Aufmerksamkeitsbelastung und Reaktionszeiten unter Opioiddauertherapie Ein Vergleich mit chronischen Schmerz- patienten und mit Nichtschmerzpatienten

Objectives: Despite increasing use of oral opioids in cancer and non cancer pain, little is known about the effects of long-term opioid therapy on psychomotor performance. This study was designed to investigate the effects of long-term opioid analgesia on attention and reaction time in cancer pain and in non-malignant pain. Methods: Three groups of patients (n=128) were studied: 48 patients on long-term opioid therapy (group O; including 33 patients with cancer pain and 15 patients with chronic non-malignant pain), 30 patients receiving non-opioid analgesic therapy for chronic non-malignant pain (group NO) and a control group (group K) of 50 patients without pain and analgesic therapy. Attention was determined by Brickenkamp’s d2-test, continuous reaction time by Schuhfried’s method (Wiener Determinationsgerät, Mödling, Austria). In addition, a modified questionnaire developed by Zerssen was used to determine the patient’s current mood. Pain, fatigue and anxiety levels were estimated by visual analogue scales. Results: Although no significant difference in attention/concentration could be demonstrated between the three groups, patients taking opioids performed Brickenkamp’s test a little worse and also demonstrated a significant decline in this parameter with advancing age. Also, in cancer patients attention/ concentration was more impaired than in non-cancer opioid patients. Auditory and optical reaction times were significantly slower in patients on opioids than in the non-opioid analgesic group and highly significant slower than in the control group, while in the more complex combinations test no such difference could be demonstrated. In addition, a highly significant deterioration in reaction times with increasing age could be demonstrated for opioid patients compared to the other groups, while only a non significant prolongation was found between cancer and non-cancer patients on opioid therapy. Conclusions: Long-term opioid therapy produces a slight (non significant) impairment of psychomotor performance in patients with cancer pain or non-malignant chronic pain. These effects become significantly more pronounced with increasing age and in patients with cancer pain, indicating a higher susceptibility of the elderly towards opioids. These results indicate that, particularly in older patients receiving long-term opioid for cancer oder non-cancer pain, careful evaluation of their effects on psychomotor function is necessary in order to estimate patient’s ability to perform his daily activities. However, since opioid effects were only minimal in the non-elderly other factors like basic disease, opioid dose, physical condition and age seem to be of greater importance than the effects of opioids per se.     

Fehldiagnosen bei verspätet erkannter beidseitiger simultaner Ruptur der Quadrizepssehnen

Es wird über den seltenen Fall einer beidseitigen, simultanen Quadrizepssehnenruptur bei einem 38j?hrigen Patienten berichtet. Die initiale Diagnose lautete dabei ,,Bandscheibenprolaps`` und es dauerte trotz intensiver Diagnostik, einschlie?lich mehrerer operativer Eingriffe sowie einer neurologischen und psychiatrischen Abkl?rung, fast 3 Monate bis das Krankheitsbild erkannt und kausal behandelt wurde. Im speziellen wird dabei die gipsfreie, intensive postoperative Mobilisation des Patienten dargestellt.      

Treatment of hand surgery patients in chronic pain

The treatment of hand surgery patients suffering from chronic pain requires an interdisciplinary procedure. An imbalance between nociception and antinociception can be seen as a reason for the chronification of pain. The complexity of the problem of chronic pain patients is marked by a wide variety of symptoms. Full diagnostic assessment to detect or to exclude other organic diseases is required. Rehabilitation to improve function and reduce pain intensity has priority. Our therapeutic strategy consists of intensive physiotherapy and analgesic drugs as well as a series of blockades with buprenorphine (Temgesic) of the ganglion stellatum (GLOA). This specific therapy achieved an improvement of the function of the upper extremity and a reduction of pain intensity. The majority of patients were satisfied with the outcome.     

Zusätzliche Hilfen bei der Erkennung von Prostatakarzinomen? PSA-Prostatavolumenquotient, PSA-Verdopplungszeit, altersabhängige PSA-Referenzwerte und PSA im Urin

Different concepts to improve the clinical utility of prostatic-specific antigen (PSA) for prostate cancer detection have been developed. PSA density and transition zone PSA density are not useful screening tools due to a high variability of prostate volume measurement. PSA velocity monitors the change in PSA in a 2-year period, therefore it is not suitable for treatment decisions in men with serum PSA levels between 4 and 10 ng/ml. Measurement of urinary PSA is not helpful for prostate cancer detection. Age-specific PSA reference ranges provide greater sensitivity for cancer detection in younger men at the expense of a greater negative biopsy rate. In older men unnecessary biopsies could be spared. However, this might lead to a lower sensitivity in these patients, missing possibly clinically insignificant tumors.     

Therapie und Ergebnisse bei lateralen Klavikulafrakturen

= 3) waren schlecht. Die konservative Therapie stabiler Frakturen ergab in allen F?llen gute bis sehr gute Ergebnisse. Die Therapie instabiler Frakturen führte zu guten Ergebnissen, wenn die Frakturinstabilit?t erkannt und bei der Therapie entsprechend berücksichtigt wurde. Laterale Klavikulafrakturen mit zus?tzlicher Sprengung des Akromioklavikulargelenks, und Frakturen, bei denen die Instabilit?t auf einen Abri? des Processus coracoideus zurückzuführen sind, sollten in der bestehenden Klassifikation gesondert berücksichtigt werden. Die PDS-Gurtung erm?glicht bei in-stabilen Frakturen mit kleinem peripheren Fragment oder bei zus?tzlicher Verletzung des Akromioklavikulargelenks eine ad?quate Frakturstabilisierung.      

Erstversorgung, Reanimation und Transport von Neugeborenen

The primary care of neonate poses a particular challenge to those unpracticed in administering first aid. In most cases it suffices to dry off the newborn child after birth, stimulate respiration, and provide warm towels. Expert measures are necessary for a minority of full-term neonates, and for premature infants this need increases in direct relation to the degree of immaturity. The international Liaison Committee on Resuscitation (ILCOR) has developed internationally valid guidelines. These recommendations are not usually based on data from controlled studies but rather on currently recognized experience and teaching theory. Well-trained personnel should be available during every delivery to provide basic care of neonates. For full-scale resuscitation measures, a specialized team is indispensable. The subsequent transport to a clinic represents a strain on the neonate and is associated with special risks. This report presents the ILCOR recommendations and clinical/practical aspects of transporting a newborn child.     

Early functional treatment of surgically managed Achilles tendon rupture

40 acute traumatic ruptures of the Achilles tendon were evaluated in a prospective study after open repair using an early functional rehabilitation protocol. The age of the patients averaged 43 (23-64) years. The operation consisted of a Kessler suture and microadaptation of the tendon. A special boot was used for after treatment. The boot was used 9 (1-18) weeks and full weight bearing was reported after 7 (1-16) weeks. The sick leave time averaged 5.5 (0-18) weeks. After 1 year, length and ankle joint motion were restored. Outcome was assessed using a 100-point score described by Thermann. After 4 months it averaged 73.5 +/- 15.5 points and after 1 year 94.5 +/- 6.0 points. There were no perioperative complications. One rerupture occurred 6 weeks postoperatively and was operated successfully. The combination of surgical repair and early functional after treatment resulted in normal function after 1 year, but requires cooperation of the patient.     

Frühlockerungen eines zementierten Hüftendoprothesenstiels aus Titan

Up to now there are no facts concerning the loosening rate of the cemented titanium stem (Trios). The central guiding canula and the longitudinal drilled stem shall ensure a symmetric cement mantle. In order to estimate the risk of aseptic loosening all Trios prostheses implanted in our clinic (n = 67; operations 1/95-11/96; max. follow-up: 3.1 years) were examined in a retrospective study and compared with a conventional femoral component (n = 141; Müller special; CoCr; operations 1977-1982). We used survivorship analysis to assess the results (Kaplan-Meier method; end point: revision). Compared to the conventional femoral stem the survival rate of the Trios prostheses was significantly worse (p = 0.0001). The probability of no revision after 3 years was 72% (conventional femoral component: 96%). Preoperative x-rays showed radiolucent lines surrounding the cement mantle. These findings as well as the loosening at the cement metal interface were confirmed intraoperatively. The explanted stems showed corresponding signs of abrasion on the surface. Our results prove that the application of cemented titanium stems might be problematic. With regard to the Trios prosthesis we recommend close routine check-ups to keep the chance of an early revision.     

Proven and unproven hygiene measures in orthopedics

Postoperative wound infections develop in approximately 2-5% of all patients after orthopedic surgery. After urinary tract infection and pneumonia, such wound infections (15%) are the third most frequent type of hospital-acquired infection. In this review we summarize all proven and unproven hygiene measures available in orthopedics, giving special attention to those implemented with the aim of preventing and controlling postoperative wound infections. Routine application only of hygiene procedures of proven efficacy will be an important contribution to economic and ecological quality assurance in hospital.     

Das Bild der Chirurgie in der Öffentlichkeit

Zusammenfassung. Chirurgie und ?ffentlichkeit stellen, je nach Sichtweise und in unterschiedlicher Bedeutung, ein hochvernetztes Interaktionsgeflecht dar. In der medialen Darstellung dominiert zunehmend die Unterhaltung über die Information (Infotainment) sowie eine Skandalisierung der Ereignisse mit überwiegend negativer Berichterstattung. Informationsdefizite bei mangelnder Transparenz tragen dazu wesentlich bei, was auch für den Wissenschafts- und Wissenstranfer in die Bev?lkerung gilt. Die ?konomiefalle mit zunehmender Verknappung der Finanzen bei st?ndiger Ausweitung des Angebotes erfordert ebenfalls eine verst?rkte Artikulation der Chirurgen in der ?ffentlichkeit. Ein heute festzustellender Paradigmenwechsel stuft den Arzt zum Leistungserbringer herab und reduziert das Arzt-Patienten-Verh?ltnis auf das Aufeinandertreffen der Begehrlichkeit von Patienten auf die der Leistungserbringer. Wir stehen somit in einer st?ndigen Auseinandersetzung mit der Macht der Medien und sind gefordert, Defizite in der ?ffentlichkeitsarbeit abzubauen. Das Bild der Chirurgie in der ?ffentlichkeit wird heute gepr?gt von Leistung und Kommunikationskompetenz.      

Erfolgreiche lokale Katheterfragmentation und Thrombolyse bei akuter Lungenembolie in der frühen postoperativen Phase nach Pankreaskopfresektion

Pulmonary embolism in the early postoperative period is characterized by high morbidity and mortality. Systemic application of thrombolytic agents during this time is contraindicated; operative thrombectomy also has a high mortality rate. We report a case of successful local lysis in combination with catheter fragmentation of a massive two-sided pulmonary embolism diagnosed on the 4th postoperative day after pylorus-preserving duodenopancreatectomy for distal carcinoma of the common bile duct. Thrombolysis was performed in three sessions by a combination of catheter-supported interventional fragmentation of the thrombus with local rt-PA lysis. There were no bleeding complications or disturbances of anastomotic healing. The patient was discharged from the hospital on the 23rd postoperative day after changing anticoagulation to a vitamin K antagonist. The case presented demonstrates the possibility of local lysis in combination with interventional methods as a therapeutic option for pulmonary embolism in the early postoperative period as an alternative to surgical strategies.     

Die Baker-Cyste – eine aktuelle chirurgische Standortbestimmung Übersicht und eigene Ergebnisse

Zusammenfassung. In der Unfallchirurgischen Universit?tsklinik K?ln wurden von 1988 bis 1997 19 Patienten an einer Baker-Cyste operiert. Die subjektiven und objektiven Ergebnisse wurden mit Hilfe eines Fragebogens sowie einer klinischen und sonographischen Nachuntersuchung erfa?t (Rücklauf: 95 %). Der pr?operative Status wurde durch klinische Untersuchung, Sonographie und Anfertigung von R?ntgenaufnahmen des Kniegelenks ermittelt. Wir differenzierten zwischen der angeborenen prim?ren Cyste (39 %) und der sekund?ren Form, die immer mit einer Kniebinnenpathologie assoziiert ist (61 %). Bei allen sekund?ren Cysten wurde eine Arthroskopie durchgeführt. Als postoperative Komplikationen traten in einem Fall ein revisionspflichtiges H?matom und in einem anderen Fall ein punktionspflichtiger Ergu? auf. Das Operationsergebnis wurde von 61 % der Patienten mit „sehr gut“ und von 39 % mit „gut“ bewertet. Alle nachuntersuchten Kniegelenke waren passiv und aktiv frei beweglich. In einem Fall kam es zu einem Rezidiv. Nach unserer klinischen Erfahrung sollten prim?re Baker-Cysten immer entfernt werden. Bei der sekund?ren Cyste mu? neben der Exstirpation die Bedeutung der arthroskopischen Diagnostik und Therapie sowie der Sanierung der Grundkrankheit diskutiert werden.      

Klinische Studien zur peripheren Wirksamkeit von Opioiden nach Kniegelenk-Operationen Ein Literaturüberblick

In this article 34 randomized controlled trials examining peripherally mediated opioid effects after knee surgery are discussed. All studies examined small doses of morphine injected intraarticularly at the end of knee surgery, but not all studies did show an analgesic effect of the peripheral opioid. Because of differing study designs a meta-analysis of the data is not possible. Some important factors like those that the respective authors try to explain the contradictory results with are discussed here: The used concentrations, volumes and doses of morphine are not of major importance. An addition of adrenaline to the study drug, as well as the use of a tourniquet and the time interval between the intra-articular injection and tourniquet release do not seem crucial either. The use of intra-articular drainage (which is opened 10 min after injection of the study drug) and of patient-controlled analgesia as an evaluative method also do not seem to play a major role. But it is remarcable that peripheral opioid effects have often been described after general and local anesthesia but only once after regional anaesthesia. It may be that the activation or expression of peripheral opioid receptors is inhibited by the blockade of input to the central nervous system. Animal experiments are needed to clarify this issue. But it may also be that postoperative pain after regional anaesthesia does not reach a level high enough to make an analgesic effect measurable. If patients after regional anesthesia are not considered, 20 studies out of 29 were able to demonstrate opioid effects whereas 9 were not: The work of Heard and coll. [14] as well as Ruwe and coll. [44] must be criticized because of methodological shortcomings. In the remaining 7 studies the patients of the comparative groups only show low pain scores which may make it impossible to measure an analgesic effect by intraarticular morphine. In summary it can be concluded that very small doses of morphine injected intraarticularly after knee surgery do exert an analgesic effect. In some studies this effect lasted even up to 48 h. But at least during the first two hours the effect is small or else doubtfull. Therefore a combination with bupivacain, a local anesthetic which acts rapidly but only for some hours can be recommended. Most authors testing this combination found it most useful.     

Die Expression von Typ-VI-Kollagen bei der Arthrofibrose Eine immunhistochemische Untersuchung*

Arthrofibrosis is a disabling complication after trauma and surgery due to massive connective tissue proliferation. The etiology and pathogenesis have never been fully understood. A strong immune response may lead to activation and proliferation of fibroblasts with excessive and disordered deposition of matrix proteins. In similar pathological conditions, like lung fibrosis or superficial fibromatoses with fibrotic transformation an increased expression of collagen type VI has been reported. We investigated fibrotic tissue samples taken from 18 patients (average age: 32.7 years), who underwent arthrolysis of the knee joint because of symptomatic arthrofibrosis following ligament injury. The mean interval between trauma and arthrolysis was 13.8 months (range 4-50 months). Tissue samples were taken from the infrapatellar fat pad and intercondylar connective tissue. All samples were stained with HE. The expression of type III and VI collagen was studied immunohistochemically using an immunoperoxidase method for light microscopic visualization. Histologic analysis from patients with arthrofibrosis showed a synovial hyperplasia with cell infiltration and vascular proliferation compared to synovial tissue samples from knee joints without any detectable pathology. Subsynovial an increased deposition of matrix proteins was visible. Type VI collagen was widely distributed as a network subsynovial and around capillary walls. Type III collagen showed a diffuse distribution. Arthrofibrotic tissue is, similar to pathological conditions with fibrotic transformation characterized by an increased expression of collagen type VI. Collagen type VI may play an important role in matrix homeostasis. It serves as an anchoring element between collagen fibers and as a cell binding structure.     

Platten- und Schraubenosteosynthese bei Femurschaftfrakturen Retrospektive Studie von 500 Femurschaftfrakturen

The authors collected 500 cases of breaks of the thighbone shaft which were treated using osteosynthesis with screws, between 1st January 1992 and 31st of December 1996 at the Department for Traumatology of the University Medical Center in Ljubljana. Most patients were male (70.6%), the average age was 36.6 years, and the majority of patients had been injured in traffic accidents. In 50% of cases, only the thighbone was broken, the rest had suffered multiple injuries, or were polytraumatised. Their stay in hospital averaged 17 days, while the average time to union was 21 weeks. In most cases (85%), treatment proceeded with no complications. Chronical post-traumatic osteitis occurred in 9 of the patients with open breaks (1.8%), and only in 2 patients (0.4%) with closed breaks, which is within the limits of tolerance. With respect to our experience and results with osteosynthesis with plates and screws in the thighbone shaft, we believe that the mentioned method is good and gives results which are comparable to those achieved using other methods.     

Die Therapie des Harnleitertumors

Nephroureterectomy is the standard treatment of tumors in the upper and middle third of the ureter. Whereas, resection of the distal ureter and uretercystoneostomy is the treatment of choice of tumors in the lower third, as long as there is enough renal function which is worthwhile to be preserved. Lymphadenectomy should be performed in all patients suspicious for invasion of the ureteral wall since already 10% of patients with pT1 and pT2 tumors will present with metastases to the lymphnodes. In case of functional or anatomic single kidney therapy has to be adapted to the patient and tumor appropriately. Endoscopic resection, partial or complete resection of the ureter with substitution by ileum or autotransplantation with pyelovesicostomy are the operative options. Elective endoscopic treatment of ureteral tumors should be done in patients with G1 tumors only. However, the recurrence rate is as high as 30 to 60% and the mean interval to recurrence is about 9 months. Regular followup by means of cytology and endoscopy is mandatory. Laparoscopic nephroureterectomy is still a experimental treatment at present time and should be not considered in the treatment of ureteral tumors because of the complexity of the procedure and the risk of tumor spillage.