Association between pain sensitivity in the hand and outcomes after surgery in patients with lumbar disc herniation or spinal stenosis

Purpose

To investigate the association between pain sensitivity in the hand pre-surgery, and patient-reported outcomes (PROs) in function, pain and health pre- and post-surgery in patients with disc herniation or spinal stenosis.

Methods

This is a prospective cohort study with 82 patients. Associations between pressure-, cold- and heat pain threshold (PPT, CPT, HPT) in the hand pre-surgery and Oswestry, VAS pain, EQ-5D, HADS, and Self-Efficacy Scale, pre- and three months post-surgery; were investigated with linear regression.

Results

Patients with disc herniation more sensitive to pressure pain pre-surgery showed lower function and self-efficacy, and higher anxiety and depression pre-surgery, and lower function, and self-efficacy, and higher pain post-surgery. Results for cold pain were similar. In patients with spinal stenosis few associations with PROs were found and none for HPT and PROs.

Conclusions

Altered pain response in pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery had associations with higher pain, lower function and self-efficacy post-surgery in patients with disc herniation.

     

Anfängeroperationen und Facharztstandard

Background

In all phases, patients are entitled to receive medical treatment according to medical specialist standards. This does not mean that patients necessarily have to be treated by a medical specialist. Operations performed by “beginners”, e.?g. assistant physicians, are permitted. However, there are increased liability risks, both for the specialist and the assistant physician. Furthermore, there are risks of criminal responsibility for causing bodily harm by negligence or negligent manslaughter.

Objectives and methods

This article portrays the requirements of civil liability and criminal responsibility concerning beginners’ operations on the basis of cases and judgments of the Federal Court and the Higher Regional Courts in Germany. Additionally, the reception of the jurisprudence by the relevant legal literature will be discussed.

Results

Jurisprudence and legal literature categorize breaches of duty of care. Assistant physicians can be subject to contributory negligence liabilities, while specialists can bear liabilities for negligent selection, organization or supervision. Responsible specialist and assistant physicians can protect themselves (and the patient) and avoid legal risks by only performing operations adequate to their educational level or by delegating operations to beginners and ensuring intervention by a specialist by supervision of the operation which is suitable to the assistant physician’s level of education.

     

Prähospitale Analgosedierung durch Notärzte und Rettungsassistenten

Background

In some German emergency medical service districts, analgesia is performed by paramedics without support of emergency physicians on scene. With regard to safety and effectiveness, paramedics should not be overshadowed by emergency physicians.

Objectives

Is prehospital analgesia performed by paramedics under medical supervision or emergency physicians comparable regarding processes and effectiveness in the case of isolated limb injury?

Material and methods

As a retrospective analysis of patients with isolated limb injury, analgesia performed by paramedics and by emergency physicians was analyzed. In addition to pain reduction, prescribed monitoring, and further airway maneuvers, vital parameters (Glasgow coma scale, systolic blood pressure, heartrate and respiratory rate, oxygen saturation) were recorded at the beginning and end of prehospital treatment.

Results

Pain was reduced from NRS 8 ± 1 to NRS 2 ± 1 in the paramedic group, and from NRS 8 ± 2 to NRS 2 ± 2 in the physician group, so the mean pain reduction was 6 ± 2 in the paramedic-group and 5 ± 2 in the physician group (p < 0.001). Adequate analgesia was found in 96.9% in the physician group and 91.7% in the paramedic group (p = 0.113). ECG monitoring and oxygen administration according to SOP was significantly more frequent in the paramedic group than in the physician group (p < 0.001). Respiratory frequency was significantly more frequent in the physician group than in the paramedic group (p < 0.001).

Conclusions

The study shows, with a given indication, that German paramedics can independently perform safe and successful analgesia under medical supervision.

     

Self-care as a professional imperative: physician burnout,depression, and suicide

Purpose

Burnout has been identified in approximately half of all practicing physicians, including anesthesiologists. In this narrative review, the relationship between burnout, depression, and suicide is explored, with particular attention to the anesthesiologist. Throughout this review, we highlight our professional imperative regarding this epidemic.

Source

The authors searched the existing English language literature via PubMed from 1986 until present using the search terms physician burnout, depression, and suicide, with particular attention to studies regarding anesthesiologists and strategies to address these problems.

Principal findings

Burnout and depression have increased among physicians, while the rate of suicide has remained relatively the same. There are many factors associated with burnout and depression as well as many causes. Certain individual factors include sex, amount of social support, and mental health history. Systems factors that play a role in burnout and depression include work compression, demands of electronic health records, production pressure, and lack of control over one’s professional life. Medical license applications include questions that reinforce the stigma of psychological stresses and discourage physicians from seeking appropriate care.

Conclusion

The concept of physician well-being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Anesthesiologists must actively engage in self-care. Anesthesiology practices and healthcare organizations should evaluate the balance between demands they place on physicians and the resources provided to sustain an engaged, productive, and satisfied physician workforce. National efforts must be rallied to support physicians seeking help for physical and psychological health problems.

     

Factors influencing inguinal hernia symptoms and preoperative evaluation of symptoms by patients: results of a prospective study including 1647 patients

Background

Current recommendations for hernia treatment suggest applying techniques aimed at reducing postoperative pain in patients experiencing intense preoperative pain. However, there is still no reliable stratification method of preoperative pain, its circumstances, intensity and frequency, and the current assessments of hernia symptoms are performed by means of a subjective evaluation. The aim of this work is to discuss preoperative pain before hernia repair and determine its nature depending on the type and length of hernia persistence and the patient’s age.

Materials and methods

The data from 1647 patients before inguinal hernia repairs (2010–2017) were registered prospectively in the National Hernia Repair Register (demographic data, pain score and influence on everyday activities).

Results

The most common symptom upon admission was pain (949 patients at rest; 57.6% and 1561 at physical activity; 94.8%). A significant influence of hernia persistence on the pain occurrence and intensity was not observed between patients with hernia?<?12-months (60.8%;VAS5.0) and >?5-years (58.3%;VAS5.4) (p?=?0.068). The occurrence and intensity of pain was significantly higher patients?<?40-years (63.7%;VAS5.4) than patients?>?60-years (54.3%;VAS4.8) (p?=?0.008).

Conclusions

While pain at rest is not a significant problem, undertaking physical activities may intensify pain and increase the number of patients suffering from it. Preoperative assessment of pain may help determine the group of younger patients who could benefit the most from inguinal hernia repair. New indications for prompter admission for treatment should be planned in future studies of patients showing pain at rest for possible prevention of postoperative neuropathy.

     

Neuromodulation for Chronic Pelvic Pain

Purpose of Review

Chronic pelvic pain is a heterogeneous condition that often requires multiple physician visits and various treatments prior to achieving an acceptable management strategy. Neuromodulation has been used to treat chronic pelvic pain that has failed other therapies.

Recent Findings

Numerous modalities of neuromodulation have been used to alleviate chronic pelvic pain with promising results.

Summary

Numerous modalities of neuromodulation have demonstrated efficacy in the management of pelvic pain. Further investigation is needed to elucidate the most effective treatment modality and to identify the patients who would benefit most from this therapy.

     

Pain relief after triamcinolone infiltration in patients with bladder pain syndrome with Hunner’s ulcers

Introduction and hypothesis

Bladder pain syndrome (BPS) is a chronic condition with severe implications in the patient’s quality of life with no definitive treatment. Our objective was to assess pain relief after triamcinolone injection in patients with BPS with Hunner’s ulcers (HU).

Methods

Retrospective study of 20 consecutive patients with BPS treated at the Hospital Clinic of Barcelona with triamcinolone injection with flexible cystoscope between 2015 and 2016. Pain was assessed according to the visual analog scale (VAS) (0–10) before and after treatment. Outcomes were compared using Student’s t test for paired samples.

Results

Twenty-seven procedures were performed in 20 patients, who were followed up for a median of 7 months (range 1–15). Median age was 75 years (52–86), and median time from diagnosis to treatment was 4.5 years (1–7). Fifteen (75 %) patients had received treatment with corticoid injection for BPS before entering the study. Pre- and postreatment VAS was 8 and 2.5 (p?<?0.001), respectively. Pre -and postreatment VAS in those with muscular pain was 8 and 5 (p?=?0.012), respectively and in those without muscular pain was 8 and 2 (p?<?0.001), respectively. Three (15 %) patients required retreatment due to nonresponse and 5 (25 %) patients for pain recurrence after 4 months (3.5–8). Four of them (50 %) were performed with triamcinolone injection again. Seven of ten patients (70 %) followed for ≥8 months required at least one retreatment.

Conclusion

Triamcinolone injection for HU in patients with BPS is associated with significant pain reduction. However, most patients will require retreatment.

     

Laparoscopic implantation of electrodes for bilateral neuromodulation of the pudendal nerves and S3 nerve roots for treating pelvic pain and voiding dysfunction

Introduction and Hypothesis

The objective of this video is to describe the technique for laparoscopic implantation of electrodes for bilateral neuromodulation of S3 and pudendal nerves. We report a successful case of a 48-year-old woman with spina bifida occulta referred with a 14-year history of intense acyclic pelvic pain, urinary hesitancy, and intermittent flow refractory to various conservative measures.

Methods

The procedure began with the removal of two previously placed InterStims. A quadripolar electrode was then laparoscopically inserted into Alcock’s canal and attached to the pelvic pectineal line. Another lead was placed juxtaneurally to S3. Lead contacts were then exteriorized, and the peritoneum closed. The same procedure was then performed on the contralateral side. The leads were connected to a 16-pole rechargeable pulse generator. Postoperatively, the patient developed an acute dissection and partial thrombosis of the external iliac artery, which was treated endovascularly.

Results

Complete pain resolution was observed with simultaneous S3 and pudendal stimulation, with pudendal stimulation turned off for voiding.

Conclusions

We conclude that laparoscopic implantation of neuromodulation electrodes allows simultaneous stimulation of S3 and pudendal nerves, providing more programming options and possibly increasing success rates in complex pelvic floor dysfunction cases.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Meeting patient expectations: patient expectations and recovery after hip or knee surgery

Background

Although patient-centred care could help increase the value of healthcare, practice variations in hip and knee surgery suggest that physicians guide clinical decisions more than patients do. This raises the question whether treatment outcomes still meet patients’ expectations. This study investigated whether treatment outcomes measured by patient-reported outcome measures fulfil patients’ main expectations (i.e. decreased pain or improved functioning).

Methods

Patients who underwent hip or knee surgery in 20 Dutch hospitals in 2014 were invited to a survey consisting of the KOOS Physical Function Short Form or the HOOS Physical Function Short Form, the NRS pain and the EQ-5D. Patients were asked their main reason for surgery and whether the expectations regarding this reason were fulfilled.

Results

A total of 2776 patients completed the survey. The most common reason for surgery was improved functioning (43.7%). Patients who were unable to choose between pain relief and improved functioning and patients who aimed for pain relief experienced more problems before surgery. However, patients who were unable to choose improved more than patients who wanted to improve their functioning on the NRS pain during use and the EQ-5D. More patients who aimed for pain relief felt that their expectations were fulfilled compared to other patients.

Conclusions

Although an expectation for an outcome was not related to a greater improvement on that outcome, patient expectations were an indication of patients’ improvement due to surgery. Differences in expectation fulfilment may be due to unrealistic expectations. To achieve optimal value, tailoring treatment using patient preferences and managing patient expectations is vital.

     

Subcutaneous dissection area contributes less to endoscopic thyroidectomy-related invasiveness

Objective

To clarify the contribution of the subcutaneous area during breast approach endoscopic thyroidectomy (BAET), with regard to invasiveness-related outcomes.

Methods

Seventy-two patients were randomly assigned to two groups: standard dissection and limited dissection. Postoperative pain and inflammatory response were compared between groups.

Results

The groups were well matched except for subcutaneous dissection area (137.11 ± 21.10 vs. 83.69 ± 12.10 cm², p < 0.0001). No significant difference was found with regard to VAS score and postoperative inflammatory response.

Conclusion

Our RCT indicated that the subcutaneous area plays a less important role with regard to BAET-related postoperative pain.

     

Patient and Surgeon Expectations Prior to Anterior Cruciate Ligament Reconstruction

Background

When discussing potential treatment with patients choosing to undergo surgery for disruption of the anterior cruciate ligament (ACL) and their families, surgeons spend considerable time discussing expectations of the short- and long-term health of the knee. Most of the research examining patient expectations in orthopedic surgery has focused largely on arthroplasty.

Questions/Purposes

The purpose of this study was to quantitatively assess the differences between the patient’s and the surgeon’s expectations before primary anterior cruciate ligament reconstruction (ACLR).

Methods

In this case series, we prospectively enrolled 93 patients scheduled for primary ACLR between 2011 and 2014. Expectations were measured using the Hospital for Special Surgery 23-item Knee Expectations Survey; scores were calculated for each subject.

Results

In all but six categories, patients had expectations that either aligned with their surgeons’ or were lower. The largest discordance between surgeon and patient expectations in which the patient had lower expectations was employment; 75% of patients had similar expectations to the surgeon when asked if the knee would be “back to the way it was before the problem started,” less than 1% had higher expectations, and 17% had lower expectations.

Conclusion

In general, patient expectations align well with surgeon expectations. Patients who are older, have a lower activity level, and who have selected allograft over autograft for ACLR could also be at risk for greater discordance. Understanding these differences, and their predictors, will help guide physicians when they are counseling patients about ACLR and also help them interact with patients after surgery as they assess outcomes.

     

Comparison of the analgesic effects of modified continuous intercostal block and paravertebral block under surgeon’s direct vision after video-assisted thoracic surgery: a randomized clinical trial

Objective

Clinical evidence comparing paravertebral (PVB) and continuous intercostal nerve (ICB) blocks for pain management post video-assisted thoracic surgery (VATS) is limited. This study confirms the analgesic effect of ICB using two catheters is not inferior to that of PVB under direct vision.

Methods

Fifty patients who underwent VATS lobectomy from July 2015 to March 2016 were prospectively recruited and randomly assigned to PVB and ICB groups. Postoperative pain was assessed using the visual analog scale (VAS). VAS score at rest at 24 h was the primary endpoint. Data on time required for catheter insertion, adverse effects, and frequency of additional analgesics as secondary endpoints were also collected. Noninferiority was assessed by adding a VAS margin of 15 mm to the PVB group.

Results

No significant differences were observed between the VAS scores of the two groups except at 48 h after surgery, with a margin noted for the PVB group. No significant differences were detected in the frequency of additional analgesics and occurrence of adverse effects.

Conclusions

Our results could not clearly establish noninferiority of ICB to PVB. Improvements in ICB may be necessary for it to be used as an alternative method to PVB.

     

Professionalism in anesthesia

Purpose

Is professionalism in medicine just another bureaucratic imposition on our practice or a fundamental concept for physicians at all stages in their career? In this review, the historical perspectives of professionalism are explored as well as the what, why, and how questions concerning this topic.

Source

The key words “professionalism” and “anesthesia” were used to conduct a search of the PubMed database, the policies and publications of relevant Canadian and international physician regulatory bodies and organizations, historical documents, and other internet publications.

Principal findings

Professionalism in anesthesia has a long history. While there are many definitions for professionalism, some very dated, all are based on virtues, behaviour, or professional identity. Professionalism plays a central role in the balance between physician autonomy and social contract, and it has a significant impact on patient safety and medicolegal litigation.

Conclusion

Considerable evidence exists to suggest that professionalism must be treated seriously, particularly in these times of social accountability and budgetary pressures.

     

Psychological profile and self-administered relaxation in patients with craniofacial pain: a prospective in-office study

Introduction

The objective of this study was to evaluate the psychological profile of craniofacial pain sufferers and the impact of patient subtype classification on the short-time effectiveness of a self-administered relaxation training.

Methods

One hundred unselected in-office patients (67% females) suffering from chronic facial pain and/or headache with the presumptive diagnose of temporo-mandibular disorder (TMD) completed a questionnaire battery comprising craniofacial pain perception, somatic complaints, irrational beliefs, and pain behavior and were classified into subtypes using cluster analysis. They underwent a self-administered progressive relaxation training and were re-evaluated for pain perception after 3 months.

Results

Pain was mild to moderate in the majority of patients. Symptom domains comprised parafunctional activities, temporo-mandibular pain and dysfunction, fronto-temporal headache, head/neck and neck/back pain. Three patient subtypes were identified regarding symptom/dysfunction level: (i) low burden (mild/moderate), (ii) psychosocial dysfunction (moderate/high), (iii) adaptive coping (moderate/mild). Self-rated adherence to the recommended relaxation training was moderate throughout the sample, but self-rated relief was significantly different between clusters. At follow-up, pain intensity was significantly decreased in all patients, whereas pain-related interference was improved only in dysfunctional and adaptive patients. Improvement of symptom domains varied between clusters and was most comprehensive in adaptive patients.

Conclusions

In conclusion, craniofacial pain sufferers can be divided in meaningful subtypes based on their pain perception, irrational beliefs, and pain behaviour. A self-administered relaxation training generally yielded positive effects on pain perception, however the benefit may be greater in patients with more marked symptom impact (both dysfunctional and adaptive).

     

The impact of subclinical depression on the postoperative perception of pain in general surgery patients

Aim-Background

Postoperative pain is a significant cause of discomfort and interferes with the recovery and mobilization of surgical patients. Depression has been shown to sensitize patients to pain. We conducted this study in order to assess its effect on general surgery patients.

Materials and methods

We conducted a prospective study involving 400 consecutive patients who underwent general surgery. Various factors known to be associated with the perception of pain were recorded, including the level of depression as well as preoperative and postoperative pain for the first week. The psychological state was assessed using the Hospital Anxiety and Depression Scale (HADS).

Results

According to the results obtained from the HADS, there were 323 patients who did not have high scores for depression and 63 who had a level of depression. Patients with depression were older, had a longer scar, scored high in the HADS for anxiety, depression, and had a lower level of education. They had greater preoperative pain and higher level of early postoperative pain (1st PO day). No difference was identified in the type and quantity of the analgesia used. Patients over 60 years of age and of lower education were mostly affected.

Conclusion

Subclinical depression is a significant predictor of pain. Measures should be taken to identify this subgroup of patients and manage them accordingly in order to minimize the effect on the perception of pain. We propose assessment of all surgical patients according to the HADS, special consultation of such patients, and medications to alleviate the psychological state.

     

A pilot study of the individual placement and support model for patients with chronic pain

Background

Individual Placement and Support (IPS) is an evidence-based work rehabilitation model with well-documented effects for people with mental illness. The model has, however, never been tested out for people with chronic pain. This pilot study aimed to investigate chronic pain patients’ experiences with the IPS job support model.

Methods

We recruited eight consecutive patients referred for various chronic pain conditions at a hospital outpatient pain clinic. They were offered IPS job support as an integrated part of their interdisciplinary pain rehabilitation. The patients’ experiences were investigated through semi-structured interviews 3 months after inclusion in the study.

Results

The participants reported mostly positive experiences with IPS. One participant dropped out of the study after deterioration of symptoms, while the remaining participants were satisfied with the intervention. Particular helpful aspects of the IPS intervention were the follow-up from the employment specialist, focus on competitive employment, focus on work despite pain complaints, reframing work into something positive, administrative support, and practice in writing applications. No participants reported adverse experiences from the IPS intervention. Within a 12-months time frame, 3 of the 8 participants gained competitive employment.

Conclusions

This is the first report of the IPS model of supported employment applied in an outpatient setting for chronic pain patients. The results suggest that IPS can be successfully integrated with interdisciplinary pain rehabilitation, and warrants large-scale testing in a randomized controlled trial.