[Therapy outcome one year after pediatric outpatient chronic pain evaluation : Chronic Pain Grading (CPG) for adolescent pain patients]. / Therapie-Outcome ein Jahr nach Erstvorstellung in einer pädiatrischen Schmerzambulanz : Das Chronic Pain Grading (CPG) für jugendliche Schmerzpatienten.

BACKGROUND: Interdisciplinary pain treatment has been shown to be effective for children and adolescents with chronic pain, both in an outpatient and inpatient setting. Until now, the effectiveness has been analyzed with various outcome measures. Although it has only rarely been used for adolescents so far, Chronic Pain Grading (CPG) developed by Von Korff could be an appropriate general outcome measure. OBJECTIVE: The study aims at prospectively investigating and comparing the therapy outcome one year after initial presentation for both outpatients and inpatients using the CPG. MATERIALS AND METHODS: Data of 258 adolescents were gathered at initial presentation and one year later and analyzed using the CPG. Changes from pretreatment to follow-up and predictors of good therapy outcome were investigated for the whole sample and separately for outpatients and inpatients. RESULTS: Compared to inpatients, outpatients were characterized by a lower CPG both before and one year after initial presentation. Large effects were found both for outpatient and inpatient therapy regarding the improvement of the CPG. In outpatient therapy, boys were two times more likely to display therapy success. CONCLUSION: The study shows that the CPG is an appropriate outcome measure to display the long-term effectiveness of an inpatient and outpatient interdisciplinary pain treatment. The interdisciplinary pain treatment needs to be better tailored to girls to improve its effectiveness.

[Therapy recommendations in a pediatric outpatient pain clinic : Adherence and effectiveness of implementation]. / Therapeutische Empfehlungen in einer pädiatrischen Schmerzambulanz : Adhärenz und Wirksamkeit der Umsetzung.

BACKGROUND: Supplementary pain-related recommendations for the treatment of chronic pain in children and adolescents are an essential component of multimodal pain treatment. Studies are scarce regarding adherence to these recommendations and their effectiveness. OBJECTIVE: The aim of this study was to evaluate patient adherence to pain-related recommendations and their effectiveness 12 months after initial presentation of children and adolescents with chronic pain to a pediatric outpatient pain clinic. MATERIALS AND METHODS: A total of 413 patients were assessed using a structured telephone interview. The assessment included pain characteristics during the last 4 weeks as well as information regarding the implementation of the pain-related recommendations and the effectiveness. Due to different recommendations given to migraine patients this subgroup was dealt with separately. RESULTS: Patients reported significant improvements 12 months after the initial presentation and 29.5 % of the patients were pain free. Adherence levels and estimated effectiveness regarding recommendations, such as change of lifestyle, multimodal inpatient treatment and use of medication were high. Other recommendations, such as active relaxation and outpatient psychotherapy had low adherence levels and low estimated effectiveness. Migraine patients had a significantly higher adherence rate and estimated effectiveness regarding the recommendation use of medication than non-migraine patients. CONCLUSION: The adherence level as well as the estimated effectiveness regarding the majority of pain-related recommendations was high. Some recommendations had low adherence rates and low estimated effectiveness. These results can help to further improve the performance of outpatient clinics for children and adolescents with chronic pain.

[Pediatric general practitioners and tertiary care structures for pain therapy. A qualitative study on the need for networking]. / Niedergelassene Pädiater und tertiäre Versorgungsstrukturen der Schmerztherapie. Eine qualitative Studie zum Bedarf an Vernetzung.

BACKGROUND: Despite the urgency of the problem of chronic pediatric pain and the importance of early interventions, many children experience intermittent episodes of pain over a long period of time. One aim of this study was to investigate the need of structured diagnostic tools and therapies of chronic pediatric pain in pediatric general practices. Another aim was to describe the aims, services and challenges of a network between pediatric practices and a tertiary pediatric pain centre, from the perspective of general pediatric practitioners. MATERIAL AND METHODS: A qualitative research design was selected and 20 general pediatric practitioners were interviewed using a semistructured interview guide. Interviews were analyzed by use of qualitative content analysis according to Mayring. RESULTS: Generally, the idea of a network between pediatric practices and the German Pediatric Pain Centre was rated positively by pediatric general practitioners. From the results of the analysis three categories were identified: (i) expectations from the network (ii) desire for cooperation in the network and (iii) recommendations for improved patient care. CONCLUSION: A network with a centre for tertiary care was preferred by the general pediatric practitioners. To optimize the care of children with chronic pain further education for general pediatric practitioners as well as structured diagnostic tools and therapies of frequent pediatric chronic pain diseases are warranted.

[Economic effects of chronic pain in childhood and adolescence: self-assessment of health care costs for affected families before and after a multidisciplinary inpatient pain therapy]. / Familiäre finanzielle Belastung durch chronische Schmerzen im Kindes- und Jugendalter : Selbsteinschätzung der Krankheitskosten für betroffene Familien vor und nach einer stationären interdisziplinären Schmerztherapie.

BACKGROUND: Chronic pain in children and adolescents causes a high utilization of the health care system and thereby significant costs. The aim of the present study is to describe the economic effects of pediatric chronic pain from the family's perspective. MATERIAL AND METHODS: Six months before and 6 and 12 months after a 3-week inpatient-based intensive interdisciplinary pain treatment, the parents of 101 children with chronic pain filled in a standardized cost questionnaire containing the following parameters: (1) child's utilization of medical and social services, (2) subjective financial burden, and (3) type and extent of direct costs. RESULTS: During the 6 months before inpatient-based intensive interdisciplinary pain treatment, children used a median of four different services. After inpatient pain treatment, service utilization has been reduced significantly (p < 0.001). One fifth of the families report a high or very high financial burden before treatment. Family's direct costs are most often caused by travelling (86 %) and drugs (60 %). After inpatient pain treatment, family's financial burden decreased significantly (p < 0.001). The frequency of additional expenditures is also reduced after treatment: parents report less additional costs due to travelling and drugs (p < 0.001, respectively). CONCLUSION: The present study emphasizes the pronounced utilization of health and social care due to pediatric chronic pain. In the future, the use of appropriate diagnostic and therapeutic standards that contribute to avoiding unnecessary and expensive interventions is preferred.

Influence of parental occupation on access to specialised treatment for paediatric chronic pain: a retrospective study.

BACKGROUND: The purpose of this study was to determine patients' travel distances to a tertiary paediatric pain clinic and to analyse the association between travel distance and the parents' occupational skill level and the patients' pain characteristics. PATIENTS AND METHODS: The retrospective study consisted of 2,248 children assessed at the first evaluation. All children (0-20 years) who visited the clinic during a 5-year period (2005-2010) were enrolled in this study. RESULTS: The mean travel distance was 81 km, and the 80 % catchment area was 109 km. Children of parents with a high occupational skill level had a 1.5-fold higher probability of travelling from outside the catchment area. The 80 % catchment area increased constantly with increasing occupational skill level. Additional significant factors for greater distance travelled were high impairment, musculoskeletal pain, long pain duration and a high number of previous physician contacts. CONCLUSION: The association between travel distance and parental occupational skill level suggests that there is social injustice due to access barriers based on socioeconomic deprivation and education. An increase in the number of health care facilities for chronic pain in children would be a first step in rectifying this injustice.

Surface origin of high conductivities in undoped In2O3 thin films.

The microscopic cause of conductivity in transparent conducting oxides like ZnO, In{2}O{3}, and SnO{2} is generally considered to be a point defect mechanism in the bulk, involving intrinsic lattice defects, extrinsic dopants, or unintentional impurities like hydrogen. We confirm here that the defect theory for O-vacancies can quantitatively account for the rather moderate conductivity and off-stoichiometry observed in bulk In{2}O{3} samples under high-temperature equilibrium conditions. However, nominally undoped thin-films of In{2}O{3} can exhibit surprisingly high conductivities exceeding by 4-5 orders of magnitude that of bulk samples under identical conditions (temperature and O{2} partial pressure). Employing surface calculations and thickness-dependent Hall measurements, we demonstrate that surface donors rather than bulk defects dominate the conductivity of In{2}O{3} thin films.

[Pain perception of adolescents with chronic functional pain : adaptation and psychometric validation of the Pain Perception Scale (SES) by Geissner]. / Schmerzempfindung bei Jugendlichen mit chronischen funktionellen Schmerzen : Adaptation und psychometrische Uberprüfung der Schmerzempfindungsskala (SES) nach Geissner.

BACKGROUND: Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects. MATERIAL AND METHODS: Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed. RESULTS: Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high. CONCLUSION: With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.

Psychosocial factors in noncompliance during liver transplant selection.

This exploratory study attempted to identify characteristics of patients selected for transplant compared to those who had not demonstrated 6 months alcohol, drug and tobacco abstinence at the time of candidacy assessment. In a consecutive sample of 112 patients referred for liver transplant, almost half failed this criteria. Comparisons on psychometric measures of coping, social support, and health status revealed noncompliant patients to be significantly less authority abiding, less concerned about their illness, and less spiritually-oriented. Persisting alcohol use was paradoxically associated with greater psychosocial support whereas depression was related to smoking. Prior drug use was associated with more cognitive symptom complaints, emotional constriction, a vulnerability to feel dejection and a proneness to abuse medications These findings were discussed as a possible opportunity to identify and address characteristics of transplant candidates to reduce their risk of perpetuating noncompliance while competing for a life saving intervention.

The impact of a short educational movie on promoting chronic pain health literacy in school: A feasibility study.

BACKGROUND: School-based health education programs on chronic pain providing information about the proper management of recurrent and chronic pain may increase health literacy in terms of pain knowledge, may thereby prevent dysfunctional coping and may decrease the risk of pain chronification. The aim of the present feasibility study was to evaluate the effectiveness of an educational movie on recurrent and chronic pain in increasing pain knowledge among students. METHODS: N = 95 adolescent students provided demographic and pain-related information and completed a pain knowledge questionnaire before and after viewing an educational movie on recurrent and chronic pain. Participants were classified as experiencing frequent pain if they reported pain at least once a week in the last 3 months. RESULTS: One-third of the participants experienced frequent pain. There was a significant increase in pain knowledge for all participants (ηp2 = 0.544). Students with frequent pain had a stronger knowledge increase regarding the management of chronic and recurrent pain than those without frequent pain (ηp2 = 0.087). Sex did not moderate the gain in pain knowledge. CONCLUSIONS: This feasibility study provides first evidence that a short educational movie on recurrent and chronic pain may increase chronic pain health literacy in students. Future studies should investigate the long-term retention of pain knowledge and any associated effects on behaviour change. Due to barriers to the implementation of interventional studies in the school setting, these studies should use a waitlist control group design and online data collection. SIGNIFICANCE: This feasibility study provides first evidence for the effectiveness of an 11-min educational movie on chronic pain in increasing chronic pain knowledge in students. Students with frequent pain benefitted more from the education than students without frequent pain.

Quantitative sensory testing profiles in children, adolescents and young adults (6-20 years) with cerebral palsy: Hints for a neuropathic genesis of pain syndromes.

INTRODUCTION: Many patients with cerebral palsy (CP) suffer chronic pain as one of the most limiting factors in their quality of life. In CP patients, pain mechanisms are not well understood, and pain therapy remains a challenge. Quantitative sensory testing (QST) might provide unique information about the functional status of the somatosensory system and therefore better guide pain treatment. OBJECTIVES: To understand better the underlying pain mechanisms in pediatric CP patients, we aimed to assess clinical and pain parameters, as well as QST profiles, which were matched to the patients' cerebral imaging pathology. PATIENTS AND METHODS: Thirty CP patients aged 6-20 years old (mean age 12 years) without intellectual impairment underwent standardized assessments of QST. Cerebral imaging was reassessed. QST results were compared to age- and sex-matched controls (multiple linear regression; Fisher's exact test; linear correlation analysis). RESULTS: CP patients were less sensitive to all mechanical and thermal stimuli than healthy controls but more sensitive to all mechanical pain stimuli (each p < 0.001). Fifty percent of CP patients showed a combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia; 67% of CP patients had periventricular leukomalacia (PVL), which was correlated with mechanic (r = 0.661; p < 0.001) and thermal (r = 0.624; p = 0.001) hypoesthesia. CONCLUSION: The combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia in our CP patients implicates lemniscal and extralemniscal neuron dysfunction in the thalamus region, likely due to PVL. We suspect that extralemniscal tracts are involved in the original of pain in our CP patients, as in adults.

Testing the validity of telephone interviews to assess chronic pain in children and adolescents: A randomized cross-over trial.

BACKGROUND: Telephone surveys are intended to reduce attrition in longitudinal studies. For paediatric chronic pain patients, the comparability of pain-related information gathered using telephone interviews and postal surveys remain unknown. Furthermore, it remains unknown how social desirability may influence answers. METHODS: To compare data from telephone interviews and postal surveys, a randomized cross-over design with two measure points 2 weeks apart and four conditions (combinations of telephone interviews (T) and postal surveys (P): P-T, T-P, P-P, T-T) was conducted in a sample of N = 323 paediatric chronic pain patients. RESULTS: In the inter-group comparison, pain-related information did not differ between telephone interviews and postal surveys except for the information on pain location (back and extremities). Agreement measures of the intra-group comparisons suggest substantial to excellent agreements for all items and did not differ between the groups. The internal consistency of a disability scale was excellent for both assessment modes; the number of missing values did not differ. Participation rate was higher for telephone interviews compared to the postal surveys. Across both time points, attrition was lowest for the groups without a switch in assessment mode compared to the groups with a switch in assessment mode. Except for pain-related school absence, no effect of social desirability occurred. CONCLUSIONS: Telephone interviews are a useful method to achieve a high response rate. Pain locations should be asked for separately and not in an open question when interviewing children and adolescents on the telephone. SIGNIFICANCE: Telephone interviews are a good method to achieve a high response rate and obtain valid data in studies with paediatric chronic pain patients.

Physician consultation in young children with recurrent pain-a population-based study.

Background. Recurrent pain is a common experience in childhood, but only few children with recurrent pain attend a physician. Previous studies yielded conflicting findings with regard to predictors of health care utilization in children with recurrent pain. Methods. The present study analyzes data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study comprising n = 2,149 children (3-10 years old) with recurrent pain to find robust predictors. We used multiple logistic regressions to investigate age, gender, socio-economic status (SES), migration background, pain intensity, pain frequency, pain-related disability, mental health problems, and health-related quality of life (HRQL) as predictors for visiting a doctor due to pain. Results. Overall, young girls with high pain-related disability, intensity, frequency, and migration background were more likely to attend a physician. Pain-related disability had the largest impact. Socioeconomic status, health-related quality of life and mental health problems were not systematically related to health care utilization. An analysis of the variability of these results indicated that several hundred participants are needed until the results stabilize. Conclusions. Our findings highlight the importance of pain-related disability and frequency in assessing the severity of recurrent pain. Generic predictors and demographic variables are of lesser relevance to children with recurrent pain. On a methodological level, our results show that large-scale studies are need to reliably identify predictors of health care utilization.

Resting metabolic rate and body composition of healthy Swedish women during pregnancy.

Body weight, resting metabolic rate (RMR), total body potassium (TBK), and total body water were measured and total body fat (TBF) was calculated in a longitudinal study of 22 pregnant, healthy Swedish women. Measurements were made before pregnancy, at gestational weeks 16-18, 30, and 36, and 5-10 d and 6 mo postpartum. RMR increased more during pregnancy than previous estimates on well-nourished women showed and the increase was significantly correlated with the birth weight of the baby. TBK decreased during the first part of pregnancy; measurements at weeks 16-18 and 30 were significantly lower than the prepregnancy value and changes in TBK and RMR were significantly correlated. TBF gain during pregnancy was 5.8 +/- 4.0 kg and 60% was already gained by gestational weeks 16-18. Gain in fat was not correlated with birth weight.

Estimation of body fat in healthy Swedish women during pregnancy and lactation.

Reliable estimates of changes in body fat are important in studies of energy requirements during human reproduction. It is not known if current methods for the estimation of total body fat (TBF) are adequate for this purpose. In this paper earlier reported data from 29 women are used to show how methodology affects estimates of changes in TBF during reproduction. Skinfold thicknesses are also reported and equations relating these measurements to TBF were developed and used to demonstrate how well the skinfold technique could estimate such changes. No correlation was found between changes in body weight and body fat during early pregnancy or between the maternal changes in body weight and body fat over the complete pregnancy. These findings are tentatively explained by changes in the degree of hydration of the body.

Energy metabolism, body composition, and milk production in healthy Swedish women during lactation.

Variables of relevance to energy requirements during reproduction were studied in 23 healthy lactating Swedish women. Body composition and resting metabolic rate (RMR) were studied before pregnancy and three times postpartum. Energy intake was studied before pregnancy and, together with breast-milk production, 2 mo postpartum. The women gained 5.8 +/- 4.2 kg fat during pregnancy and their average fat content was unchanged during the first 2 mo of lactation whereas a slight loss (1.7 +/- 4.2 kg) occurred during the following 4 mo. RMR increased slightly during lactation in spite of a decrease in fat-free body weight 2 and 6 mo postpartum. Energy intake increased during lactation (280 +/- 440 kcal/d). The women produced 740 +/- 150 g breast milk/d containing 0.64 +/- 0.08 kcal/g. The results indicate that current estimates of energy needs during lactation may be too high.

Treatment of chronic renal failure with dietary fiber.

We have tested the hypothesis that dietary fiber, by inhibiting colonic bacterial ammonia generation and increasing fecal nitrogen excretion, might decrease hepatic urea synthesis and thereby reduce plasma urea in patients with chronic renal failure. Six and 8 week courses of two different hemicelluloses, arabinogalactan and ispaghula, reduced mean plasma urea in uremic subjects by 11% and 19% respectively. Ispaghula also reduced the rate of rise of plasma creatinine to zero and, in one formal balance study, increased fecal nitrogen excretion by 39%. Experiments in vitro showed that ispaghula depressed anaerobic fecal bacterial net ammonia generation by 30%, and adsorbed neither urea nor ammonia. The reduction in plasma urea caused by dietary fiber is likely to be due to inhibition of colonic bacterial production of ammonia; such therapy could conceivably alleviate some of the symptoms of uremia and postpone dialysis in patients with endstage renal disease.

A benign serous ovarian cystadenoma studied by chromosome and quantitative DNA analysis.

In a benign serous ovarian cystadenoma studied by chromosome and quantitative DNA analysis, a diploid mode was found in cells from the cystic wall. The cells from the cystic fluid, however, showed both a diploid and a triploid population. The latter may represent a fist step into malignant transformation.

Identifying subgroups of paediatric chronic pain patients: a cluster-analytic approach.

BACKGROUND: Paediatric chronic pain patients are a heterogeneous group. Individuals respond differently to standardized treatment. OBJECTIVES: This study aimed to identify subgroups of adolescent chronic pain patients. METHODS: Subgroups were identified by means of a cluster analysis (Sample A, nA = 266). The stability of clusters was tested in a cross-validation with a second sample (Sample B, nB = 108). In a third sample (Sample C, nC = 83), differences in change scores of the outcome parameters were tested between cluster subgroups 12 months after a standardized treatment. RESULTS: Five distinct cluster subgroups with pain problems differing by pain intensity, school absence, pain-related disability, passive pain coping and affective pain perception were identified. Two groups reported overall moderate pain problems and differed with regard to passive pain coping, which was low in Cluster 1 and moderate in Cluster 2. The patients in Cluster 3 reported severe pain problems, including high pain-related disability and frequent school absences. The patients in Clusters 4 and 5 reported very severe pain problems, with those in Cluster 5 reporting very frequent school absences. Cross-validation was performed to assess the accuracy of our subgrouping and indicated a stable cluster solution (κ = 0.64). The five subgroups displayed distinct patterns in treatment outcome after a standardized multidisciplinary treatment program. The mean change scores were significantly different between subgroups [F(4,78) = 5.88; p = 0.017]. CONCLUSIONS: The patient subgroups that were established proved stable across samples. Depending on the subgroup classification, patients differed in changes of core outcomes. These results offer initial hints for the need for subgroup-specific treatment planning.

Classifying the severity of paediatric chronic pain - an application of the chronic pain grading.

BACKGROUND: The chronic pain grading (CPG), a standard approach to classify the severity of pain conditions in adults, combines the characteristics of pain intensity and pain-related disability. However, in children and adolescents, the CPG has only been validated in a school sample, but not in the actual target population, i.e., clinical populations with pain. METHODS: In the present study, we applied the CPG to a tertiary sample of adolescents with chronic pain (n=1242). Construct validity, sensitivity to change and prognostic utility were examined. RESULTS: Results indicate that most adolescents were equally classified into the three higher severity grades. Higher CPG classification was associated with more pain locations, higher pain frequency, longer pain duration, extensive use of health care and more depressive symptoms. Adolescents with a high CPG received recommendations for inpatient treatment more often; however, the prognostic utility for therapy recommendation - as operationalized in this study - was low. Sensitivity to change was assessed via reassessment at follow-up for a subsample of 490 adolescents. The majority of adolescents improved to a less severe CPG; changes were more common in the high severity range. CONCLUSION: The CPG may be applied to adolescent tertiary care samples and to assess outcomes in clinical trials. However, in this study it was not appropriate to assign adolescent patients to different treatment options. Future work should focus on developing a comprehensive assessment tool for assigning patients to different treatments.