Pain-phenotyping in osteoarthritis: Current concepts, evidence, and considerations towards a comprehensive framework for assessment and treatment.

Objectives: Pain as central symptom of osteoarthritis (OA) needs to be addressed as part of successful treatment. The assessment of pain as feature of disease or outcome in clinical practice and drug development remains a challenge due to its multidimensionality and the plethora of confounders. This article aims at providing insights into our understanding of OA pain-phenotypes and suggests a framework for systematic and comprehensive assessments. Methods: This narrative review is based on a search of current literature for various combinations of the search terms "pain-phenotype" and "knee OA" and summarizes current knowledge on OA pain-phenotypes, putting OA pain and its assessment into perspective of current research efforts. Results: Pain is a complex phenomenon, not necessarily associated with tissue damage. Various pain-phenotypes have been described in knee OA. Among those, a phenotype with high pain levels not necessarily matching structural changes and a phenotype with low pain levels and impact are relatively consistent. Further subgroups can be differentiated based on patient reported outcome measures, assessments of comorbidities, anxiety and depression, sleep, activity and objective measures such as quantitative sensory testing. Conclusions: The complexity of both OA as disease and pain in OA prompt the definition of a set of variables that facilitate assessments comparable across studies to maximize our understanding of pain, as central concern for the patient.

Does biventricular pacing improve hemodynamics in children undergoing routine congenital heart surgery?

Biventricular (BiV) pacing or cardiac resynchronization therapy (CRT) is an established therapy for heart failure in adults. In children, cardiac dyssynchrony occurs most commonly following repair of congenital heart disease (CHD) where multisite pacing has been shown to improve both hemodynamics and ventricular function. Determining which patient types would specifically benefit has not yet been established. A prospective, repeated measures design was undertaken to evaluate BiV pacing in a cohort of children undergoing biventricular repair for correction of their CHD. Hemodynamics, arterial blood gas, electrocardiographic (ECG), and echocardiographic data were collected. Pacing protocol was undertaken prior to the patient's extubation with 20 min of conventional right ventricular (RV) or BiV pacing, preceded and followed by 10 min of recovery time. Multivariate statistics were used to analyze the data with p values <0.05 considered significant. Twenty-five (14 female) patients underwent surgery at a median (range) age of 5.2 (0.1-37.4) months with no early mortality. The Risk-adjusted classification for Congenital Heart Surgery (RACHS) scores were 2 in 14 patients, 3 in eight patients, and 4 in three patients. None had pre-existing arrhythmias, dyssynchrony, or required pacing pre-operatively. No patient required implantation of a permanent pacemaker post-operatively. The median cardio-pulmonary bypass time was 96 (55-236) min. RV and BiV pacing did not improve cardiac index from baseline (3.23 vs. 3.42 vs. 3.39 L/min/m2; p > 0.05). The QRS duration was not changed with pacing (100 vs. 80 vs. 80 ms; p > 0.05). On echocardiography, the time-to-peak velocity difference between the septal and posterior walls (synchrony) during pacing was similar to baseline and was also not statistically significant. BiV pacing did not improve cardiac output when compared to intrinsic sinus rhythm or RV pacing in this cohort of patients. Our study has shown that BiV pacing is not indicated in children who have undergone routine BiV congenital heart surgery. Further prospective studies are needed to assess the role of multisite pacing in children with ventricular dyssynchrony such as those with single ventricles, those undergoing reoperation or those with high RACHS scores.

Incidence of auditory ossicle luxation and petrous bone fractures detected in post-mortem multislice computed tomography (MSCT).

As the auditory ossicles are difficult to display without harming them in conventional autopsies, lesions of these minute bones and the ossicular chain are regularly missed. In this study, the method of choice in clinical medicine for the examination of such lesions, namely multislice computed tomography, was applied to 100 corpses. The hereby obtained results regarding ossicle luxation and petrous bone fracture indicated that the lesions were not dependant on the amount, but rather on the type of energy inflicted to the head.

[Intestinal perforation after preoperative colonic tattooing with India ink]. / Darmperforation nach präoperativer kolonoskopischer Tuschemarkierung.

Since the ability to palpate the bowel is lost in laparoscopic colon surgery preoperative marking of lesions is required to avoid "blind" resection. Endoscopic tattooing with India ink is the agent of choice because of its simplicity and the long-lasting stain. Only few complications have been reported using this technique. We present a case with localized necrosis and retroperitoneal perforation after endoscopic tattooing. Due to the formation of a local inflammatoric pseudotumor laparoscopic resection was impossible and open right hemicolectomy was necessary. Fever, abdominal pain and signs of local peritonitis after endoscopic tattooing should remind clinicians of this rare complication.

[Perianal mucinous adenocarcinoma. A further reason for histological study of anal fistula or anorectal abscess]. / Das perianale mucinöse Adenocarcinom. Ein weiterer Grund für die histologische Untersuchung bei Analfistel oder Anorectalabscess.

A 39-year-old man came to us for surgical treatment of a hidradenitis suppurativa. Upon excision of a perianal abscess, the diagnosis of a rare tumor, a perianal mucinous adenocarcinoma (pT4, pN 1, MO), was made. An abdominoperineal resection was performed, followed by a combination of adjuvant radiation and chemotherapy. A year after the operation, the patient is doing well without any signs of recurrence. This carcinoma probably arises in the anal glands. It often presents as a perirectal abscess and/or an anal fistula. Therefore, the diagnosis is often delayed. At presentation, the tumor is bigger than 5 cm in diameter in 80% of the cases, and the prognosis is poor. It metastasizes mostly to the superficial inguinal or to the retrorectal lymph nodes. There are only case reports and no comparative studies in the literature. In the last 10 years, the carcinoma has mostly been treated by neoadjuvant radiation and chemotherapy, followed by abdominoperineal resection. Since then, the median survival has increased to 3 years. This is the first case report of a combination of a perianal mucinous adenocarcinoma with a hidradenitis suppurativa.

[Endoscopic bursa shaving in acute bursitis]. / Das endoskopische Bursashaving bei akuter Bursitis.

OBJECTIVES: After resection of olecranon or prepatellar bursa for bursitis there can be long-term skin complications in up to 20%. We wanted to determine the outcome after endoscopic resection, a technique first described in 1990. METHODS: In a period of three years (6/97-7/00) 13 Patients with bursitis were prospectively enclosed in the study and underwent endoscopic resection of the bursa. All patients were examined clinically three weeks and six months postoperatively. RESULTS: In nine patients a resection of the Olecranon bursa was performed, in four patients of the pre-patellar bursa. 11 cases showed a septic bursitis, two a chronic. 50% of the operations were conducted in general anesthesia. We observed no intra- or postoperative complications. The follow-up examinations showed no pain, no recurrence and no loss of joint motion. CONCLUSION: It is our opinion that the endoscopic resection of the Olecranon and pre-patellar bursa for septic bursitis is a promising technique and shows favourable results compared to the open resection.

[Traumatic perforation of the small intestine--a rare complication of inguinal hernia]. / Die traumatische Dünndarmperforation--eine seltene Komplikation der Leistenhernie.

Groin hernias are among the most common surgical diseases. Traumatic rupture of the intestine is a rare complication compared to incarceration. We report on a 90-year old male with a left-sided hernia and a traumatic rupture of the small bowel. The treatment consisted of an emergency laparoscopy with simple closure of the perforation, repair of the hernia by herniorrhaphy and drainage of the abdomen.

[The need for blood transfusions in elective colon surgery--is preoperative autotransfusion useful?]. / Der Bedarf an Bluttransfusionen bei elektiven Koloneingriffen--Ist die präoperative Eigenblutspende sinnvoll?

All elective surgical procedures of the colon from 1992-1994 at Kreisspital Männedorf were analyzed retrospectively. The goal of this study was to find out if a preoperative autologous blood donation before elective colon surgery is useful and if so to determine the amount of blood to be donated. In 87 surgical procedures of the colon, the use of homologous blood transfusions was studied. The need for transfusion was highest in abdominoperineal resection with 6.8 (+/- 4.45) units and lowest in sigmoid resections with 0.68 (+/- 0.88) units. The estimated intraoperative blood loss was 868.67 (+/- 732.54) ml and 1.8 (+/- 2.6) units of homologous blood were transfused. The need for transfusion depended on the preoperative hemoglobin, the estimated intraoperative blood loss and the duration of the operation. We concluded that a preoperative donation of autologous blood before sigmoid resection is unnecessary. For all other colon resections with malignant or benign disease autologous blood transfusion is useful provided the patient meets the requirements for donation. A donation of 2 units of autologous blood is sufficient. With a preoperative hemoglobin value. > or = 11 g/dl and an estimated intraoperative blood loss < or = 1000 ml or an operation time < or = 150 min. the need for additional transfusion with homologous blood is minimal.

[Management of lateral type B malleolar fracture with penetrating wires, cerclage and hemicerclage]. / Versorgung der lateralen Malleolarfraktur Typ B mit Spickdrähten, Cerclagen und Hemicerclagen.

In this retrospective study 52 cases of malleolar fractures type B, that were treated with Kirschner wires, cerclages and hemicerclages, between 1981 and 1991 at the Männedorf Hospital, were compiled and completed with the corresponding synopsis. The results show that the osteosynthesis technique, in certain cases, is absolutely justifiable and represents a reliable alternative to tensile screw osteosynthesis. This procedure of osteosynthesis is a good method in comminuted fractures as well as osteoporotic bone, in which the screws grip badly. A minimum of osteosynthesis material is implanted in precarious soft tissue conditions. As in the tensile screw osteosynthesis, the removal of the material can be done ambulatory under local anaesthetic with stab incision. The functional after-treatment is not recommended. We suggested a postoperative plaster of Paris treatment for 6 weeks (2 weeks without and 4 weeks with strain). As the postoperative course shows comparable results, osteosynthesis of the lateral malleolar fracture type B with Kirschner wires, cerclages and hemicerclages represents a good variation to plate osteosynthesis and tensile screw osteosynthesis.

[Necrosis of the terminal ileum after drug poisoning. Case report]. / Nekrose des terminalen Ileum nach Tablettenintoxikation. Fallbericht.

In an attempt to commit suicide, a 32-year-old women swallowed a vast amount of psychiatric drugs, i.e. tranquilizers, amphetamines, hynotic and antidepressant agents. By intensive care, using high doses of catecholamines and appropriate antidota, satisfactory circulation and oxygenation could be maintained. 3 days after admission a peritonitis became apparent. A 50 cm long section of the distal ileum was found to be completely necrotic and had to be resected. However, circulation of the correspondent mesenterium was not disturbed at all. A drug-induced non-occlusive intestinal ischemia was postulated to be the pathophysiological mechanism of intestinal necrosis. Non-occlusive intestinal ischemia is rare; it has been reported in young adults intoxicated by cocaine or phenobarbital, in children with high overdosage of iron compounds, in elderly individuals suffering from low-output congestive heart disease and in patients treated with digitalis drugs, with or with or without overdosage.

[Complications of diverticuli of the proximal small intestine. 3 case reports and review of the literature]. / Die Komplikationen von Divertikeln im oberen Dünndarm. Drei Fallbesprechungen und Literaturübersicht.

Three cases of small bowel diverticula are presented. In the first patient perforation of a congenital diverticulum in pars II of the duodenum occurred, the second case is the first description of bezoar in a duodenal diverticulum with bleeding of the diverticulum at the same time and the third patient suffered from ileus due to unusually large jejunal diverticulum. Up to 20% of all autopsied patients present duodenal diverticula. In other parts of small bowel diverticula are not as frequent. Most cases are asymptomatic and require no treatment. As soon as ailments occur, further investigations and probably surgical treatment is necessary. Perforation, bleeding and obstruction are indications for surgical interventions. The symptomatology is unspecific, therefore preoperative diagnosis is difficult. At least during the operation the possibility of small bowel diverticula and their complications should be considered. Till today complications of small bowel diverticula are affected with a mortality of 33-48%. More awareness of their existence could possibly improve this unfavourable outcome.

[Ten cases of rare breast tumors. Review and surgical management]. / Zehn Fälle von seltenen Mammatumoren. Ubersicht und chirurgisches Management.

Ten cases of rare breast tumors are reported along with review of the literature. Three of the patients had cystosarcoma phylloides, one a primary carcinoid of the breast, two metastasis to the breast (bronchus carcinoma and carcinoma of the maxillary sinus), two malignant lymphoma and two Hodgkin lymphoma of the breast. We present a discussion of diagnostic and therapeutic procedures of breast tumors. Specially in rare breast tumors an exact histological diagnosis is important in order to avoid unnecessary surgical treatment and to guide further therapy.

[Primary closure of traumatically ruptured bursae]. / Primärverschluss traumatisch eröffneter Schleimbeutel.

Normally a bursectomy is the choice of therapy when a bursa of a joint is opened through trauma. A primary closure was performed on 10 patients, selected according to certain specific criteria. Nine out of ten cases showed no complications with good short and long-term results.

Humeral mobility after treatment with hanging cast.

A retrospective review of 23 patients after treatment of humeral fractures with hanging cast was performed. The average followup time was 8.59 years (range, 1.0 to 15.5 years). Functional results were good in eight (34.8%) and excellent in 15 patients (65.2%). To assess the flexibility of shoulder and elbow joints 24 parameters were measured on each body side using the neutral-zero method of Debrunner. A cumulative comparison of each parameter revealed decreased flexibilities of the upper limb after treatment with hanging cast: reduced abduction without moving shoulder blade (84.08 +/- 7.53 vs. 77.34 +/- 11.38; p less than 0.05), reduced free abduction (166.09 +/- 14.4 vs. 158.22 +/- 19.28; p less than 0.01), reduced anteelevation (155.26 +/- 10.12 vs. 149.35 +/- 3.22; p less than 0.01), reduced external rotation with hanging arm (48.96 +/- 19.05 vs. 41.18 +/- 16.75; p less than 0.01), increased flexion of the shoulder (25.65 +/- 10.37 vs 27.3 +/- 10.0; p less than 0.05) and reduced extension of the elbow (0.86 +/- 6.92 vs. -2.68 +/- 9.63; p less than 0.05). These findings show that longterm deficiencies of humeral mobility after treatment with hanging casts exist.

[Surgical treatment of diabetic malum perforans by ray resection]. / Chirurgische Behandlung des diabetischen Malum perforans durch Strahlresektion.

The main cause of the diabetic perforating ulcer is peripheral neuro- and angiopathy. Trivial injuries of the foot, wounds (chiropody), bacterial or mycotic infections often lead to tissue defects in the form of a perforating ulcer (in which neuropathy predominates) or of gangrene (in which angiopathy predominates). The deeply penetrating trophic ulcer with secondary development of osteitis in the foot bones often present us with difficult therapeutic decisions. Several measures for its treatment are given in the literature. We report on 5 patients in whom a plantar perforating ulcer was present beneath the 2nd an 3rd metatarsal heads with radiologically confirmed osteitis. The entire ray, including the corresponding toe, is excised as a wedge from the plantar and dorsal aspects, and the wound left open to heal. The indications, the course of healing, the duration of hospital admission and the complications are described.

[The significance of preoperative autologous blood donation in general surgery]. / Die Bedeutung der präoperativen Eigenblutspende in der Allgemeinchirurgie.

In the surgical department of a county hospital, the total number of heterologous blood transfusions has been reduced by transfusing autologous blood units in elective surgery. Orthopedic, urologic, vascular and plastic surgery qualify mainly for autologous blood transfusion.

[Morphological breast diagnosis in daily practice]. / Morphologische Mammadiagnostik in der täglichen Praxis.

Two approaches are currently in use for diagnosis of breast cancer: triple diagnosis or excision for histopathologic evaluation. For practical and economical reasons we favor the bioptic approach, because it closes the diagnostic endeavour in malignant and in benign lesions. Objections to biopsy based on arguments of tumor-biology are not scientifically founded. If the palpatory finding and the mammography are indicative of carcinoma, the diagnosis can also be sufficiently confirmed by fine needle aspirate cytology to warrant further therapy. If, using this triple-diagnostic measure, a carcinoma is not unequivocally confirmed, the suspect lesion has to be excised. At the slightest suspicion of a cyst we use diagnostic punction in order to avoid unnecessary cystectomies. Areas that are not palpable but suspicious on mammography can only be diagnosed reliably by excision under radiologic control.

[Abdominal actinomycosis--ileo-vaginal fistula as clinical manifestation. Case report and literature review]. / Abdominale Aktinomykose--ileo-vaginale Fistel als klinische Manifestation. Fallbericht und Literaturübersicht.

In 1985 sigmoid resection was performed in an 81-year-old patient with recurrent sigmoid diverticulitis. Due to adenomyosis uteri, hysterectomy was performed at the same time. Approximately one year after an uneventful recovery fetid leukorrhea occurred. Radiograms revealed a fistula between the terminal ileum and vagina. Adhesions between the terminal ileum and vaginal stump were surgically resolved and an ileum segment resection was performed. Postoperative recovery was uncomplicated and the patient has been symptom-free since. The histological findings of Actinomyces microorganisms, thread-like foreign material and detritus drew our attention to a rare instance of abdominal actinomycosis. Publications of purely historical interest dealing with therapeutic measures before the antibiotic era are not taken into consideration. The clinical picture, incidence and therapy of abdominal actinomycosis are described in the light of the literature.

[Semiquantitative lipase determination--a useful screening test for pancreatitis?]. / Die semiquantitative Bestimmung der Lipase--ein nützlicher Screeningtest für die Pankreatitis?

In 233 sera, taken from 112 patients and 20 healthy blood-donors, we have compared RapiTex-Lipase, a semi quantitative immunochemical latex test for the determination of the lipase, with the conventional quantitative method of determination in order to establish its diagnostical value as a screening test for acute pancreatitis. It appeared that, with a positive result of the test increased values of lipase were found in 98% of the cases, but that a negative result of the test did not exclude an increased lipase. The sensitivity of the test as to the quantitative determination of the lipase depended directly on the activity of the lipase and turned out to be acceptable at 88% only with values 4 X higher than the upper limit of the normal range. With values 5 X higher and more, it reached 100%. Even if the test, due to its very high level of discrimination, did not show a reaction in every case of unspecific extrapancreatic hyperlipasemia, its organ-specificity for the pancreas was reduced and came to 80 to 96% in patients with renal insufficiency, diseases of the liver, abuse of alcohol and in various non-pancreatic intra- or extra-abdominal affections. In 16/18 patients with acute pancreatitis the test used for screening turned out positive (sensitivity 89%), two patients with values between 2 and 4 X the upper limit of the norm had a negative test.(ABSTRACT TRUNCATED AT 250 WORDS)

[Abdominal actinomycosis. Ileo-vaginal fistula as a clinical manifestation. Case report and review of the literature]. / Abdominale Aktinomykose. Ileo-vaginale Fistel als klinische Manifestation. Fallbericht und Literaturübersicht.

In 1985, a resection of the sigmoid colon was performed on an 81-year-old patient with recurrent and stenotic sigmoid diverticulitis. Vaginal hysterectomy was carried out at the same time for adenomycosis. After an uneventful recovery, approximately 1 year later the patient was presented with fetial leucorrhoea. Radiologically, a fistula was apparent between the terminal ileum and the vagina. Adhesions between the terminal ileum and the vaginal stump were surgically resolved and an ileum segment resection performed. Postoperative recovery was smooth and the patient has remained symptom-free since then. The histological findings of actinomyces spores, thread-like foreign material and detritus drew out attention to the rare manifestation of abdominal actinomycosis. The relevant literature was compiled as completely as possible. Not included are publications of historical interest on therapeutic measures before the antibiotic era. The clinical picture, frequency and therapy of abdominal actinomycosis are discussed on the basis of this review of the literature.