[Interdisciplinary pain assessment in the hospital setting : Merely a door-opener to multimodal pain therapy?] / Interdisziplinäres Schmerzassessment im stationären Setting : Nur ein Türöffner zur multimodalen Schmerztherapie?

BACKGROUND: Chronic pain is characterized by a complex interaction of somatic, mental and social factors. Assessing these factors in patients with chronic pain is vital during the diagnostic work-up and when making a structured treatment plan. Interdisciplinary pain assessment (ISA) is the most promising method to deal with these challenges. This article presents our experience in performing pain assessments in the hospital setting and also illustrates the characteristic features of chronic pain patients undergoing such assessments. METHODS: This study reviews and evaluates patient data from 2704 ISAs performed at the Interdisciplinary Pain Centre of the Zentralklinik Bad Berka, Germany, between 2008 and 2015. RESULTS: The majority of our ISA patients are severely handicapped and show distinct signs of chronic disease. A large proportion of patients is either unable to work or receiving benefits (invalidity pension or retirement pension). In addition, patients reported long disease durations and high emotional distress. Treatment recommendations were based on the patients' individual clinical presentations and examination results. More than half of the patients required multimodal pain management, while adjustments or therapeutic withdrawal of pain medications, in particular of opioids, were indicated in many patients. DISCUSSION: Our study shows that ISA enables fast, high-quality diagnostic assessments of chronic pain while taking the biopsychosocial model of pain in particular into account. In addition, ISA is not biased with regard to outcome results and recommends the further treatment that appears best for the individual patient. ISA leads not only to inpatient treatment, but also to treatment in other therapeutic settings and, as such, is not merely a door-opener to multimodal pain therapy.

Controlling the structure of sequence-defined poly(phosphodiester)s for optimal MS/MS reading of digital information.

Digital polymers are monodisperse chains with a controlled sequence of co-monomers, defined as letters of an alphabet, and are used to store information at the molecular level. Reading such messages is hence a sequencing task that can be efficiently achieved by tandem mass spectrometry. To improve their readability, structure of sequence-controlled synthetic polymers can be optimized, based on considerations regarding their fragmentation behavior. This strategy is described here for poly(phosphodiester)s, which were synthesized as monodisperse chains with more than 100 units but exhibited extremely complex dissociation spectra. In these polymers, two repeating units that differ by a simple H/CH3 variation were defined as the 0 and 1 bit of the ASCII code and spaced by a phosphate moiety. They were readily ionized in negative ion mode electrospray but dissociated via cleavage at all phosphate bonds upon collisional activation. Although allowing a complete sequence coverage of digital poly(phosphodiester)s, this fragmentation behavior was not efficient for macromolecules with more than 50 co-monomers, and data interpretation was very tedious. The structure of these polymers was then modified by introducing alkoxyamine linkages at appropriate location throughout the chain. A first design consisted of placing these low dissociation energy bonds between each monomeric bit: while cleavage of this sole bond greatly simplified MS/MS spectra, efficient sequencing was limited to chains with up to about 50 units. In contrast, introduction of alkoxyamine bonds between each byte (i.e. a set of eight co-monomers) was a more successful strategy. Long messages (so far, up to 8 bytes) could be read in MS3 experiments, where single-byte containing fragments released during the first activation stage were further dissociated for sequencing. The whole sequence of such byte-truncated poly(phosphodiester)s could be easily re-constructed based on a mass tagging system which permits to determine the original location of each byte in the chain. Copyright © 2017 John Wiley & Sons, Ltd.

Selective coronary arteriography in congenitally corrected transposition of the great arteries.

Three cases of congenitally corrected transposition of the great arteries in adults who underwent selective coronary arteriography are presented. The morphologic features of the epicardial coronary anatomy are distinctive and are identifiable angiographically as morphologically right and left coronary arteries that are specifically concordant with the morphologically right and left ventricles. This relation is constant in the presented cases, in previously published coronary arteriograms of congenitally corrected transposition of the great arteries and in a review of the anatomic studies of congenitally corrected transposition of the great arteries that identify the coronary arterial pattern. Thus the angiographic characteristics of the epicardial coronary arterial pattern permit identification of the morphologic features of the underlying ventricle regardless of other spatial relations.

Acute endocarditis: surgical treatment of aortic regurgitation and aortico--left ventricular discontinuity.

The clinical course of five patients with acute endocarditis resulting in aortic regurgitation and aortico--left ventricular discontinuity was reviewed. All five patients were operated upon less than 6 weeks after the onset of the antibiotic therapy. Aortic valve replacement and repair of the left ventricular discontinuity were done successfully in all five patients. The repair was accomplished in two patients primarily, with interrupted horizontal pledget-supported sutures placed through the left ventricular and aortic walls and through the ring of a valve prosthesis. In the remaining three patients, the repair was performed with the interposition of a Dacron patch between the left ventricle and the aorta, and the valve prosthesis was then sutured to the graft and to the remaining native aortic anulus. The latter technique has many attractive features for the repair of left ventricular discontinuity when there exists a large gap between the aorta and left ventricle.

Partial replacement of the left ventricular free wall with a Dacron graft: a 14 year follow-up.

The 14 year follow-up is presented of a patient in whom the free wall of the left ventricle was replaced with a Dacron graft subsequent to a self-inflicted gunshot wound. The excellent surgical results are evidenced by a benign clinical course and confirmed physiologically by serial exercise tests and anatomically by repeat angiocardiography.

Single-field total lymphoid irradiation in the treatment of refractory rejection after heart transplantation.

Nine heart transplant recipients were treated with single-field total lymphoid irradiation (TLI) for early (<1 year) or late (>1 year) rejection that was refractory to multiple regimens of immunosuppressive therapy. For patients with early rejection (n = 6), the rejection frequency (rejections/patient/month) decreased from pre-TLI of 1.63 to post-TLI of .02 (p < .001), and for patients with late rejection (n = 3), the rejection frequency decreased from pre-TLI of .23 to post-TLI of .05 (p < .02). The reduced rejection frequencies have been maintained for a mean follow-up of 28.6 (8 to 78) months, and adverse events during or late after TLI were uncommon. Single-field TLI is a safe and effective technique in the management of refractory rejection early or late after heart transplantation.

Important anatomical and physiological considerations in performance of complex mammary-coronary artery operations.

One or more internal mammary artery (IMA) anastomoses were performed in 87% of 692 consecutive coronary artery bypass operations performed over a 20-month period. One IMA was used in 68% (N = 469) and both IMAs were used in 19% (N = 130). Only saphenous vein grafts were used in 13% (N = 93). The mean number of anastomoses (all types) was 3.5. Fifty-seven patients were having a reoperation; bilateral IMA grafting was performed in 23% (N = 13). In 60 patients, 3 or more IMA anastomoses were performed: 3 IMA anastomoses, 50 patients; 4, 9 patients; and 5, 1 patient. In 27 patients, repeat coronary arteriography was performed within 30 days of operation to evaluate dynamics of IMA, saphenous vein, and native coronary artery flow. Major flow or all flow was through the graft (vs. the native coronary artery) in 62% of in situ IMA bypass grafts, 86% of free IMA grafts and 94% of saphenous vein grafts. Hospital mortality excluding patients having reoperation was 1.7% (11/635); it was less than 1% for patients having either single IMA grafting procedures (4/437) or bilateral IMA grafting procedures (1/117). Hospital mortality for patients receiving only saphenous vein grafts was surprisingly high, 7.4% (6/81). Major determinants of flow through the in situ IMA sequential graft are the size and flow of the IMA, the degree of proximal native coronary artery narrowing, the distally grafted to proximally grafted coronary artery size ratio, and probably the size of the side-to-side anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombotic occlusion of a Bjork-Shiley mitral valve.

Thrombosis of a mechanical cardiac valve is a complication potentially preventable by adequate anticoagulation. A patient is described who discontinued anticoagulant therapy, with resultant near-fatal thrombosis of a mitral Bjork-Shiley valve. The literature is reviewed concerning the incidence of thrombotic prosthetic valve occlusion in the various anatomical sites and potential factors contributing to its occurrence.

Mitral valve prolapse.

Mitral valve prolapse (MVP) now is a commonly recognized syndrome with an apparent prevalence of approximately 4-6%. It appears to occur more frequently in females and occasionally it is familial. In most instances, the syndrome is idiopathic, although it occurs in association with many other conditions, particularly Marfan's syndrome, rheumatic heart disease, coronary heart disease, congestive cardiomyopathy, ostium secundum atrial septal defect, Ehlers-Danlos syndrome or abnormalities of the thoracic cage. The majority of patients with the syndrome have minimal, if any, symptoms and have a benign course. When symptoms do occur, more frequently they are palpitations, chest pain, dyspnea on exertion or fatigue. Neuropsychiatric symptoms or even transient ischemic episodes may occur rarely. Very rarely, complications such as severe mitral regurgitation, arrhythmias or infective endocarditis may occur. Characteristically, patients have a midsystolic click, occasionally followed by a systolic murmur. The timing of the click and the onset of the murmur usually is variable, depending on the ventricular volume. The electrocardiogram frequently shows ST-T wave changes. The diagnosis usually can be confirmed by echocardiography or left ventricular angiography. Most patients with MVP require no treatment other than reassurance. If a systolic murmur is present, prophylaxis against infective endocarditis during dental work probably is useful. Patients with palpitations or chest pain usually respond well to treatment with propranolol. Patients with progressive severe mitral regurgitation require mitral valve replacement.

Use of exercise testing in noncoronary heart disease.

Although the application of exercise testing has not been as extensive in patients with noncoronary heart disease as in those with atherosclerotic coronary heart disease, the body of knowledge of the roles of exercise testing in these disorders is increasing. The usefulness of this extension of the clinical examination in the evaluation of patients with a variety of noncoronary cardiovascular disorders is becoming increasingly apparent.

Extended use of the internal mammary artery graft: important anatomic and physiologic considerations.

Of 336 isolated coronary artery bypass procedures performed over an 11 month period, one internal mammary artery (IMA) was used in 81% of cases. In 41 patients, two IMAs were used for grafting three or more arterial segments in single or sequential fashion. Repeat coronary arteriography was performed in 26 of these patients 7 to 10 days after bypass surgery. The left IMA in situ was used either singly or sequentially to graft the left anterior descending (LAD) and diagonal arteries and all branches of the circumflex system. The right IMA was used to graft the LAD, diagonal, mid marginal, right, and posterior descending branch of the right coronary artery. Blood flow to a grafted arterial segment occurred primarily through the IMA in situ in 61% of segments bypassed but was equally distributed through the IMA graft and native circulation in 35%. This was in contradistinction to the free IMA and saphenous vein graft, in which the majority of flow was via the graft in 86% and 94% of grafted segments, respectively. For those instances in which major flow was via the IMA graft in situ, the mean diameter reduction of the proximally grafted arterial segment was 83% vs 63% for those segments in which flow was equally shared between native coronary and IMA graft (p less than .05). There was a trend, although not statistically significant, for increasing flow to occur via the native circulation if the first anastomosis in a sequential IMA graft in situ was performed to a larger artery than the distally grafted segment. This was especially true when there was low-grade stenosis in the proximally grafted arterial segment.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic-left ventricular discontinuity and aortic regurgitation from acute endocarditis.

During the past 14 years, eight patients have had surgical intervention for acute aortic endocarditis and aortic-left ventricular discontinuity at our institution. Repair of the defect between the aorta and left ventricle was accomplished in two patients with interrupted horizontal pledgeted sutures placed through the left ventricular and aortic walls and through the ring of a valve prosthesis. In the remaining six patients the repair was done with the interposition of a Dacron patch graft between the left ventricle and the aorta, and then the valve prosthesis was sutured to the graft and to the remaining native aortic annulus. One patient died during the operation, one was lost to follow-up four months after operation, and one died of cerebral hemorrhage two years postoperatively. The remaining five patients have had from three months to four years of follow-up. Closure of large defects between the aorta and left ventricle with a patch graft and then suturing the aortic valve to the patch and to the remaining native aortic annulus allows debridement of all necrotic tissue, placement of the sutures through normal tissue, closure of the defect under no tension, and suturing of the new valve at its normal anatomic level. It also requires no surgical manipulation of the coronary arteries and allows completion of the procedure in the shortest time possible.

"Pseudo-tumor" of the right ventricular outflow tract and congenital pulmonary valve regurgitation: a case report.

The M-mode and 2-D echocardiographic features of an unusual case of a "pseudo-tumor" of the right ventricular outflow tract are reported. The unique pathologic findings of the pulmonary valve with congenital fenestrations and the clinical implications of this "pseudo-tumor" are discussed. Whenever calcification is noted at fluoroscopy to exist in a region or structure being evaluated by echocardiography, caution must be taken to avoid overestimating the size. Indistinct, dense reflectances without specific motion or appearance of a mass further helps to distinguish the reflectances from an actual structure of significance. Furthermore, all clinical, angiographic, and echocardiographic information must be interpreted together when either the angiogram or the echocardiogram is confusing and potentially misleading.

Nitroglycerin as an adjunct to hypothermic hyperkalemic cardioplegia.

The efficacy of nitroglycerin as an adjunct to hyperkalemic hypothermic cardioplegia was assessed by measurement of changes in coronary vascular resistance. Thirty patients undergoing coronary artery bypass grafting were studied. During a 1000 ml infusion of cardioplegia, a bolus of 1 mg of nitroglycerin or control solution was injected while the infusion rate was kept constant. Measurement of aortic root pressure allowed calculation of coronary vascular resistance. There was a mean decrease of 21.2% in coronary vascular resistance after a bolus of 1 mg of nitroglycerin was injected in the study group (p less than .001, n = 15); there was no significant change in resistance in the control group. There was also no significant change in systemic vascular resistance in either group. A retrospective blind analysis of the anatomic angiographic features of the heart with a quantitative assessment of both coronary stenoses and coronary collaterals was made. There was no correlation between coronary scores and preinjection coronary vascular resistance. There was also no correlation between collateral scores and the change in coronary vascular resistance with nitroglycerin. These results suggest that nitroglycerin is an effective coronary vasodilator when used as an adjunct in hypothermic hyperkalemic cardioplegia and that baseline coronary vascular resistance or change in coronary vascular resistance with nitroglycerin cannot be predicted on the basis of current assessments of coronary angiograms.