Diagnostik und Therapie funktioneller Schmerzsyndrome

If a patient presents with symptoms of a functional somatic pain syndrome in the primary care setting, it is important to confirm the diagnosis based on a thorough history and physical examination including selected diagnostic tests to exclude somatic diseases with a similar clinical presentation. Important aspects of psychosomatic medicine in the primary care setting are to discuss the diagnosis, treatment options, and prognosis of the functional psychosomatic pain syndromes with the patient in detail. Patients who present with a functional somatic pain syndrome to secondary or tertiary care centers, should be screened for additional functional pain syndromes. A psychiatric-psychosomatic evaluation might be indicated. Based on criteria of evidence-based medicine, psychotherapy and/or tricyclic antidepressants seem to be the most promising treatment approaches for the functional somatic pain syndromes.     

Using a Single Item to Measure Burnout in Primary Care Staff: A Psychometric Evaluation

Background

Burnout affects nearly half of all U.S. nurses and physicians, and has been linked to poor outcomes such as worse patient safety. The most common measure of burnout is the well-validated Maslach Burnout Inventory (MBI). However, the MBI is proprietary and carries licensing fees, posing challenges to routine or repeated assessment.

Objective

To compare a non-proprietary, single-item burnout measure to a single item from the MBI Emotional Exhaustion (MBI:EE) subscale that has been validated as a standalone burnout measure.

Design

Cross-sectional online survey.

Participants

A sample of primary care providers (PCPs), registered nurses, clinical associates (e.g., licensed practical nurses (LPNs), medical technicians), and administrative clerks in the Veterans Health Administration surveyed in 2012.

Main Methods

We compared a validated one-item version of the MBI:EE and a non-proprietary single-item burnout measure used in the Physician Work Life Study. We calculated kappa statistics, sensitivity and specificity, positive predictive (PPV) and negative predictive values (NPV), and area under the receiver operator curve (AUC). We conducted analyses stratified by occupation to determine the stability of the correlation between the two measures.

Key Results

We analyzed responses from 5,404 participants, including 1,769 providers and 1,380 registered nurses. The prevalence of burnout was 36.7 % as measured on the single MBI:EE item and 38.5 % as measured on the non-proprietary single-item measure. Relative to the MBI:EE, the non-proprietary single-item measure had a correlation of 0.79, sensitivity of 83.2 %, specificity of 87.4 %, and AUC of 0.93 (se = 0.004). Results were similar when stratified by respondent occupation.

Conclusions

A non-proprietary single-item measure served as a reliable substitute for the MBI:EE across occupations. Because it is non-proprietary and easy to interpret, it has logistical advantages over the one-item MBI.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3112-6) contains supplementary material, which is available to authorized users.Key words: Workforce, Psychometrics, Physician satisfaction     

Study quality and effect-sizes - a metaanalysis of EMDR-treatment for posttraumatic stress disorder

Although the good efficacy of eye movement desensitization and reprocessing (EMDR) in the treatment of patients with PTSD is up to now documented by a number of studies, this new treatment technique is still the target of highly controversial critique. Our meta-analysis tries to answer the question of whether EMDR-therapy studies with higher quality standards achieve better results than others. Therefore, all published studies underwent a scoring procedure of study quality and effect sizes were computed. It can be shown that carefully planned studies, including treatment by well-trained therapists and with a sufficiently high number of treatment session achieve better results compared to studies with low methodological standards.     

Haemodynamic, endocrine and nociceptive response to gynaecological procedures under epidural local anaesthesia during continuous epidural infusion or bolus epidural fentanyl dosing

This study aimed to evaluate the analgesic effects and hormonal responses of a single epidural bolus compared to continuous epidural infusion of fentanyl as supplements to intraoperative local epidural anaesthesia for major gynaecological surgery. Forty patients undergoing total vaginal hysterectomy were randomised to receive in a double blind fashion either 1.5 μg kg⁻¹ fentanyl epidurally (group A) or saline (group B) as bolus injections followed by epidural infusion of saline or fentanyl (0.7 μg kg⁻¹h⁻¹) respectively at a rate of 10 ml h⁻¹. Postoperative pain intensity was assessed by visual analogue scale (VAS). Prolactin and cortisol plasma levels were used as stress markers. The onset of anaesthesia was significantly shorter in group A (p<0.05) but the duration of T₁₀ blockade was significantly longer in group B (p<0.01). Pain intensity was significantly higher in group A at 90, 105 and 120 minutes after skin incision (p<0.001). There was no intraoperative difference in heart rate or mean arterial pressure between the two groups nor was there any difference in the incidence of adverse effects such as nausea, vomiting or shivering. Both groups had a progressive decrease in serum cortisol and prolactin concentrations 30 and 60 min after skin incision, but cortisol and prolactin concentrations were higher in group A (p<0.05) 120 minutes after skin incision.Our observations suggest that perioperative continuous epidural infusion of fentanyl begun intraoperatively attenuates the endocrine stress response, but a bolus dose of fentanyl given along with bupivacaine lacks this protective effect. A possible explanation for these findings is that an infusion begun intraoperatively, just after administration of epidural bupivacaine, prolongs the duration of sensory blockade and provides a better quality of analgesia, and thereby attenuates the endocrine response triggered by regression of the intraoperative level of anaesthesia.     

Wieviel Schmerz ist ertr?glich? Zielvorstellungen chirurgischer Patienten für die Schmerztherapie Zielvorstellungen chirurgischer Patienten für die Schmerztherapie

Einleitung: Gute perioperative Analgesie ist Teil jeder chirurgischen Therapie. Dazu geh?ren auch Verfahren wie die patientenkontrollierte Analgesie (PCA), bei der sich Patienten mit Hilfe eine Pumpe selbst Schmerzmittel verabreichen k?nnen. Je mehr die Patienten selbst in die Gestaltung der Schmerztherapie einbezogen werden, desto mehr gewinnen ihre Zielvorstellungen für die Schmerztherapie an Bedeutung. Methoden: In einer prospektiven Beobachtungsstudie wurden die Zielvorstellungen von chirurgischen Patienten in Abh?ngigkeit von der jeweiligen Grundkrankheit und der Intensit?t des aktuell empfundenen Bewegungsschmerzes auf einer visuellen Analogskala (VAS) ermittelt. Es wurden 53 Patienten mit Hilfe eines speziellen Schmerzanamnesebogens befragt. Die Vergleichsgruppe bildete ein Kollektiv gesunden Pflegepersonals (n = 44). Ergebnisse: Patienten mit benigner (n = 29) und maligner (n = 24) Grundkrankheit zeigten keine signifikanten Unterschiede in den von ihnen als Ziel einer erfolgreichen Schmerztherapie angegebenen VAS-Werten (Mittelwerte: 25 VAS-Punkte in der Gruppe der konservativ, 27 Punkte in der Gruppe der operativ behandelten Tumorpatienten sowie 21 Punkte bei den operativ behandelten Patienten mit benigner Schmerzursache und 18 Punkte bei den Patienten, die an chronischen Schmerzen benigner Genese litten). Ebenso ergab sich keine Abh?ngigkeit der Zielvorstellungen vom momentan empfundenen Bewegungsschmerz. W?hrend die Vergleichsgruppe der gesunden Krankenschwestern und -pfleger wesentlich weniger aktuellen Schmerz empfand, unterschieden sich die Zielvorstellungen (25 VAS-Punkte) nicht signifikant von denen der befragten Patienten.     

Effectiveness of an acute pain service in surgical patients — a hospital comparison study

The implementation of an acute pain service (APS) has been advocated as the cornerstone of effective pain management. However, convincing evidence demonstrating the effectiveness of an APS in controlled studies is scarce. In this study we compared both subjective and objective variables of surgical patients in two similar hospitals, one of which had established an APS. During the study period of two years 498 patients were prospectively enrolled. Pain and other related variables (appetite, mobility, need for sleep, fatigue, and general satisfaction) were assessed pre- and postoperatively by means of 10 cm VAS scales printed on two identical questionnaires. Additional data were retrieved from the patients' records. Those patients who were cared for by an APS suffered less pain (25 mm VAS at rest), sleepiness (13 mm VAS), mobility restriction, and loss of appetite. For most measures the beneficial effects of the APS were present pre- and postoperatively. However, hospital stay was similar in both hospitals (13.7 vs 14.3 days; A vs B). Our data indicate large and patient-relevant benefits of an APS, but our study design was vulnerable to various kinds of bias.     

The Hannover consultation liaison model: Some empirical findings

Starting from the definitions concerning the concepts 'Liaison medicine' and 'Consultative Psychiatry' we begin with remarks with regard to the Consultation Liaison-Situation in West Germany on the basis of the key-words 'Brief history', 'Independent university units with regard to Psychotherapy and Psychosomatics as well as the connected organization' and 'Teaching procedures'. Following it the Hannover Consultation Liaison model is presented particularly with regard to both the psychosomatic inpatient ward including the functional organization and psychotherapeutic processes as well as the so-called 'Innere Ambulanz' which includes the consultation liaison services in the clinico-medical departments outside Psychiatry and Psychosomatics. Within the 'Innere Ambulanz', which is closely connected to our psychosomatic inpatient ward, the consultation liaison activities and the resulting supportive psychotherapeutic strategies are performed by student auxiliary therapists who are interested in completing their 4-5 months internship-time in our department. We describe both the three supportive psychotherapeutic steps, which may last months to years including subsequent dynamically psychotherapeutic strategies as well as the reactions of the auxiliary therapist function on the students. Furthermore, we may state that there exists no one more optional education procedure of graduate students than the student's confrontation with his partial self-responsibility vis-à-vis a patient who is being supportive-psychotherapeutically treated by him. Specific empirical proofs concerning our patient oriented consultation liaison activities are demonstrated on the basis of previous psychotherapeutic findings in Crohn patients. Here we are able to demonstrate the effectivity of psychotherapy in the case of the supplementarily psychotherapeutically treated patients in comparison to the patients who received medical therapy only. Finally we are able to present quantitative clinico-medical inpatient needs with regard to consultation liaison activities starting from our 'Innere Ambulanz'. On the basis of our conservative estimate, 31-42% of patients showed severe psychosomatic or psychic symptoms who should be treated by psychological means in addition to the medical treatment.     

Kommentar auf Anforderung der Schriftleitung

Ohne Zusammenfassung     

Risk factors for subsequent cervicovaginal human papillomavirus (HPV) infection and the protective role of antibodies to HPV-16 virus-like particles

A high incidence of initial infection with human papillomavirus (HPV) was previously reported in a cohort of 608 women monitored at 6-month intervals for 3 years. Risk factors for subsequent infections with different HPV types and whether antibodies against HPV-16 virus-like particles (VLPs) protected against these infections were examined. Subsequent infections with HPV are very common. Seventy percent of women acquired a different HPV type within 24 months of the initial infection. Risk factors included being nonwhite, having an increased number of male sex partners, and having had a new male sex partner. Use of oral contraceptive pills was protective. A sustained high level of IgG antibody to HPV-16 VLPs was associated with reduced risk for subsequent infection with HPV-16 and its genetically related types (i.e., HPV-31, -33, -35, -52, and -58).