Guidelines in pain treatment--methodical quality of guidelines for treatment of pain patients

The committee for quality assurance of the German IASP chapter (DGSS) evaluated all relevant guidelines concerning pain treatment. Quality of guidelines was analysed according to the checklist "Methodical quality of guidelines" by Ollenschl?ger and the user manual released by the German Medical Centre for Quality Assurance. The guideline for the treatment of back pain released by the German Medical Association was examined as well as the one released by the German Association for physical therapy and rehabilitation, the guideline on cervical and lumbal nerve root compression syndrome of the German Association of Neurosurgeons, the guideline for cancer pain of the Drug Committee of the German Medical Association was compared with the one of the German Interdisciplinary Association for Pain Treatment. The guideline for the treatment of chronic headache and facial pain of the Medical Association was evaluated and the guideline for the treatment of trigeminal neuralgia of the German Association of Neurosurgery and Neurology, also the guideline for the treatment of acute postoperative and posttraumatic pain. All guidelines show deficiencies in different aspects and of different severity. At first there are deficiencies in interdisciplinary formulation of the guidelines and identification and interpretation of evidence of multimodal pain treatment options. The most prominent deficiency is the lack of implementation and application trials or impulses by all author associations. This way all expenditure on releasing guidelines is given away without improving quality of pain treatment. The authors' recommendation is to adjust to guidelines and, if they are working or not, tell the authors and improve interdisciplinary in pain treatment guidelines.     

Enzymes in lymph: a review

Lymph is the minute net volume of contending hydrostatic and osmotic capillary forces. It is built up extravasculary in tissues and reaches the intravasal space by definite lymph collecting vessels, which enter the venous system at the angulus venosus at the root of the neck. Sampling methods for lymph from individual tissues or from lymph collecting vessels of man and various animals are cited and the preparation of lymph for enzymatic analysis is described. The extracellular distribution and transport of enzymes is important for diagnostic enzymology, because enzymes released from cells in continuous physiological processes, or after injury to the tissue, reach the intravasal space mainly via the lymphatics. This is evident from the high lymph-plasma ratios of diagnostically important enzymes. The type of enzyme transport (lymphatic or by direct interstitial-venous entry) depends on the heterogeneity of the capillary barrier characteristic of the different organs. The permeability is extremely high in liver, i.e. enzymes in hepatic lymph originate mainly from blood, which they have reached through the large openings in the sinusoidal endothelial lining; in contrast the permeability is extremely low in skeletal muscle, where lymphatic transport therefore predominates. The phenomenon of increased enzyme activities in plasma after physical exertion is explained by alterations of lymph flow. A table gives a survey of enzyme activities, lymph-plasma quotients, and lymph flow from lymph vessels of various tissues as well as from the lymph collecting vessels of man and animals, with comments on the signficance for diagnostic enzymology.     

Catalytic enzyme activity concentration in tissues of man, dog, rabbit, guinea pig, rat and mouse. Approach to a quantitative diagnostic enzymology, III. Communication

The catalytic activity of up to fifteen enzymes was investigated in the liver, heart, skeletal muscle, kidney (medulla, cortex), brain, lung, duodenum, spleen and pancreas from man and animals. Human specimens were obtained from autopsies and immediately post-mortem from dogs, rabbits, guinea pigs, rats and mice. The differences between our results and previous reports of considerably lower activities for structural enzymes (e.g. creatine kinase) and for enzymes partly of mitochondrial origin (e.g. glutamate dehydrogenase, aspartate aminotransferase, malate dehydrogenase), is attributed to our use of a detergent extraction technique. The superiority of the detergent technique with regard to enzyme yield is exemplified by a comparison of various methods of extraction in rat liver, heart and skeletal muscle. Use of standardized assays allows a qualitative inter-species comparison of results. The influence of autolysis on catalytic activity of human autopsies is considered of minor importance.     

Evaluation of granulocyte-releasing products and chemiluminescence during cytapheresis

During the procedures of centrifugation leukapheresis and plateletpheresis, donors occasionally experience adverse clinical reactions. The possibility of whether the activation of granulocytes and the subsequent release reactions, which may have been triggered by this extracorporeal circuit, were responsible for these adverse effects was evaluated. Six blood samples were obtained at set intervals during cytapheresis. Of these samples, four were taken directly from the donor. The remaining two were drawn from the efferent lines, i.e., those which return blood from the cytapheresis machine to the donor. Reactive oxygen species produced by granulocytes were measured by chemiluminescence (CL) using microamounts of whole blood or isolated granulocytes. Furthermore, secreted granulocyte products such as neutral proteinase elastase, which is present in plasma in a complex with alpha-1-proteinase inhibitor (E-alpha-1-PI), and lysosomal beta-glucuronidase were examined. A complete blood cell count and the values of hemoglobin, hematocrit, lactate dehydrogenase, protein, albumin, and proteinase inhibitors such as alpha-2-macroglobulin and alpha-1-proteinase inhibitor were also determined. Clinical chemical and cytologic values, with the exception of those for E-alpha-1-PI, were 10 to 17 percent lower than values before apheresis. These results can be attributed to inherent plasma volume expansion. Reduced CL was observed on the stimulation of phagocytes in the whole blood assay, as well as with stimulated granulocytes. Unstimulated granulocytes, on the other hand, showed an increased native CL. These data do not indicate a cytapheresis-mediated activation of the oxidative metabolism of granulocytes, and the concomitant discharge of proteolytic enzymes remains, therefore, of no clinical importance.     

Prozesse und Interventionen auf den deutschen Palliativstationen

Since 1996 a working group of palliative care physicians has been developing a core documentation for palliative facilities. The data on a total of 1304 patients were collected in 2001. Treatment in palliative care units was provided for 531 patients until their death (Pat-V), 604 patients could be discharged home, and 169 patients were transferred to other facilities (Pat-E). Infusion therapy, physical therapy, positioning and mobilization, together with counseling and social services were initiated in more than 30% of the patients, while specific measures such as ascites or pleura puncture were instituted in less than 10%. Chemotherapy, radiotherapy, immunotherapy, urinary catheter, physical therapy, mobilization, positioning, psychotherapy, and social services were documented more frequently in the Pat-E group than in the Pat-V group. Chemotherapy was started in only 35 patients and radiotherapy in only 31 patients while they were in the palliative care unit. Parenteral nutrition, infusion therapy, wound management, and counseling were documented more frequently in the Pat-V group. Advanced directives were available for 9,9% of the patients omission or discontinuation of therapies was documented for 28,1%.Specific indications for the quality of palliative care provided could not be identified with the documentation instruments applied. The core documentation does however furnish data from a representative sample of in-patient palliative care in Germany, which can be used as a comparative data pool for other studies and quality assurance measures.     

The decline of catalytic enzyme activity concentration of in vivo ageing erythrocytes of the man, the dog and the rat. Approach to a quantitative diagnostic enzymology, IV. Communication

Human, dog and rat erythrocytes were separated by centrifugation on a discontinuous buffered Percoll gradient into fractions of progressively increasing mean cell age to measure the in vivo decline in catalytic activity of eleven enzymes during the erythrocyte lifespan. Erythrocyte enzymes decline exponentially at different rates and also differ between the species. The maximal and minimal catalytic activities (erythrocyte catalytic activity at the beginning and at the end of the appropriate erythrocyte life-span for a given species) and the intracellular half-life of enzymes estimated. To test the hypothesis that circulating erythrocytes make a significant contribution to the normal catalytic activity in plasma it was assumed as a working hypothesis that the measured loss of catalytic activity in ageing erythrocytes is equivalent to the amount of the enzymes released in catalytically active form into plasma. This contribution was calculated.     

Catalytic enzyme activity concentration in thoracic duct, liver, and intestinal lymph of the dog, the rabbit, the rat and the mouse. Approach to a quantitative diagnostic enzymology, II. Communication

In the mixed body lymph of the thoracic duct and in the defined organ lymph of the liver and the intestine, the catalytic activity concentrations of up to sixteen enzymes and the concentrations of albumin and protein were determined, as well as the transport rate of these substances and their lymph/plasma ratio. Thoracic duct lymph specimens were obtained from an extracorporeal lymph shunt in anaesthetized and conscious dogs and from short-term fistulas in anaesthetized rabbits, rats and mice. Additionally, rabbits and rats underwent passive motion of the hind limbs in another experimental trial. Thoracic duct flow in anaesthetized dogs is only half that seen in conscious dogs, due to bypassed muscular lymph. A similar flow change is seen during passive motion of hind limbs in anaesthetized rabbits and rats. From a literature review of flow in the four main lymphatics of the body, it is concluded that the thoracic duct flow should account for 50-70% of total body lymph flow. In the anaesthetized state, flow is mainly of visceral origin. In the conscious state and during passive motion the increased flow is of muscular origin. In the latter case, the catalytic activities of enzymes like lactate dehydrogenase, malate dehydrogenase, creatine kinase, aldolase and phosphohexose isomerase, increase in lymph as does their lymph/plasma ratio. These enzymes have high catalytic activities in muscle. Their transport into the blood increases 2-3-fold, due to a doubling of lymph flow. Reported data for anaesthetized and immobile animals therefore far underestimate the significance of thoracic duct enzyme transport. Liver lymph was obtained from anaesthetized dogs and rabbits. Our finding that lymph catalytic activity for several enzymes is higher than in plasma is not compatible with the proposed delivery of plasma proteins directly into the sinusoidal space without prior mixing with the Space of Disse. Enzymes in liver lymph should derive from parenchymal and endothelial lining cells. Their site of delivery from the hepatocyte seems different from that of proteins. Liver lymph is an important transport route of enzymes into the blood. Intestinal lymph was sampled from anaesthetized dogs, rabbits and rats. It was shown that most enzymes from the intestine are primarily released into the interstitial space and from there are transported via the lymph into the blood.     

Deutscher Schmerzfragebogen (DSF) und standardisierte Dokumentation mit KEDOQ-Schmerz

KEDOQ-Schmerz was developed by the German Pain Society (formerly DGSS) as a basic tool for documentation and quality management of pain therapy. It is planned to use KEDOQ-Schmerz as the data basis for nationwide, cross-sectional and independent scientific research in health services in Germany. With comparatively little effort, each participating institution (practices, pain clinics) will be able to provide quality control of their own diagnostic procedures and therapeutic effects by using benchmarking. In future KEDOQ-Schmerz will also be used as a method for external quality management in pain therapy in Germany.