Thrombozytopathie und Blutungskomplikationen bei Urämie

Bleeding diathesis and thrombotic tendencies are characteristic findings in patients with end-stage renal disease. The pathogenesis of uremic bleeding tendency is related to multiple dysfunctions of the platelets. The platelet numbers may be reduced slightly, while platelet turnover is increased. The reduced adhesion of platelets to the vascular subendothelial wall is due to reduction of GPIb and altered conformational changes of GPIIb/IIIa receptors. Alterations of platelet adhesion and aggregation are caused by uremic toxins, increased platelet production of NO, PGI(2), calcium and cAMP as well as renal anemia. Correction of uremic bleeding is caused by treatment of renal anemia with recombinant human erythropoietin or darbepoetin alpha, adequate dialysis, desmopressin, cryoprecipitate, tranexamic acid, or conjugated estrogens. Thrombotic complications in uremia are caused by increased platelet aggregation and hypercoagulability. Erythrocyte-platelet-aggregates, leukocyte-platelet-aggregates and platelet microparticles are found in higher percentage in uremic patients as compared to healthy individuals. The increased expression of platelet phosphatidylserine initiates phagocytosis and coagulation. Therapy with antiplatelet drugs does not reduce vascular access thrombosis but increases bleeding complications in endstage renal disease patients. Heparin-induced thrombocytopenia (HIT type II) may develop in 0-12 % of hemodialysis patients. HIT antibody positive uremic patients mostly develop only mild thrombocytopenia and only very few thrombotic complications. Substitution of heparin by hirudin, danaparoid or regional citrate anticoagulation should be decided based on each single case.     

Migräne bei Kopfschmerzexperten und Neurologen

Throughout the world, migraine is one of the most common neurological disorders. It is probable that 11% of the world’s population suffer from migraine. Some recent studies have investigated the prevalence of headache in neurologists and other medical doctors; most of these studies have been performed in the USA. One study in Taiwan investigates how migraine is treated in Taiwanese neurologists. Within Europe, two small observational studies conducted in Italy and Spain are available. A study in Germany analyses the attitudes of headache specialists and neurologists who themselves suffer from migraine to migraine treatment and to the whole concept of migraine. Most of these studies point out that the prevalence of migraine in headache specialists and neurologists is higher than that in the general population and that this phenomenon has an impact on the treatment they offer and on their attitudes to the condition.     

Chronifizierungsmechanismen und Abhängigkeitspotenziale bei Tumorschmerz

Background

Due to advances in oncological therapy options and increasing survival rates, the number of cancer patients with persistant pain, who are in need of analgesic therapy has increased. It has been proven that biopsychosocial mechanisms exist in patients with persistant non-cancer pain leading to chronification. Furthermore, addiction has been identified as a complication of analgesic therapy.

Objective

Can the multidimensional model of chronic pain enhancement and chronification be used for patients with cancer pain, analogue to patients with non-cancer pain? Can addiction sydromes as a result of analgesic treatment be demonstrated?

Material and methods

In this non-systematic review, a literature search was carried out for somatic and psychosocial chronification mechanisms in patients with cancer pain. Indications for potential addiction syndromes in cancer patients are demonstrated based on selected publications. A Medline search provided a number of relevant publications that are listed (see Supplementary Material).

Results and discussion

Somatic chronification mechanisms, such as pain intensity, repetitive algesic stimuli, topical and demographic factors, are found both in persistant non-cancer pain and cancer pain. Cancer-induced peripheral and central sensitization mechanisms that can be due to underlying genetic variations, are specific for cancer pain. With regard to psychosocial determinants for pain chronification, both cancer and non-cancer patients show similar patterns. Furthermore, data from the literature support the existence of addiction in cancer patients.

Conclusion

In order to optimize treatment more attention should be paid to the risk of chronification and addiction in cases of chronic persistant cancer pain.

     

Immunologische Auffälligkeiten bei Migräne und Clusterkopfschmerz

An increasing number of papers deal with immunological factors in headache syndromes such as migraine and cluster headache. The aim of this review is to give an overview of the factors that have been measured and to assess their reliability and relevance for the pathogenesis of these headaches. Most of the studies are handicapped by methodological problems, especially the different classifications of headaches, the lack of adequate controls and methodological problems with the measurement of certain immune parameters. Nevertheless, immunological abnormalities have been shown to be reproducible. These are the increased number of autoantibodies in migraine and the augmented number of deficient NK cells and monocytes in cluster headache. Furthermore, some cytokine levels (IL-2) have been shown to be decreased in migraine and tension-type headache, while others (IL-1, TNFalpha) seem to be elevated. Cluster headache seems to be associated with persisting viral infections. Studies of immunoglobulins and immuncomplex levels and analyses of immunomediators such as prostaglandins and histamine still yield contradictory results. Although the immunological changes have been shown to be valid, their pathogenesis in these headaches is unclear. With the increasing recognition of the existence of a neuroimmunologic network, alterations in each system should always be considered to be associated with changes in an other. Acute or chronic pain seems to trigger immunological abnormalities.     

Medikamentöse Schmerztherapie bei Kindern und bei älteren Menschen

The subject of treatment of pain in children and elderly patients has been neglected to date. This symposium deals with the problems of pain treatment in these two age groups and shows the importance of adequate therapy to improve their quality of life.     

Schlafverhalten und Kopfschmerzattacken bei primären Kopfschmerzen

Headache is connected with sleep quality, e.g. hypnic headache and chronic paroxysmal headache attacks occur preferentially during REM sleep; this is possibly also true for cluster headache and migraine. REM sleep is typically characterized by the occurrence of ponto-geniculo-occipital spikes (PGOs). These PGOs should be able to trigger cortical spreading depression (CSD), which, although often clinically silent, is assumed to be an essential element of a migraine attack and possibly also of other forms of headache. CSDs are considered a correlate of migraine aura. They could lead to the secondary activation of trigeminovascular afferences, which would then induce a headache. Interestingly, illnesses that are comorbid with migraine cause an increase in the amount of REM sleep; conversely, various drugs administered prophylactically for these illnesses reduce the quantity of REM sleep.     

Überlastungsschäden und Sportverletzungen bei Bundesligaringern

Wrestling injuries, overuse problems, and other pathologies of a league wrestling team are described. Most frequently the team doctor has to deal with open wounds and ear injuries. Use of better equipment has reduced the incidence of injuries to the AC and SC joint, but freestyle wrestling has a higher incidence of knee injuries. Spine injuries are less frequent but more severe. A routine team check-up can reveal other pathologies needing treatment.     

Medikamentenmissbrauch bei Läufern und die Folgen

A high percentage of recreational athletes unthinkingly take pain-killing drugs, particularly nonsteroidal anti-inflammatory drugs (NSAIDs) before and during participation in sports. Just as with other medications, NSAIDs can lead to side effects on the gastrointestinal, cardiac and nephrourogenital systems. Furthermore, the intake of analgesic drugs leads to a loss of the physical and mental warning function of pain. This can result in a chronification of improper load bearing and overloading giving rise to chronic structural damage. Such consequences are illustrated by case examples.     

Manuelle Medizin und Orthopädie bei Dorsalgie

Manuelle Medizin - Die Orthopädie und die manuelle Medizin sind sich ergänzende bzw. zusammengehörende Fachrichtungen der Medizin. Die manuelle Medizin stellt hierbei eine...     

Streß- und Krankheitsbewältigung bei Migräne

During a semi-structured interview 82 migraine patients were asked biographical and illnessrelated questions. They completed psychological instruments on coping behavior (Stressverarbeitungsfragebogen), self-concept (Frankfurter Selbstkonzeptskalen), attributional style (IE-SV-F), illness behavior, and illness-related attributions (Tübinger Attributions-fragebogen). The theoretical background of this research is a cognitive model of coping with stress and illness. The results support the interrelations between coping with stress and coping with illness assumed in the model. They justify considering coping with illness to be scopespecific coping behavior. Furthermore, the results emphasize the importance of cognitive processes for stress-coping in general, as well as for illness-related coping behavior. With regard to personality variables, migraineurs, as compared with healthy persons, show to a larger extent coping strategies that are apt to maintain rather than to reduce stress, such as resignation, withdrawal, and avoidance behavior. They also have a more unfavorable selfconcept of achievement, emotional stability and selfassertiveness, lower self-esteem and a more external pattern of causal attributions. Some of the pain behavior strategies could be identified as being focused on illness (guarding behavior, avoidance and social withdrawal, resignation and complaint); only the attempt to relax is regarded as being focused on health. Migraine patients show a preference neither for medical nor psychological causal attributions of their illness but score significantly higher on medical than psychological control attributions. The results have implications for psychological therapy.     

Subjektive Belastung und Religiosität bei chronischen Schmerzen und Brustkrebs

Background

Studies show that especially ill people turn to their religious faith to find help in dealing with their diseases. However, religiousness is assumed to vary in its extent and effect depending on different kinds of strain.

Material and methods

In order to differentiate patterns of strain and coping, a sample of 178 patients with chronic pain was compared with 167 breast cancer patients.

Results

Pain patients show higher strain and impairment on almost all variables. Regression analyses indicate that patients with chronic pain are less religious in comparison to the breast cancer patients.

Conclusions

Different values of the religious variables can be explained by different characteristics of the strain: Due to the threat to life experienced by the patients, the breast cancer group is more likely to turn to religiousness for help. Specific characteristics of chronic pain (e.g. longer illness duration, a stronger impairment in everyday activities) lead to higher resignation, also concerning religious efforts.     

Kommunikation und Befundaustausch zwischen Hausärzten und Orthopäden bei Rückenschmerzen

Introduction

Low back pain is a frequent reason for consultation in general practice. Many patients are treated in cooperation with an orthopaedic surgeon which requires an effective exchange of information. The aim of this study was to investigate the level of communication between general practitioners (GPs) and orthopaedic surgeons.

Material and methods

In this retrospective observational study referrals from GPs and corresponding response letters from orthopaedic surgeons were analyzed. GPs were asked to provide reasons for referral and to rate the quality of the response letters.

Results

A total of 12 out of 82 GPs from the teaching network of the Medical School of Göttingen participated in the study. Of 911 referrals to ambulatory orthopaedic surgeons within 3 months, 34% (n=312) were referred for low back pain. GPs provided little information beyond a diagnosis on the referral contrary to their self-perception. Most referrals (61%) were initiated by patients and most of them were considered at risk for chronification (72%) by the referring GP. Despite a formal obligation to report back, GPs received a response letter for only one-third (114/312) of the patients. GPs rated most of them as satisfactory, however, 59% were unsatisfied with the treatment recommendations. Only 10% of the letters contained psychosocial details. The information provided in the orthopaedic response letters was heterogeneous and only partly fulfilled the criteria set by the Interdisciplinary Society for Orthopaedic Pain Management.

Conclusion

Incomplete and scant information on referral forms from GPs and a high non-response rate from orthopaedic surgeons suggest that current health care system and referral forms do not promote effective communication about the patient. This might explain the satisfaction of GPs with the orthopaedic response letters despite the lack of information. The GPs dissatisfaction with the treatment recommendations reflects the limited treatment options for chronic low back pain in ambulatory care.     

Haltungsasymmetrie bei Säuglingen und deren osteopathische Behandlung

Purpose

To assess the therapeutic efficacy of osteopathic treatment in infants with postural asymmetry.

Patients and methods

A randomized clinical trial of efficacy with blinded videoscoring was performed. Sixty-one infants with postural asymmetry aged 6–12 weeks (median: 9) were recruited. Thirty-two infants (18 male, 14 female) with a gestational age ≥36 weeks were found to be eligible and randomly assigned to the intervention groups; 16 received osteopathic treatment and 16 sham therapy. After a treatment period of 4 weeks the outcome was measured using a standardised scale (40–24 points).

Results

With sham therapy, five infants improved (=3 points), eight infants were unchanged (±<3 points) and three infants deteriorated (>?3 points); the mean improvement was 1.2 points (SD±3.5). In the osteopathic group 13 infants improved and 3 remained unchanged; the mean improvement was 5.9 points (SD±3.8). The difference was significant (p=0.001).

Conclusion

Osteopathic treatment in the first months of life improves the degree of asymmetry in infants with postural asymmetry.     

Schmerz und Lebensqualität nach Nephrektomie bei Lebendspendern

Background

This survey focusesed on chronic postoperative pain and impairment of quality of life after living donor nephrectomy.

Methods

Out of a total of 82 donors 58 (71%) were examined using the Chronic Pain Grade (CPG) by von Korff and Short-Form 12 (SF-12).

Results

Of the donors 34% suffered from chronic postoperative pain 22 months (range 9-57 months) after nephrectomy and in 55% of these cases the pain interfered with daily life activities. The quality of life was almost comparable with those of the average German population, but was reduced by chronic postoperative pain particularly with respect to the mental state.

Conclusion

Measures have to be taken to prevent chronic postoperative pain and donors should be encouraged to express their pain to ensure an adequate pain therapy.     

Schmerztherapie bei Kindern und Jugendlichen mit Hämophilie

Background

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

Objectives

This paper discusses how to improve pain management for children and adolescents (0–18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

Materials and methods

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

Result

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

     

Die verletzte Halswirbelsäule bei Kindern und Jugendlichen

Trauma of the infant or juvenile spine is a very rare occurrence (less than 2%). Nevertheless, it is almost always dramatic. In 21 years 1630 patients with spinal cord injuries were treated. Of these, 21.7% (357 patients) had injuries in the area of the cervical spine. 23 patients (1.4%) were younger than 17.5 years, 8 of them were younger than 10 years. In 10 cases the cause was a traffic accident, in 7 cases it was a jump in too shallow water. In 4 times other leisure activities were the cause. A fall from a window sill and a falling tree were further reasons. Neck segment C0 to C3 was involved eight times, segment C3 to C7/Th1 was involved 15 times. The average age of the group with injuries in C0 to C3 was 5.6 years, in the group with injuries of segments C3 to C7/Th1 it was 15.8 years. In 11 cases the trauma caused complete tetraplegia, in six cases the paralysis was partial. In six further cases no neurological deficit occurred. 14 cases were treated surgically, six were treated conservatively. Four children younger than 10 years with complete tetraplegia died. In seven cases tetraplegia persisted; out of six patients with incomplete neurological deficit three improved and three patients recovered completely.     

Psychotherapie und ihre Wirksamkeit bei chronischen Schmerzzuständen

The gate control theory resulted in intensified consideration and investigation of psychological factors in the pathogenesis and continuation of chronic pain. This had led to an increasing interest in the efficacy of psychotherapy for such patients. The different forms of psychotherapy (hypnosis, relaxation, behavior therapy, psychodynamically oriented therapy) currently most often applied are reviewed with notes on the methods and the efficacy recorded for each. The psychodynamically oriented approach has most often been omitted from previous reviews but is integrated in this paper. Four psychodynamic mechanisms are differentiated: the narcissistic mechanism ("psychoprothetic function" of pain), the conversion mechanism ("symbolic function" of pain), the psychovegetative tension mechanism (pain as equivalent of emotion) and the learning mechanism (secondary gain from pain). Generally speaking, a good level of efficacy was ascertained for each form of psychotherapy considered. Hypnosis and relaxation can reduce depression and the perception of pain. Operant programs reduce medication intake and increase the level of activity. Cognitive behavioral strategies are aimed at changing the pain patient's fixation on the body. Psychodynamic approaches concentrate on biographical factors and communication with significant others before the onset of pain reflected in the therapist-patient relationship. However, the value of the results is restricted by the lack of information on patient selection in nearly all the studies considered. The small numbers of patients evaluated in most of the studies suggest that the population investigated may well not be representative, especially if the difficulty of motivating chronic pain patients to present for psychotherapy is taken into account. In addition, a diagnostic classification of the population investigated is lacking. Conclusions are drawn for the planning of future therapy studies.     

Alimentäre Triggerfaktoren bei Migräne und Kopfschmerz vom Spannungstyp

Based on a review of the literature the authors discuss the role of nutrition in the precipitation of migraine and tension-type headache (TTH). The available information relies largely on the subjective assessment of the patients. Controlled trials suggest that alcohol and caffeine withdrawal are the most important nutritional precipitating factors of migraine and TTH. In addition, there is some evidence that missing meals is also an important factor. Dehydration seems to deserve more attention. A selective sensitivity to red wine has been shown in some patients, the importance of chocolate has been doubted seriously, and scientific evidence for cheese as a precipitating factor is lacking. Despite a series of experimental studies demonstrating that NO donors such as nitroglycerin and parenteral histamine cause headache the role of histamine, nitrates, and nitrites in food remains unclear. Similarly, other biogenic amines and aspartame have not been proven to precipitate headache. Sodium glutamate causes adverse reactions including headache probably at large doses ingested on an empty stomach. Therefore, patients should be advised that food plays a limited role as a precipitating factor of migraine and TTH. Subjective sensitivity to certain foods should be examined critically, and proven precipitating factors should be avoided. General dietary restrictions have not been proven to be useful.