Investigation of Behavioural Pain Scale, Critical Care Pain Observation Tool, nociceptive flexion reflex and pupillary dilatation reflex as predictors of behavioural reactions to nociceptive procedures in critically ill patients unable to self-report pain.

BACKGROUND: Procedural pain is a common burden in critical care treatment and the prediction of nociceptive reactions remains challenging. Thus, we investigated the Behavioural Pain Scale (BPS), the Critical Pain Observational Tool (CPOT), the nociceptive flexion reflex (NFR), the pupillary dilation reflex (PDR) and the Richmond Agitation-Sedation Scale (RASS) as predictors of behavioural reactions to nociceptive procedures. METHODS: In this monocentric, prospective, observational study, we analysed data of 128 critically ill adults unable to self-report pain to investigate the predictability of behavioural reactions to two procedures: endotracheal suctioning and turning. Next to routine clinical data, CPOT, BPS, PDR, NFR, RASS, propofol and sufentanil doses were recorded before the procedures. RESULTS: For endotracheal suctioning, NFR, BPS, CPOT and RASS showed predictive performances significantly better than chance, but none of them performed significantly better than the sufentanil dose rate. For turning, BPS, CPOT and RASS showed predictive performances significantly better than chance, but only the RASS performed significantly better than the propofol dose rate. CONCLUSIONS: Behavioural reactions to both investigated clinical procedures can be predicted by observational scales or nociceptive reflexes. For endotracheal suctioning, none of the predictors performed superior to using the sufentanil dose rate as a predictor. As using sufentanil as a predictor requires no extra effort in contrast to the other predictors, none of the here investigated tools seem advisable for predicting behavioural reactions to endotracheal suctioning. For patient turning, the RASS predicts reactions better than any other tool. SIGNIFICANCE: In this observational study, we demonstrate that behavioural reactions to potentially nociceptive procedures in critical care treatment can be predicted by observational scales and nociceptive reflexes. However, for endotracheal suctioning, none of the predictors is superior to using the opioid dose rate as a predictor. For patient turning, the RASS predicts reactions better than any other parameters.

Prevalence and complications of orthostatic dizziness in the general population.

Although orthostatic dizziness (OD) is a common complaint, its prevalence and medical impact in the general population are unknown. The study aims to assess prevalence, medical sequelae and healthcare and social impact of OD in the general population. Participants of the representative German National Health Interview Survey 2003 (n = 4077, age 18-89 years, response rate 52%) were screened for moderate or severe dizziness or vertigo. As part of a larger study on the epidemiology of dizziness and vertigo, a consecutive subsample of screen-positive participants (n = 825) underwent a structured medical interview for OD based on the criteria: (1) non-vestibular dizziness (i.e. diffuse non-rotational dizziness, light headedness, feeling of impeding faint), (2) provocation by sudden postural change (i.e. standing up from supine or sitting), (3) duration of seconds to several minutes, (4) absence of vestibular vertigo according to a validated neurotologic interview. The 12-month prevalence of OD was 10.9% (women 13.1%, men 8.2%), lifetime prevalence was 12.5% (women 15.0%, men 9.6%). OD accounted for 42% of all participants with dizziness/vertigo and for 55% of non-vestibular dizziness diagnoses. The prevalence of OD was highest in young people, although the proportion with severe OD steadily increased with age. OD led to syncope in 19%, falls in 17% and traumatic injury in 5% of affected subjects. Almost half of the individuals with OD (45%) had consulted a physician and 4% had been treated in hospital. OD is a frequent cause of non-vestibular dizziness for which patients often seek medical advice. It carries a considerable risk of syncope, falls and traumatic injury.

High-dosage betahistine dihydrochloride between 288 and 480 mg/day in patients with severe Menière's disease: a case series.

The objective of this study was to evaluate the clinical benefit and the side effects of high dosages of betahistine dihydrochloride (288-480 mg/day) in patients with severe Menière's disease (MD). In this case series 11 patients with MD who had not responded sufficiently to a dosage of 144 mg/day of betahistine dihydrochloride were treated on an individual basis with daily dosages between 288 and 480 mg of betahistine dihydrochloride. The number of attacks per month and the side effects were monitored. Non-parametric tests were used for statistical analysis. As a result, the frequency and the severity of vertigo were significantly reduced in all patients. The side effects were mild, self-limiting, and did not require any change in the treatment strategy. Despite the considerable limitations of an observational study--in particular in MD--high dosages of betahistine dihydrochloride between 288 and 480 mg/day seem to be effective in patients who do not sufficiently respond to lower dosages. Moreover, such dosages are well tolerated.

Clinical evaluation of the bed cycling test.

OBJECTIVE: Additionally to the forearm rolling test to detect mild unilateral upper limb dysfunction, the bed cycling test (BCT) for detection of mild to moderate lower limb dysfunction was developed, evaluated and compared to the leg holding test. METHODS: In a prospective observer-blinded study, 60 patients with MRI/CT-proven focal cerebral hemisphere lesions and a mild to moderate unilateral paresis of the lower limb (graduated MRC 3-4/5), and 60 control persons with normal imaging were examined and filmed. Nine observers blinded to the diagnosis evaluated these videos. The sensitivity, specificity and the positive and negative predictive values of the clinical tests were analyzed. RESULTS: The observers gave a correct evaluation of BCT in 35.5% of all patients with focal cerebral lesions compared to 26.0% for the leg holding test. On the other hand, observers had false negative results in 29.1% of cases with BCT and 44.7% with leg holding test. In 36.7% of patients, only BCT was pathological while leg holding test was unremarkable. The sensitivity of the combination of both tests was 0.68 (95% CI 0.61-0.75). The BCT is more sensitive (64.3%) than leg holding test (46.2%) while the specificity of leg holding test (85.6%) is higher than of BCT (70.1%) to detect a cerebral lesion affecting the lower limb. The inter-rater variability is high with no differences comparing different types of clinical experience. CONCLUSIONS: The BCT is a useful additional clinical bedside test to detect subtle unilateral cerebral lesions. The BCT is easy to perform and can be added to the routine neurological examination.

Burden of dizziness and vertigo in the community.

BACKGROUND: Dizziness and vertigo are common, however, the cause often remains unexplained. The percentage of vertigo of vestibular origin in individuals with unselected dizziness has not been well examined, and its underestimation may lead to diagnostic bias in primary care. The purpose of this study was to reassess the burden of dizziness in the community and to quantify the contribution of vertigo of vestibular origin. METHODS: A nationally representative sample of 4869 adults living in Germany was screened for moderate or severe dizziness, and 1003 individuals with dizziness underwent validated neurotologic interviews to differentiate vestibular vertigo from nonvestibular dizziness according to explicit diagnostic criteria. RESULTS: Dizziness/vertigo had a prevalence of 22.9% in the last 12 months and an incidence (first episode of dizziness/vertigo) of 3.1%. For vestibular vertigo, the prevalence was 4.9% [corrected] and the incidence was 1.4%. We also found that 1.8% of unselected adults consulted a physician in the last 12 months for [corrected] dizziness/vertigo (0.9% for vestibular vertigo). Compared with nonvestibular dizziness, vestibular vertigo was more frequently followed by medical consultation (70% vs 54%; P < .001), sick leave (41% vs 15%; P < .001), interruption of daily activities (40% vs 12%; P < .001), and avoidance of leaving the house (19% vs 10%; P = .001). However, more than half of the participants with vestibular vertigo reported nonvestibular diagnoses. Age- and sex-adjusted health-related quality of life was lower in individuals with dizziness and vertigo compared with dizziness-free control subjects. CONCLUSIONS: The occurrence of dizziness and vertigo is frequent and associated with a considerable personal and health care burden. Vestibular vertigo accounts for a considerable percentage of this burden, which suggests that diagnosis and treatment of frequent vestibular conditions are important issues in primary care.