[Critical discussion of new data regarding prevalence of opioid use disorder in patients with chronic pain in Germany]. / Kritische Auseinandersetzung mit neuen Daten zur Prävalenz von Opioidgebrauchsstörungen bei Patienten mit chronischen Schmerzen in Deutschland.

BACKGROUND: There is no opioid crisis in Germany. However, new studies involving patients with chronic noncancer pain (CNCP) in Germany show an unexpectedly high prevalence of opioid use disorder according to DSM­5 (Diagnostic and Statistical Manual for Psychiatric Diseases). OBJECTIVES: Critical discussion of new study results on the prevalence of opioid use disorder in CNCP patients in Germany. MATERIALS AND METHODS: Selective literature search and multiprofessional classification of results by an expert panel (pain therapy, neurology, psychiatry, palliative medicine, general medicine and addiction therapy). RESULTS: The DSM­5 criteria for the diagnosis of "opioid use disorder" have limited applicability to patients with CNCP, but may raise awareness of problematic behavior. The diagnosis of opioid use disorder is not the same as the diagnosis of substance dependence according to ICD-10, as the DSM­5 diagnosis covers a much broader spectrum (mild, moderate, severe). Risk factors for opioid use disorder include younger age, depressive disorders, somatoform disorders, and high daily opioid doses. The interdisciplinary guideline on long-term opioid use for CNCP (LONTS) includes recommendations intended to reduce the risk for opioid use disorder. CONCLUSION: An adaptation of the DSM­5 diagnostic criteria of opioid use disorder to the specific situation of CNCP patients and a validation of these criteria could help to collect more accurate data on opioid use disorders of patients with chronic pain in Germany in the future. Prescribers should be sensitized to this problem without pathologizing or even stigmatizing patients. Further research is needed to classify this previously underestimated phenomenon.

[Palliative care of patients receiving opioid substitution therapy]. / Palliativversorgung von Patienten in Opioidsubstitutionsbehandlung.

Patients with opioid use disorder survive longer and reach higher ages due to harm reduction and maintenance programs. Therefor and because of concomitant comorbidities there is an increased incidence of life-limiting diseases. Thus, increasing numbers of patients with opioid use disorder or in maintenance programs will require palliative care. However, both inpatient and outpatient service providers are uncertain about providing palliative care for these patients. Home-care teams and inpatient hospices have been known to refuse admission for patients with opioid use disorder. Providing medical care to patients receiving substitution therapy can be challenging because maintenance programs require strict compliance with their rules and regulations; however, an individualized approach with knowledge of basic legal requirements enables good palliative care. In this manner, it is possible to ensure healthcare for these aging patients.

[Motivation of High-risk Patients to Stop Smoking in the DMP]. / Motivation von Risikopatienten zum Rauchstopp im DMP.

AIM OF THE STUDY: Patients in disease management programmes (DMP) have a high overall cardiovascular risk. Smoking is the most important preventable risk factor. A reduction in the overall risk could be achieved in studies by multiple risk consulting. Direct influence on the smoking behaviour has not been investigated. ARRBIA heart is a risk calculator that can represent mainly the possible risk reduction through a change in behaviour such as smoking cessation. The MOTOR study should therefore review the possibility of integrating ARRBIA heart DMP in order to increase the motivation to stop smoking. METHODOLOGY: As part of the usual consultation DMP 47 patients were informed about their personal overall cardiovascular risk. Then a smoking brief intervention was performed depending on the predetermined motivation stage and handed out in a self-help manual at the end of the consultation. In the control group, 33 patients were treated as usual in the DMP. RESULTS: The integration of a risk consulting with ARRIBA heart is possible at a mean intervention period of 10 min in the regular DMP. Most doctors want to continue to work with ARRIBA heart. A change in smoking behaviour could not be determined by a single risk consulting. It was found, however, that the perception of risk increased with increasing motivation to stop smoking. CONCLUSIONS: In a subsequent study, the effectiveness of multiple risk consulting on the smoking behaviour and the overall risk must now be checked. The integration of ARRIBA heart is a possible approach to achieve regular smoking brief interventions in the DMP.

Different effects of mexiletine on two mutant sodium channels causing paramyotonia congenita and hyperkalemic periodic paralysis.

Effects of the antiarrhythmic and antimyotonic drug mexiletine were studied on two sodium channel mutants causing paramyotonia congenita (R1448H) and an overlap paramyotonic and hyperkalemic paralytic syndrome (M1360V). Channels were expressed in human embryonic kidney cells and studied electrophysiologically, using the whole-cell patch-clamp technique. Compared to the wild-type, channel, both mutants showed alterations of inactivation, i.e. slower inactivation, left shift of steady-state inactivation and faster recovery from inactivation. Mexiletine caused a significantly larger use-dependent block of the R1448H mutant when compared to M1360V and wild-type channels. This can be explained by a prolonged recovery from mexiletine block as observed for R1448H channels, since the affinity of mexiletine for the inactivated state was similar for all three clones. The use-dependent block of sodium channels by mexiletine reduces repetitive series of action potentials and therefore improves muscle stiffness in myotonic patients. The enhanced use-dependent block as seen with R1448H may explain the extraordinary therapeutic efficacy of mexiletine in most patients with paramyotonia congenita.

Blocking effects of the anaesthetic etomidate on human brain sodium channels.

Sodium channels from human brain tissue were incorporated into voltage-clamped planar lipid bilayers in presence of batrachotoxin and exposed to increasing concentrations of the intravenous anaesthetic drug etomidate (0.03-1.02 mM). Etomidate interacted with the sodium-conducting pathway of the channel causing a concentration-dependent block of the time-averaged sodium conductance (computer fit of the concentration-response curve: half-maximal blocking concentration, EC50, 0.19 mM; maximal block, block(max), 38%). This block of sodium-conductance resulted from two distinct effects (I) major effect: reduction of the sodium-channel amplitude and (II) minor effect: reduction of the fractional channel open-time. These results were observed at concentrations above clinically-relevant serum concentrations (up to 0.01 mM), suggesting only a limited role for human brain sodium channels in the mechanism of action of etomidate during clinical anaesthesia.

[Autoimmune encephalopathy in Hashimoto's thyroiditis. A differential diagnosis in progressive dementia syndrome]. / Autoimmunenzephalopathie bei Hashimoto-Thyreoiditis. Eine Differentialdiagnose bei progressivem Demenzsyndrom.

HISTORY AND CLINICAL FINDINGS: A 58-year-old woman, known for 10 years to have Hashimoto's thyroiditis, was admitted from another hospital where, after an initial period of unconsciousness, she had developed progressive severe dementia, abnormal arousal and generalized myoclonia. Jakob-Creutzfeldt disease (JCD) was suspected. INVESTIGATIONS: The electroencephalogram (EEG) showed marked slowing of the basic activity and episodes of triphasic waves. The titres of thyroid antibodies (TPO 764 kU/l, TgAk 398 kU/l) and of the antinuclear antibodies (ANA 1:1280) were raised, as was the erythrocyte sedimentation rate (80/120 mm and the cerebrospinal fluid albumin concentration (1 g/l). TREATMENT AND COURSE: The history and findings suggested autoimmune encephalitis (AIE) and treatment with prednisolone, 2 mg/kg body weight daily, was initiated, achieving lasting improvement of arousal within two days. 6 weeks later the EEG merely showed mild alteration of basic activity. The thyroid antibody titres were now within normal limits and the signs of inflammation were regressing. CONCLUSION: In case of rapidly progressive dementia autoimmune antibodies should be looked for in the differential diagnosis, because autoimmune disease may be the treatable cause.