitalized geriatric patients]. / Lebensqualität und Schmerz bei Patienten einer medizinisch-geriatrischen Abteilung.

BACKGROUND: To determine objective and subjective indications of quality of life in hospitalized geriatric patients. METHODS: Data were collected on 267 items using standardized interviews of 90 patients, including B-L and SF-36. RESULTS: In comparison to the control population, geriatric patients have worse SF-36 values; 91% have pain, and 63% depression and elevated B-L values. Pain therapy is usually with non-opiates and with warm/cold physical therapies. CONCLUSION: Pain therapy in the geriatric population surveyed does not reach the same standard as is usually offered to hospitalized medical and surgical patients.

[Pain experience and pain therapy of tumor patients in the view of general practitioners]. / Schmerzerleben und Schmerzbehandlung von Tumorpatienten aus der Sicht von Allgemeinmedizinern.

AIM: The aim of the study presented in this paper is to find out how general practitioners evaluate their cancer patients' health, quality of life and type and extent of pain. In addition the study aims to get information about the training in pain therapy and palliative medicine. METHODS: A representative sample of 440 of all Austrian general practitioners was interviewed via a standardized questionnaire. The consent for the questioning had been obtained by telephone. RESULTS: The state of health and quality of life of the treated cancer patients are described as little satisfying and most unfavourably affected by the disease. The physicians suppose that the patients experience pain more intense than could be expected of them as endurable. Nevertheless the cancer patients appreciate pain therapy. CONCLUSION: As a result the medical training in pain therapy and palliative medicine should be improved. At the same time the future general practitioners should gain psychological competences, which would consequently provide them with a broad spectrum of treatment needed when dealing with pain patients (suffering from cancer).

Accuracy of whole-body 18F-FDP-PET for restaging malignant lymphoma.

BACKGROUND: The aim of this retrospective study was to evaluate the accuracy of fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG-PET) images, which were interpreted under daily routine conditions, in patients with Hodgkin's disease (HD) or non-Hodgkin lymphoma (NHL) for restaging after chemotherapy and/or radiotherapy. For this purpose, 18F-FDG-PET results were compared with morphological imaging methods and the patients' clinical background. METHODS: 121 PET images of 93 lymphoma patients (44 HD, 49 NHL) were investigated after chemotherapy/radiotherapy. For PET imaging, 160-200 MBq 18F-FDG was administered intravenously, followed by an infusion of 20 mg Furosemid in 250 mL saline. Whole-body 18F-FDG-PET images were obtained using a partial-ring PET scanner without attenuation correction. The morphological imaging consisted in computed tomography and ultrasound (CT/US) in all patients, additional MRI in some patients, and iliac crest biopsy in cases of suspicious bone marrow involvement. The standard of reference was composed of biopsy data, clinical status at the time of investigation, and follow-up of at least 12 months. The PET images were evaluated for their sensitivity, specificity and accuracy based on written reports, which were compiled from other imaging data and the clinical history of the patients. RESULTS: Sensitivity, specificity, and accuracy of 18F-FDG-PET was 91 %, 81 %, and 85 %; of CT/US, 88 %, 35 %, 56 %, respectively. Major sources of error in 18F-FDG-PET were due to asymmetric muscular hypermetabolism and inflammatory lesions misinterpreted as persistent viable lymphoma tissue. Furthermore, secondary malignancies other than lymphomas were another reason for misinterpretations of 18F-FDG-PET studies. CONCLUSIONS: 18F-FDG-PET showed a comparable sensitivity but a higher specificity and accuracy compared with CT/US. To achieve a high accuracy in 18F-FDG-PET, the nuclear medicine specialist needs imaging and clinical data as background information, which can only be acquired through close co-operation with the referring clinicians. Pharmacological muscular relaxation in the course of 18F-FDG-PET imaging may be advisable, as nonspecific muscular hypermetabolism was one of the problems at the image readings and a source of incorrect 18F-FDG-PET interpretations.

[Preemptive randomized, double-blind study with lornoxicam in gynecological surgery]. / Lornoxicam bei gynäkologischen Eingriffen. Eine präemptive randomisierte, doppelblinde Studie.

AIM: Lornoxicam is a non opioid analgesic belonging to the oxicam group. The aim of this study was to determine whether lornoxicam has a preemptive analgesic effect. METHODS: This study was carried out in a randomized, double-blind fashion with 66 patients divided into three groups undergoing gynecological operations. Group I was administered 8 mg of lornoxicam i.v. preoperatively followed by an 8-mg bolus every 8 h for a total dose of 24 mg in the first 24 h. Group II was administered 8 mg of lornoxicam i.v. bolus before the end of the operation followed by 8 mg every 8 h for a total dose of 24 mg in the first 24 h. Group III was administered placebo before and after the operation and for the first 24 h. The effectiveness was assessed postoperatively using the visual analogue scale (at rest, on exertion) and by calculating the total analgesic consumption of morphine hydrochloride in the first 24 h following operation. Vital signs and side effects were documented. RESULTS: Groups I and II demonstrated significantly reduced pain scores compared to group III at various points in time. Group I also demonstrated a weakly significant reduction in analgesic consumption of morphine hydrochloride postoperatively compared to groups II and III. CONCLUSION: Lornoxicam administered preemptively appears to improve the quality of postoperative analgesia and lead to reduced consumption of opioid analgesics postoperatively in patients undergoing gynecological operations.

[Results of a poll of cancer patients with respect to pain and quality of life]. / Ergebnisse einer Umfrage zu Schmerzen und Lebensqualität bei Tumorpatienten.

AIM: Bernatzky et al. recently published a study on the prescribing practices of general practitioners in Austria with respect to the prescribing of opioids in cancer patients. The aim of the study was to assess the adequately of pain therapy and the resulting quality of life in chronic cancer patients. METHODS: A representative sample of patients was taken from the Carinthian tumor register. These patient were sent a questionnaire alone with an explanatory letter and at a later date a reminder letter by mail. RESULTS: Of the 1.895 returned questionnaires 665 (35%) were completed. In this study only the data of the 429 patients who indicated that they experienced pain were processed. More than one fifth of the patients complained of a poor or a very poor quality of life and 80% of the patients were limited in their activities of daily living by pain. There are still many prejudices and informational gaps with respect to the effects of morphine. The main focus of treatment was medication therapy and was generally carried out by the family physician. The satisfaction with pain therapy was at best moderate. This is insofar of importance, as the satisfaction with pain therapy has a massive impact on the quality of life. CONCLUSIONS: More extensive information and education are required with respect to the various options and possibilities of pain control. Explanations of the mode of action and side-effects of pain medication in order to deal with the prejudices. Earlier and more focused use of pain therapy (long duration of pain), and use of coping aids for activities of daily living (limited through pain) and a broadening of the spectrum of treatment are all necessary. Patient satisfaction with pain therapy should be the main focus, as this is the deciding factor in terms of the quality of life.

Suppressive levothyroxine therapy has no significant influence on bone degradation in women with thyroid carcinoma: a comparison with other disorders affecting bone metabolism.

The aim of this study was to examine different influences on bone degradation (estrogen status, thyroid function, parathyroid function, bone metastases) with special interest focusing on the significance of suppressive levothyroxine therapy (LT4) on bone degradation in patients with differentiated thyroid carcinoma (DTC). Two markers of bone degradation (ELItest NTx = U-NTx; Serum CrossLaps = S-CTx) were used (1) to quantify the influence of different metabolic influences on bone degradation and (2) to compare these two markers with each other. One hundred forty samples of 98 female patients ages 23-86 years were analyzed. The correlation between the two assays of bone degradation was high (r = 0.825; p < 0.001). Both assays demonstrated that estrogen deficiency, hyperparathyroidism, and bone metastases caused significant increases of bone degradation. A suppressive LT4 therapy, as used for patients with DTC, led to no significant increases of S-CTx and U-NTx. The study indicates that a well-controlled suppressive LT4 therapy has only a minor effect on the degree of bone degradation and that a possible estrogen deficiency in patients with DTC has a greater impact on bone degradation. Thus, female patients with DTC on suppressive LT4 therapy and estrogen deficiency may benefit from hormone replacement therapy, as patients with DTC and normal estrogen levels presented similar results to euthyroid controls.

[Postoperative transcutaneous electrical nerve stimulation (TENS) in shoulder surgery (randomized, double blind, placebo controlled pilot trial)]. / Postoperative transkutane elektrische Nervenstimulation (TENS). Randomisierte, doppelblinde, plazebokontrollierte Pilotstudie bei Eingriffen im Schultergelenkbereich.

BACKGROUND: The aim of this study was to determine whether 3 days of TENS therapy postoperatively after shoulder operations would result in better pain relief and/or reduced analgesic intake when compared to placebo. METHOD: The study was carried out randomized, double-blind and placebo controlled. Thirty patients were randomized to two groups. The verum group received TENS SM1AKS 80 Hz 6 mA and the placebo group received TENS SM1AKS 80 Hz 0 mA. The pain was assessed pre-operatively using the Hamburg Pain Adjective List. Premedication and Anaesthesia were standardized. TENS was applied to the patients immediately postoperatively for 8 hours and then on the following days 5 times daily for 45 minutes. The effectiveness was evaluated postoperatively using a visual analogue scale (rest, activity), the Hamburg Pain Adjective List and postoperative analgesic consumption. RESULTS: The visual analogue scale at rest and on activity showed no significant difference between the groups. Postoperative analgesic consumption of morphine hydrochloride in the first 24 hours was at time 8 hours postoperative significantly and at all other time points markedly less in the verum group compared to the placebo group. The sensory secondary scale score of the "Hamburg Pain Adjective List" was significantly lower postoperatively compared to preoperatively in the verum group. CONCLUSION: We were able to show in this study that TENS applied postoperatively after shoulder surgery clearly reduced analgesic consumption in the first 72 hours. Furthermore there was a significant difference in the pain scores using the "Hamburg Pain Adjective List" in favour of the verum group. TENS applied postoperatively is a effective, simple modality with few side-effects.

[Opioid therapy in Austria: results and analysis of a survey]. / Opioidtherapie bei Arzten für Allgemeinmedizin in Osterreich: Ergebnisse und Analyse einer Umfrage.

INTRODUCTION: Many causes are given as the main reason for inadequate pain therapy. The objective of our study was to demonstrate the current position of doctors in general practice all over Austria who prescribe prescriptions. METHODS: A total of 5,359 questionnaires were sent out to general practitioners in all federal states of Austria. These questionnaires contained 21 main questions on subjects relevant to pain therapy. RESULTS: On average, 16% of all general practitioners returned the questionnaires; 89.3% of these are acquainted with the WHO graduated scale, 87% have prescribed strong opioids. Old prejudices such as concerns about the side effects are hardly to be found now. Modern therapy strategies are used. CONCLUSION: Based on the data at hand, pain therapy for patients should be excellent. The reality, however, is somewhat different. The large number of doctors who did not reply makes it enormously difficult to make a statement about the position of pain therapy in Austria.

Peripheral morphine analgesia in dental surgery.

The recent identification of opioid receptors on peripheral nerve endings of primary afferent neurons and the expression of their mRNA in dorsal root ganglia support earlier experimental data about peripheral analgesic effects of locally applied opioids. These effects are most prominent under localized inflammatory conditions. The clinical use of such peripheral analgesic effects of opioids was soon investigated in numerous controlled clinical trials. The majority of these have tested the local, intraarticular administration of morphine in knee surgery and have demonstrated potent and long-lasting postoperative analgesia. As the direct application of morphine into the pain-generating site of injury and inflammation appears most promising, we examined direct morphine infiltration of the surgical site in a unique clinical model of inflammatory tooth pain. Forty-four patients undergoing dental surgery entered into this prospective, randomized, double-blind study. Before surgery they received, together with a standard local anesthetic solution (articaine plus epinephrine) a submucous injection of either 1 mg of morphine (group A) or saline (group B). Postoperative pain intensity was assessed using the visual analog scale (VAS) and numeric rating scale (NRS) at 2, 4, 6, 8, 10, 12, 16, 20 and 24 h after surgery. In addition, patients recorded the occurrence of side effects and the supplemental consumption of diclofenac tablets. Results of 27 patients were analyzed (group A: n=14, group B: n=13). Pain scores which were moderate to severe preoperatively were reduced to a similar extent in both groups up to 8 h postoperatively. Thereafter, pain scores in group A were significantly lower than those in group B for up to 24 h, demonstrating the analgesic efficacy of additional morphine. The time to first analgesic intake and the total amount of supplemental diclofenac were less in group A than in group B. No serious side effects were reported. Our results show that 1 mg of morphine added to a local anesthetic for dental surgery results in significant improvement of postoperative analgesia. Since the majority of dental surgeries is accompanied with an inflammatory reaction, supplemental morphine may be of benefit for the relief of postoperative dental pain.

[Randomized, double-blind study with ketoprofen in gynecologic patients. Preemptive analgesia study following the Brevik-Stubhaug design]. / Randomisierte, doppelblinde Studie mit Ketoprofen bei gynäkologischen Eingriffen. Präemptive Analgesiestudie nach dem Design Breivik/Stubhaug.

STUDY OBJECTIVE: The clinical effect of ketoprofen is based not only on the inhibition of prostaglandin synthesis. Ketoprofen also acts through kynurenic acid as a central antagonist on the NMDA receptor. Due to this central analgesic mechanism of ketoprofen, we expected an analgesic preemptive effect. This study was carried out following the Breivik/Stubhaug preemptive effect study design. METHODS: In 81 patients scheduled for gynaecological surgery a randomized double-blind study was performed. Three groups were studied: Group I received preoperative ketoprofen 100 mg i.v., 12 mg/h during surgery and for 48 hours afterwards. Group II received 100 mg ketoprofen as a bolus injection before the end of surgery, thereafter 12 mg/h ketoprofen continuously for 48 hours. Group III received a placebo during surgery and for 48 hours after surgery. The effects were measured postoperatively using a visual analog scale (VAS; at rest and on exertion) and the total analgesic consumption (PCA piritramide) within the first 48 hours after surgery. Furthermore, the time to first analgesic request was recorded. The vital signs and side effects were documented. RESULTS: The time to first analgesic request in group I was significantly longer than in groups II and III. In addition, the cumulative postoperative analgesic consumption during the first 24 hours after surgery was significantly lower in group I than in group III. Furthermore, the combination of an opioid with a non-opioid led to a lower pain score (VAS) at rest and on exertion. CONCLUSIONS: We showed a preemptive effect with ketoprofen, which was expressed significantly both in terms of the time to first analgesic request and by the lower analgesic consumption in the first 24 hours after surgery.

Evaluation of thyroid nodules with technetium-99m tetrofosmin dual-phase scintigraphy.

Technetium-99m tetrofosmin, a lipophilic cationic complex molecule, was introduced for myocardial imaging. In some biodistribution studies it has also been reported to accumulate in the thyroid gland. Our objectives were to determine which thyroid nodules retain tetrofosmin and whether preoperative evaluation of malignancy is possible. Tetrofosmin scintigraphy was performed in 57 patients with a cold thyroid nodule on previously performed pertechnetate scintigraphy. All patients had undergone ultrasonography and sonographically guided fine-needle aspiration biopsy. The tetrofosmin scintigrams were obtained 5 min (early image) and 1 h (late image) after intravenous injection of 370 MBq. Only nodules that showed clear tracer retention after 1 h in comparison with retention at 5 min were classified as TETRO positive. Nodules without late retention were classified as TETRO negative. All patients underwent surgery and the histological results were compared with the results of tetrofosmin scintigraphy. Ten out of 11 patients with thyroid carcinoma (two pT1, three pT2, five pT4) were TETRO negative. One patient with papillary carcinoma (pT2) was TETRO positive. The mean nodular to thyroid tissue (N/T) ratio for the late scan was 1.0+/-0.20. There were 21 patients with thyroid adenomas (seven follicular, seven microfollicular and seven oxyphilic); 15 of these patients were TETRO positive and six TETRO negative. The mean N/T ratio for the late images was 1.34+/-0.41. All patients with degenerative goitre (24 cases) and the one patient with Hashimoto's disease were TETRO negative after 1 h and the N/T ratio was 0.92+/-0.12 on the late scan. Our results indicate that 99mTc-tetrofosmin scanning is of little value preoperatively in distinguishing thyroid carcinoma from other thyroid nodules. Tetrofosmin tends to demonstrate thyroid adenomas but does not have a routine role in the assessment of thyroid nodules.