Comprehensive geriatric assessment as an essential tool to register or update DNR codes in a tertiary care hospital

PURPOSE

To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration.

PATIENTS AND METHODS

Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared.

RESULTS

At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic.

CONCLUSION

After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.

The Importance of Initial Epidurography Prior to Any Drug Administration in Three-Day Adhesiolysis Procedure

Percutaneous epidural adhesiolysis (PEA) is a minimal invasive procedure to relieve sciatalgia caused by post lumbar surgery syndrome (PLSS). Fluoroscopic-guided contrast-epidurography is essential to ensure a safe procedure. We present a case of a 28-year-old male patient who underwent a PEA which was complicated by a dural puncture. We highlight the dangers of such complications and discuss associated risk factors.

Pupillary reflex dilation and pain index evaluation during general anesthesia using sufentanil: a double-blind randomized controlled trial

Aim: In a single-center, double-blind, randomized controlled trial, we evaluated whether pupillometry-controlled use of sufentanil is better than free-choice administration of sufentanil by anesthesiologists. Patients & methods: 61 patients undergoing daycare gynecological or abdominal surgery were enrolled. A pupillometry pain index score chart was introduced for administration guidance of sufentanil. Results: The first objective, patient well-being, did not show a significant difference with painkiller usage and health state index at day 1 postoperatively. Secondly, we experienced difficulty in interpretation of the pupillometry score. Thirdly, opioid usage was higher in the intervention group (20.1 vs 14.8 mcg; p = 0.017). Conclusion: The use of pupillometry and pain index chart for bolus sufentanil with our protocol showed an unwanted higher sufentanil usage without a significant difference in patient wellbeing. (Ethics Committee EC17/28/319 of the University Hospital of Antwerp. Registration at clinicaltrials.gov NCT03248908.).

[First report in the Liege province (Belgium) of a concomitant aortic and mitral valve surgery via a minimally invasive right latero-thoracic approach]

Compared to median sternotomy, the potential benefits of minimally invasive single aortic or mitral valve surgery include reduction of blood loss, lower morbidity, and shorter intensive care unit and hospital length of stay. However, there are few reports regarding concomitant aortic and mitral valves minimally invasive surgery via mini-thoracotomy. To the authors knowledge, this is the first report in the Liege area, of a successful minimally invasive right latero-thoracic approach for aortic and mitral valve surgery in a 78-year old woman who presented severe and symptomatic aortic stenosis and mitral insufficiency. In addition to the description of the surgical approach, the authors will summarize the current literature on this approach, as well as the clinical evolution of the patient.

Laboratory analysis of two Delta SARS-CoV-2 variant outbreaks in the Port of Antwerp

INTRODUCTION

The B.1.617.2 SARS-CoV-2 or Delta variant, first detected in India, has shown a rapid global spread due to its high transmissibility and now represents more than 99% of the currently circulating variants in Europe.

METHODS AND RESULT

In May 2021, two ships that had recently arrived in the Port of Antwerp reported crew members with COVID-like symptoms. SARS-CoV-2 RNA was detected in nasopharyngeal swabs in 30 out of 45 skippers and the B.1.617.2 variant was identified via whole genome sequencing. Crew members were isolated or quarantined and repeatedly tested to assess the evolution of their SARS-CoV-2 viral load based on the cycle threshold (CT) values of the PCR reaction. Viral cultures were also taken at day 7 to detect viable virus and were compared with the subjects CT value at that moment. The shipper's clinical condition was closely observed using a digital home monitoring tool. Eleven crew members (37%) required hospitalization, with CT values of SARS-CoV-2 RNA being a good predictive factor for the hospitalization need. Furthermore, a clear correlation between CT values and positive viral culture was observed, hinting infectiousness even longer than 10 days after the intitial positive PCR test.

CONCLUSION

Our study of 2 Delta variant clusters shows that the initial CT value is a good predictor for hospitalization need and suggests that patients infected with this variant may remain infectious for a longer time period.

Localised neuropathic pain in the primary care setting: a cross-sectional study of prevalence, clinical characteristics, treatment patterns, quality of life and sleep performance

BACKGROUND

Localised Neuropathic Pain (LNP) is challenging to diagnose and manage in primary care.

OBJECTIVE

To describe clinical characteristics, treatment patterns, quality of life and sleep performance of patients with LNP and estimate its prevalence in primary care.

METHODS

Cross-sectional study in 4 European countries. Patients were identified using a screening tool for LNP. Patients completed the EQ-5D VAS score and Chronic Pain Sleep Inventory (CPSI).

RESULTS

There were 1030 LNP patients for analysis. They presented a median pain intensity of 6.0 (IQR 4.0-7.0) with a median duration of 30.9 months (IQR 12.0-75.3), despite 97% receiving pain treatment. Main sites affected were the limbs (62% upper/58% lower) and spine (41%). Main aetiologies were neuropathic low back pain (47%), post-surgical neuropathic pain (17%), and diabetic poly-neuropathy (12%). Thirty percent received a single analgesic (2% topical), while combinations comprised 43% systemic-systemic, 24% topical-systemic, 1% topical-topical. Medications included NSAIDs (45%), anticonvulsants (38%), WHO step 2 opioids (35%), and topical analgesics (27%). In the previous 6 months, 40% had switched treatment. The mean (SD) EQ-5D VAS score was 58 (22.3) and the mean (SD) EQ-5D summary score (UK tariff) was 0.62 (0.25). Patients had a CPSI mean index of 41/100, and sleeping pills were used by 33% of patients. The standardized prevalence of LNP by age and sex was 2.01% in the general population and 43.3% among chronic pain patients.

CONCLUSIONS

Many LNP patients reported pain intensities of six on a ten-point scale in average for durations longer than 2.5 years, with quality of life and sleep performance affected, with frequent treatment combinations and switches, suggesting suboptimal pain management.

[Acute right heart failure]

Even though, it has long been considered as a passive channel allowing communication between the systemic and pulmonary circulations, it is now clearly established that the right ventricle plays an essential role in cardio-pulmonary couple physiology. Its failure results in a clinical presentation that reflects the systemic congestion and reduced cardiac output. It is the consequence of two pathological situations frequently encountered in intensive care including pulmonary vascular resistance increase and right ventricle contraction alteration. Mechanical ventilation, certain drugs and volume overload can also participate. The management of the acute right heart failure is based on the combination of supportive treatment and causal treatment, specific to the etiology. Supportive therapy aims to optimize filling pressures, reduce afterload and support cardiac contractibility. With the growing number of therapeutic options used according to co-morbidities, decision-making by a multidisciplinary heart team seems essential.

[Heart transplantation, indications and results at the University Hospital of Liege]

Heart transplantation remains undoubtedly the most effective treatment for end-stage heart failure, whatever its cause. Last decade has witnessed significant improvements in terms of morbidity and mortality following heart transplant. The 5-year survival rate is now beyond 70 %. However, the shortage of potential donors limits its use and requires strict criteria before listing a candidate for heart transplantation. Herein, we present a review of current indications and results of the heart transplantation program at the University hospital of Liège.

Reference Correction: Preliminary Evaluation of a Web-Based Psychological Screening Tool in Adolescents Undergoing Minimally Invasive Pectus Surgery: Single-Center Observational Cohort Study

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Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

Preliminary Evaluation of a Web-Based Psychological Screening Tool in Adolescents Undergoing Minimally Invasive Pectus Surgery: Single-Center Observational Cohort Study

BACKGROUND

Preoperative anxiety and depression are predominant risk factors for increased postoperative pain. Thoracic wall deformities in adolescents often cause low self-esteem, which contributes to psychological concerns. Several studies have suggested a relationship between preoperative mental health support and enhanced recovery after surgery.

OBJECTIVE

This study investigated the validity of screening questionnaires concerning psychological trait and state characteristics via a patient-specific online platform.

METHODS

Patients scheduled for elective pectus surgery between June 2017 and August 2017 were invited to participate in clinical interviews and online self-report questionnaires. All patients were recruited in the Anesthesiology Department, Antwerp University Hospital, Belgium. This single-center observational cohort study was performed in accordance with the ethical standards of the International Council for Harmonisation-Good Clinical Practice guidelines and the Declaration of Helsinki after obtaining study approval by the Institutional Review Board and Ethics Committee of the Antwerp University Hospital, Belgium (study identifier: 17/08/082). An online preoperative psychological inventory was performed using the Rosenberg Self-Esteem Scale, Hospital Anxiety and Depression Scale, and State-Trait Anxiety Inventory. Postoperatively, pain intensity and interference were assessed using the Multidisciplinary Pain Inventory, Coping With Pain Questionnaire, and numeric pain rating scale assessment. Patient satisfaction of the Web-based platform was evaluated.

RESULTS

A total of 21 adolescent patients used our Web-based psychological perioperative screening platform. Patients rated the mobile phone app, usability, and accessibility of the digital platform as good or excellent in 85% (17/20), 89% (17/19), and 95% (20/21) of the cases, respectively. A total of 89% (17/19) of the patients rated the effort of generating answers to the online questionnaires as low. The results from the completed questionnaires indicated a strong negative correlation between self-esteem and the anxiety trait (R=-0.72, P<.001) and overall anxiety characteristics (R=-0.49, P=.04). There was a positive correlation between depressive and anxiety characteristics and the anxiety trait (R=0.52, P=.03 and R=0.6, P=.02, respectively) measured by the online self-report questionnaires. Moreover, preoperative anxiety was positively correlated with postoperative pain interference (R=0.58, P=.02). Finally, there was a negative correlation between self-esteem and pain interference (R=-0.62, P=.01). Conclusions: Perioperative screening of psychological symptoms and trait characteristics with specific treatment, if necessary, could further improve postoperative pain and overall health status. Research on eHealth technology, even for psychological patient care, is rapidly increasing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03100669; https://clinicaltrials.gov/ct2/show/NCT03100669 (Archived by WebCite at http://www.webcitation.org/6zPvHDhU5).

Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults

BACKGROUND

In response to noxious stimulation, pupillary dilation reflex (PDR) occurs even in anaesthetized patients. The aim of the study was to evaluate the ability of pupillometry with an automated increasing stimulus intensity to monitor intraoperative opioid administration.

METHODS

Thirty-four patients undergoing elective surgery were enrolled. Induction by propofol anaesthesia was increased progressively until the sedation depth criteria (SeD) were attained. Subsequently, a first dynamic pupil measurement was performed by applying standardized nociceptive stimulation (SNS). A second PDR evaluation was performed when remifentanil reached a target effect-site concentration. Automated infrared pupillometry was used to determine PDR during nociceptive stimulations generating a unique pupillary pain index (PPI). Vital signs were measured.

RESULTS

After opioid administration, anaesthetized patients required a higher stimulation intensity (57.43 mA vs 32.29 mA, P < .0005). Pupil variation in response to the nociceptive stimulations was significantly reduced after opioid administration (8 mm vs 28 mm, P < .0005). The PPI score decreased after analgesic treatment (8 vs 2, P < .0005), corresponding to a 30% decrease. The elicitation of PDR by nociceptive stimulation was performed without changes in vital signs before (HR 76 vs 74/min, P = .09; SBP 123 vs 113 mm Hg, P = .001) and after opioid administration (HR 63 vs 62/min, P = .4; SBP 98.66 vs 93.77 mm Hg, P = .032).

CONCLUSIONS

During propofol anaesthesia, pupillometry with the possibility of low-intensity standardized noxious stimulation via PPI protocol can be used for PDR assessment in response to remifentanil administration.

Pupillary dilation reflex and pupillary pain index evaluation during general anaesthesia: a pilot study

Background

Pupillary response by pupillary dilatation reflex (PDR) is a robust reflex, even measurable during general anaesthesia. However, the ability of infrared pupillometry to detect PDR differences obtained by intraoperative opioid administration in anaesthesized patients remains largely unknown. We analyzed the performance of automated infrared pupillometry in detecting differences in pupillary dilatation reflex response by a inbuilt standardized nociceptive stimulation program in patients under general anesthesia with a standardized propofol/fentanyl scheme.

Methods

In this single center, interventional cohort study 38 patients (24-74 years) were enrolled. Patients were anesthetized with propofol until loss of consciousness. Two dynamic pupil measurements were performed in each patient (before opioid administration and after opioid steady state). Automated infrared pupillometry was used to determine PDR during nociceptive stimulations (10-60 mA) applied by a inbuilt pupillary pain index protocol (PPI) to the skin area innervated by the median nerve. Increasing stimulations by protocol are device specific and automatically performed until pupil dilation of > 13%. Pupil characteristics, blood pressure, heart rate values were collected.

Results

After opioid administration, patients needed a higher stimulation intensity (45.26 mA vs 30.79 mA, p = 0.00001). PPI score showed a reduction after analgesic treatment (5.21 vs 7.68, p = 0.000001), resulting in a 32.16% score reduction.

Conclusions

PDR via automated increased tetanic stimulation may reflect opioid effect under general anaesthesia. Further research is required to detect possible confounding factors such as medication interaction and optimization of individualized opioid dosage.

Influence of Morphine and Naloxone on Pain Modulation in Rheumatoid Arthritis, Chronic Fatigue Syndrome/Fibromyalgia, and Controls: A Double-Blind, Randomized, Placebo-Controlled, Cross-Over Study

BACKGROUND

Impaired pain inhibitory and enhanced pain facilitatory mechanisms are repeatedly reported in patients with central sensitization pain. However, the exact effects of frequently prescribed opioids on central pain modulation are still unknown.

METHODS

A randomized, double-blind, placebo-controlled cross-over trial was carried out. Ten chronic fatigue syndrome (CFS)/fibromyalgia (FM) patients, 11 rheumatoid arthritis (RA) patients and 20 controls were randomly allocated to the experimental (10 mg morphine or 0.2 mg/mL Naloxone) and placebo (2 mL Aqua) group. Pressure pain thresholds (PPTs) and temporal summation at the Trapezius and Quadriceps were assessed by algometry. Conditioned pain modulation (CPM) efficacy and deep tissue pain pressure were assessed by adding ischemic occlusion at the opposite upper arm.

RESULTS

Deep tissue pain pressure was lower and temporal summation higher in CFS/FM (P = 0.002 respectively P = 0.010) and RA patients (P = 0.011 respectively P = 0.047) compared to controls at baseline. Morphine had only a positive effect on PPTs in both patient groups (P time = 0.034). Accordingly, PPTs increased after placebo (P time = 0.015), and no effects on the other pain parameters were objectified. There were no significant effects of naloxone nor nocebo on PPT, deep tissue pain, temporal summation or CPM in the control group.

CONCLUSIONS

This study revealed anti-hyperalgesia effects of morphine in CFS/FM and RA patients. Nevertheless, these effects were comparable to placebo. Besides, neither morphine nor naloxone influenced deep tissue pain, temporal summation or CPM. Therefore, these results suggest that the opioid system is not dominant in (enhanced) bottom-up sensitization (temporal summation) or (impaired) endogenous pain inhibition (CPM) in patients with CFS/FM or RA.

Impact of topical 5% lidocaine-medicated plasters on sleep and quality of life in patients with postherpetic neuralgia

Aim: To determine the impact of 5% lidocaine-medicated plasters on sleep, quality of life and pain in 265 patients with postherpetic neuralgia (PHN). Patients & methods: An 8-week, open-label arm of a double-blind controlled withdrawal study. Results: Patients treated with 5% lidocaine had less trouble falling asleep, used less sleep medication, had fewer awakenings due to pain at night or in the morning and their perception of quality of life was improved. The 15 pain descriptors in the Short-Form McGill Pain Questionnaire were improved from baseline to week 8, with a decrease in the proportion of patients reporting ‘severe’ pain and an increase in the number reporting ‘none/mild’ pain. Conclusion: 5% lidocaine-medicated plasters provide benefits beyond pain relief for patients with postherpetic neuralgia.

A pharmacological treatment algorithm for localized neuropathic pain

Neuropathic pain is caused by a lesion or disease affecting the somatosensory system and is difficult to manage, often proving refractory to existing treatments. In more than half of cases, it is localized and affects a specific, clearly circumscribed area of the body (localized neuropathic pain, or LNP). A recently developed screening tool enables patients with probable neuropathic pain/LNP to be identified quickly and easily. In view of the conflicting current treatment recommendations, an advisory board of pain specialists met in June 2015 to develop a complementary treatment guidance algorithm, for use in the primary care setting and by non-pain specialists. The starting point of the algorithm is a diagnosis of LNP and there was consensus that first-line treatment should be a topical analgesic agent, because the benefit/risk ratios are far better than for systemic agents. Topical application offers site-specific delivery, a lower total systemic dose and avoidance of first-pass metabolism, reducing the risk of adverse events and drug/drug interactions. The 5% lidocaine medicated plaster has most evidence supporting its use in LNP, producing effective analgesia and reducing the associated area of allodynia, but other topical agents include capsaicin, clonidine and botulinum toxin type A. Treatment should be commenced with the topical agent of choice, and the patient re-assessed after an appropriate period. Where the response is good the topical agent is continued, with a re-evaluation after 3-6 months. A systemic agent (e.g. gabapentin, pregabalin, duloxetine, venlafaxine) is added if there is only a partial response, or substituted if there is no response, and the patient re-assessed after a month. If there is poor or no response to the systemic agent the patient should be switched to an alternative one and, if this also proves ineffective, referred to a pain specialist.

Two different techniques of facial mask induction of anesthesia in children provide identical intubation conditions despite different anesthetic depth

BACKGROUND

Sevoflurane induction in chil- dren is performed using different techniques. Constricted, centered, and symmetrical pupils (CCSP) are classically the endpoint to be achieved before laryngoscopy is performed.

OBJECTIVES

We investigated whether two different inhalation induction techniques with the same clinical end- point provided similar intubating conditions and comparable depth of anesthesia as assessed by the Bispectral Index (BIS).

METHODS

Following IRB approval, and informed parental consent, 20 children were recruited. They were sched- uled for general anesthesia with tracheal intubation, and randomly assigned to Group 1, where the practitioner used 6% inspired sevoflurane in 50% 0₂/N₂0, and no manually assisted ventilation, or Group 2, where inspired sevoflurane was 8% in 50% 0₂/N₂0, and ventilation was manually supported upon loss of consciousness. BIS values were blinded. Laryngoscopy was performed after CCSP. Intubation conditions scoring was based on jaw relaxation (mobile = 1, partially mobile = 2, fixed = 3), position of vocal cords (open = 1, half-closed = 2, closed = 3), and cough (no cough = 1, 1 or 2 coughing efforts = 2, persistent coughing = 3). A total score > 3 corresponded to non-optimal conditions.

RESULTS

Upon CCSP, BIS values were significantly lower in Group 1 [mean (SD) : 30 (8) - 48 (18), p <0.001], despite significantly higher end-tidal sevoflurane concentration in Group 2 [mean (SD) : 5.0 (0.7) - 6.2 (0.5) ; p <0.001]. Time to CCSP was slightly shorter in Group 2. Intubation conditions were always optimal except for one patient of Group 1.

DISCUSSION

Both induction techniques achieve good intubating conditions. Possible explanations for the between-group BIS difference include variable appreciation of the CCSP endpoint, different induction lengths or sevoflurane equilibration times, or sevoflurane-induced increase in electroencephalogram power. A better indicator of the best time to intubate is needed to avoid too deep anesthesia in children.

Is an easy and reliable diagnosis of localized neuropathic pain (LNP) possible in general practice? Development of a screening tool based on IASP criteria

BACKGROUND AND OBJECTIVE

Neuropathic pain (NP) is a common type of chronic pain in which 60% of patients present with localized symptoms. Early diagnosis of NP is often a challenge in primary care. Moreover, so far no standard diagnostic procedure for localized NP (LNP) is available. To help general practitioners, a screening tool was developed and evaluated.

RESEARCH DESIGN AND METHODS

The development of the screening tool was based on the grading system principles for NP proposed by the IASP, focusing on medical history and distribution of painful symptoms and sensory signs. It was tested by 31 general practitioners and evaluated against the NP diagnosis of three pain specialists as reference in a single center prospective study in Spain using a cohort study design including an adult population of chronic pain patients. This design avoids spectrum bias where the spectrum of disease is not correctly reflected in the study population.

MAIN OUTCOME MEASURES

General practitioners rated usefulness, simplicity, and time requirements of the tool. Diagnostic accuracy was expressed by sensitivity, specificity, and positive and negative predictive values.

RESULTS

General practitioners consecutively screened 2079 chronic pain patients (mean age 60.7 ± 11.1 years, 69.9% female). Using the tool, 394 patients were diagnosed with LNP. Screening including sensory examination took 7 min (median). General practitioners rated the tool as useful (24/31; 77.4%) or very useful (7/31; 22.6%) for diagnosing LNP and facilitating clinical practice (30/31; 96.8%). Under daily practice conditions, sensitivity and specificity of the tool for detecting LNP was 46.7% and 86.6%, respectively.

CONCLUSIONS

The proposed screening tool was shown to be easy and useful for detecting NP and LNP in chronic pain patients as a fast first assessment tool in primary care, thus facilitating the choice of a topical treatment. LIMITATIONS AND STRENGTHS: The drop-out rate was high but was accounted for by using correction factors in the diagnostic accuracy calculations. A strength is the unselected chronic patient population: spectrum of disease correctly reflects day-to-day clinical practice and is not biased. Diagnostic accuracy of the tool therefore appears to be realistic.

Belgian consensus on chronic pancreatitis in adults and children: statements on diagnosis and nutritional, medical, and surgical treatment

Chronic pancreatitis (CP) is an inflammatory disorder characterized by inflammation and fibrosis, resulting in a progressive and irreversible destruction of exocrine and endocrine pancreatic tissue. Clinicians should attempt to classify patients into one of the six etiologic groups according to the TIGARO classification system. MRI/MRCP, if possible with secretin enhancement, is considered the imaging modality of choice for the diagnosis of early-stage disease.In CP, pain is the most disabling symptom, with a significant impact on quality of life. Pain should be assessed using the Izbicki score and preferably treated using the "pain ladder" approach. In painful CP, endoscopic therapy (ET) can be considered as early as possible. This procedure can be combined with extracorporeal shock-wave lithotripsy (ESWL) in the presence of large (> 4 mm), obstructive stone(s) in the pancreatic head, and with ductal stenting in the presence of a single main pancreatic duct (MPD) stricture in the pancreatic head with a markedly dilated MPD. Pancreatic stenting should be pursued for at least 12 months in patients with persistent pain relief. On-demand stent exchange should be the preferred strategy. The simultaneous placement of multiple, side-by-side, pancreatic stents can be recommended in patients with MPD strictures persisting after 12 months of single plastic stenting. We recommend surgery in the following cases: a) technical failure of ET ; b) early (6 to 8 weeks) clinical failure ; c) definitive biliary drainage at a later time point; d) pancreatic ductal drainage when repetitive ET is considered unsuitable for young patients; e) resection of an inflammatory pancreatic head when pancreatic cancer cannot be ruled out; f) duodenal obstruction. Duodenopancreatectomy or oncological distal pancreatectomy should be considered for patients with suspected malignancy. Pediatricians should be aware of and systematically search for CP in the differential diagnosis of chronic abdominal pain. As malnutrition is highly prevalent in CP patients, patients at nutritional risk should be identified in order to allow for dietary counseling and nutritional intervention using oral supplements. Patients should follow a healthy balanced diet taken in small meals and snacks, with normal fat content. Enzyme replacement therapy is beneficial to symptomatic patients, but also in cases of subclinical insufficiency. Regular follow-up should be considered in CP patients, primarily to detect subclinical maldigestion and the development of pancreatogenic diabetes. Screening for pancreatic cancer is not recommended in CP patients, except in those with the hereditary form.

Endogenous pain modulation in response to exercise in patients with rheumatoid arthritis, patients with chronic fatigue syndrome and comorbid fibromyalgia, and healthy controls: a double-blind randomized controlled trial

OBJECTIVE

Temporal summation (TS) of pain, conditioned pain modulation (CPM), and exercise-induced analgesia (EIA) are often investigated in chronic pain populations as an indicator for enhanced pain facilitation and impaired endogenous pain inhibition, respectively, but interactions are not yet clear both in healthy controls and in chronic pain patients. Therefore, the present double-blind randomized placebo-controlled study evaluates pains cores, TS, and CPM in response to exercise in healthy controls, patients with chronic fatigue syndrome and comorbid fibromyalgia (CFS/FM), and patients with rheumatoid arthritis (RA), both under placebo and paracetamol condition.

METHODS

Fifty-three female volunteers - of which 19 patients with CFS/FM, 16 patients with RA, and 18 healthy controls - underwent a submaximal exercise test on a bicycle ergometer on 2 different occasions (paracetamol vs. placebo), with an interval of 7 days. Before and after exercise, participants rated pain intensity during TS and CPM.

RESULTS

Patients with rheumatoid arthritis showed decreased TS after exercise, both after paracetamol and placebo (P < 0.05). In patients with CFS/FM, results were less univocal. A nonsignificant decrease in TS was only observed after taking paracetamol. CPM responses to exercise are inconclusive, but seem to worsen after exercise. No adverse effects were seen.

CONCLUSION

This study evaluates pain scores, TS, and CPM in response to submaximal exercise in 2 different chronic pain populations and healthy controls. In patients with RA, exercise had positive effects on TS, suggesting normal EIA. In patients with CFS/FM, these positive effects were only observed after paracetamol and results were inconsistent.

[Narcolepsy-cataplexy today]

Diagnostic criteria and pathophysiology of narcolepsy-cataplexy have evolved considerably over the last 10 years. The main cause, already mentioned in a previous paper, in the Revue Médicale de Liège (65), in 2002, is based, in human beings, on a destruction of specific cells located in the lateral and posterior part of the hypothalamus (the perifornical nuclei, containing some 70,000 neurons), producing peptides which stimulate the central nervous system; they are called hypocretins or orexins. The role of autoimmunity in their disappearance becomes more evident. The treatment is simplified, but remains symptomatic. It is mainly based on Sodium Oxybate or Gamma-Hydroxybutyrate, syrup, prescribed for the night. The authors report on their own experience in this regard and on future therapeutics more targeted towards the cause of the disease.

Does acetaminophen activate endogenous pain inhibition in chronic fatigue syndrome/fibromyalgia and rheumatoid arthritis? A double-blind randomized controlled cross-over trial

BACKGROUND

Although enhanced temporal summation (TS) and conditioned pain modulation (CPM), as characteristic for central sensitization, has been proved to be impaired in different chronic pain populations, the exact nature is still unknown.

OBJECTIVES

We examined differences in TS and CPM in 2 chronic pain populations, patients with both chronic fatigue syndrome (CFS) and comorbid fibromyalgia (FM) and patients with rheumatoid arthritis (RA), and in sedentary, healthy controls, and evaluated whether activation of serotonergic descending pathways by acetaminophen improves central pain processing.

STUDY DESIGN

Double-blind randomized controlled trial with cross-over design.

METHODS

Fifty-three women (19 CFS/FM patients, 16 RA patients, and 18 healthy women) were randomly allocated to the experimental group (1 g acetaminophen) or the placebo group (1 g dextrose). Participants underwent an assessment of endogenous pain inhibition, consisting of an evaluation of temporal summation with and without conditioned pain modulation (CPM). Seven days later groups were crossed-over. Patients and assessors were blinded for the allocation.

RESULTS

After intake of acetaminophen, pain thresholds increased slightly in CFS/FM patients, and decreased in the RA and the control group. Temporal summation was reduced in the 3 groups and CPM at the shoulder was better overall, however only statistically significant for the RA group. Healthy controls showed improved CPM for both finger and shoulder after acetaminophen, although not significant.

LIMITATIONS

The influence of acetaminophen on pain processing is inconsistent, especially in the patient groups examined.

CONCLUSION

This is the first study comparing the influence of acetaminophen on central pain processing in healthy controls and patients with CFS/FM and RA. It seems that CFS/FM patients present more central pain processing abnormalities than RA patients, and that acetaminophen may have a limited positive effect on central pain inhibition, but other contributors have to be identified and evaluated.

Safety and efficacy outcomes of long-term treatment up to 4 years with 5% lidocaine medicated plaster in patients with post-herpetic neuralgia

OBJECTIVE

Prospective evaluation of the long-term efficacy and safety of the 5% lidocaine medicated plaster in patients with post-herpetic neuralgia (PHN).

RESEARCH DESIGN AND METHODS

Patients with persisting pain for ≥3 months after acute herpes zoster and a baseline pain intensity of at least 4 on an 11-point numerical rating scale (NRS 0-10) were treated with 5% lidocaine medicated plasters for up to 5 years and monitored in regular intervals. Efficacy parameters are presented for the first 4 years and include patients' recall of pain relief (6-point verbal rating scale (VRS), clinical global impression of change (CGIC), patients' global impression of change PGIC), and the global evaluations of study medication. Safety parameters (clinical examination, skin evaluation, laboratory) and adverse events (AEs) were assessed at regular visits.

CLINICAL TRIAL REGISTRATION

KF10004/02.

RESULTS

A total of 102 patients continuing from a 1 year main study period were included in an extension phase of up to 3 years. Ten patients (9.8%) dropped out due to lack of efficacy and 9 patients (8.8%) due to treatment-related AEs; 56 patients (54.9%) left the study for non-treatment-related reasons. Twenty-seven patients (26.4%) were still under treatment after a total treatment period of 4 years. On average, a pain relief of at least 4.3 (between moderate and a lot) was achieved throughout the study. At all visits the CGIC and the PGIC were much or very much improved in about 80% of patients. At the final visit, study medication was rated at least to be good by 91% of physicians and 89% of patients. Drug-related adverse events (DRAEs) were reported in 19 of 102 patients, mainly mild to moderate localized skin reactions. There were no hints for a reduced analgesic effect or an increase of DRAEs with long-term treatment.

CONCLUSIONS

This study demonstrates that long-term treatment of ≥12 months with the 5% lidocaine medicated plaster is effective and well tolerated in PHN patients. These findings support the recommendations to use the 5% lidocaine medicated plaster as baseline therapy for localized neuropathic pain after herpes zoster infection (PHN).

In the mind or in the brain? Scientific evidence for central sensitisation in chronic fatigue syndrome

BACKGROUND

Central sensitisation entails several top-down and bottom-up mechanisms, all contributing to the hyperresponsiveness of the central nervous system to a variety of inputs. In the late nineties, it was first hypothesised that chronic fatigue syndrome (CFS) is characterised by hypersensitivity of the central nervous system (i.e. central sensitisation). Since then, several studies have examined central sensitisation in patients with CFS. This study provides an overview of such studies.

MATERIALS AND METHODS

Narrative review.

RESULTS

Various studies showed generalised hyperalgesia in CFS for a variety of sensory stimuli, including electrical stimulation, mechanical pressure, heat and histamine. Various tissues are affected by generalised hyperalgesia: the skin, muscle tissue and the lungs. Generalised hyperalgesia in CFS is augmented, rather than decreased, following various types of stressors like exercise and noxious heat pain. Endogenous inhibition is not activated in response to exercise and activation of diffuse noxious inhibitory controls following noxious heat application to the skin is delayed.

CONCLUSIONS

The observation of central sensitisation in CFS is in line with our current understanding of CFS. The presence of central sensitisation in CFS corroborates with the presence of several psychological influences on the illness, the presence of infectious agents and immune dysfunctions and the dysfunctional hypothalamus-pituitary-adrenal axis as seen in these severely debilitated patients.

What is localized neuropathic pain? A first proposal to characterize and define a widely used term

SUMMARY According to several guidelines, topical agents should be considered for the pharmacological management of localized neuropathic pain. As a definition for the term ‘localized neuropathic pain’ that might facilitate easier identification of patients who are putatively responsive to topical treatments could not be found in the literature, six pain specialists met in 2010 to address this challenging issue. The following nucleus of a definition that is based on the International Association for the Study of Pain (IASP) definition of neuropathic pain, is the most detailed that can currently be proposed: ‘Localized neuropathic pain is a type of neuropathic pain that is characterized by consistent and circumscribed area(s) of maximum pain’. An extended version of this core definition and the difficulties in covering all aspects of localized neuropathic pain are presented, and discussions within the scientific community are encouraged to develop a definition that might help to identify patients who could benefit most from topical treatment.

Serotonergic descending inhibition in chronic pain: design, preliminary results and early cessation of a randomized controlled trial

AIM

We examined whether activation of serotonergic descending pathways improves pain inhibition during exercise in patients with chronic fatigue syndrome (CFS) and comorbid fibromyalgia (FM) in comparison with rheumatoid arthritis (RA) and sedentary, healthy controls in a double-blind randomized controlled trial with cross-over design.

PATIENTS AND METHODS

Three female CFS/FM patients, one female RA patient and two healthy women were randomly allocated to the experimental group (2 ml of citalopram intravenously) or the placebo group (2 ml of 0.9% NaCl intravenously). Participants performed a submaximal exercise protocol, preceded and followed by an assessment of endogenous pain inhibition. Seven days later, groups were crossed over.

RESULTS

Significant side-effects were observed in all, but one participant immediately after intravenous administration of citalopram. One CFS/FM patient withdrew because of severe post-exertional malaise.

CONCLUSION

It was decided that proceeding with the study would be unethical. No conclusion could be made regarding pain inhibition during exercise in CFS/FM compared to RA and controls.

Outcome predictors for treatment success with 5% lidocaine medicated plaster in low back pain with neuropathic components and neuropathic pain after surgical and nonsurgical trauma

Five percent lidocaine medicated plaster has been proven efficacious for the symptomatic relief of neuropathic pain in diverse pain conditions which might be attributed to a common localized symptomatology in these indications, possibly with common predictors of treatment success. To discuss potential symptoms and other factors predicting response to treatment with lidocaine plaster for the indications of low back pain with neuropathic components and neuropathic pain after surgical and nonsurgical trauma, 44 pain specialists from 17 countries attended a two-day conference meeting in December 2009. Discussions were based on the retrospective analysis of case reports (sent in by participants in the four weeks prior to the meeting) and the practical experience of the participants. The results indicate some predictors for success with 5% lidocaine medicated plaster for the two indications. Localized pain, hyperalgesia and/or allodynia, and other positive sensory symptoms, such as dysesthesia, were considered positive predictors, whereas widespread pain and negative sensory symptoms were regarded as negative predictors. Paresthesia, diagnosis, and site of pain were considered to be of no predictive value. Common symptomatology with other neurologic pathologies suggests that treatment of localized neuropathic pain symptoms with the plaster can be considered across different neuropathic pain indications.

Comparison of the surgical Pleth Index™ with haemodynamic variables to assess nociception-anti-nociception balance during general anaesthesia

BACKGROUND

The Surgical Pleth Index (SPI) is proposed as a means to assess the balance between noxious stimulation and the anti-nociceptive effects of anaesthesia. In this study, we compared SPI, mean arterial pressure (MAP), and heart rate (HR) as a means of assessing this balance.

METHODS

We studied a standard stimulus [head-holder insertion (HHI)] and varying remifentanil concentrations (CeREMI) in a group of patients undergoing neurosurgery. Patients receiving target-controlled infusions were randomly assigned to one of the three CeREMI (2, 4, or 6 ng m⁻¹), whereas propofol target was fixed at 3 µg ml⁻¹. Steady state for both targets was achieved before HHI. Intravascular volume status (IVS) was evaluated using respiratory variations in arterial pressure. Prediction probability (Pk) and ordinal regression were used to assess SPI, MAP, and HR performance at indicating CeREMI, and the influence of IVS and chronic treatment for high arterial pressure, as possible confounding factors.

RESULTS

The maximum SPI, MAP, or HR observed after HHI correctly indicated CeREMI in one of the two patients [accurate prediction rate (APR)=0.5]. When IVS and chronic treatment for high arterial pressure were taken into account, the APR was 0.6 for each individual variable and 0.8 when all of them predicted the same CeREMI. That increase in APR paralleled an increase in Pk from 0.63 to 0.89.

CONCLUSIONS

SPI, HR, and MAP are of comparable value at gauging noxious stimulation-CeREMI balance. Their interpretation is improved by taking account of IVS, treatment for chronic high arterial pressure, and concordance between their predictions.

A C-fiber-mediated neuropathic brachioradial pruritus

A 56-year-old man presented to the outpatient clinic with a 3-year history of itch within the innervation territory of C-6 of the left arm. Sudden neck movements induced intermittent paresthesias in the same dermatome. No dermatological diseases, allergies, or trauma to the affected extremity or the spine or a history of familial pruritus were reported. Neurological physical examination and electromyography revealed normal findings. Quantitative sensory testing demonstrated selective C-fiber dysfunction at C6-8 on the left, and cervical MR imaging revealed multilevel degenerative cervical spine pathology with neuroforaminal stenoses. Brachioradial neuropathic pruritus caused by cervical neuroforaminal stenosis was the final diagnosis. Treatment consisted of 2 cervical epidural steroid applications that resulted in clinical disappearance of the itch and improvement in C-fiber function on quantitative sensory testing.

Methadone-induced toxic leukoencephalopathy: MR imaging and MR proton spectroscopy findings

We report the clinical, MR imaging, and proton MR spectroscopy findings in a middle-aged woman with proved methadone-induced toxic leukoencephalopathy. The imaging characteristics of this unusual condition have been reported only rarely in the medical literature. We show that the imaging findings in methadone-induced toxic leukoencephalopathy are similar, though not identical, to previously reported cases of neurologic deterioration due to heroin inhalation.

Lidocaine 5% patch for localized neuropathic pain: progress for the patient, a new approach for the physician

Neuropathic pain (NeP) syndromes remain a difficult-to-treat medical entity. Despite a growing number of pharmacological and invasive analgesic therapies the results remain less than optimal because of insufficient analgesic efficacy and/or occurrence of pronounced side effects. Current guidelines propose the use of multimodal and balanced pharmacological therapies, focused on the underlying pathophysiological mechanisms (mechanistic approach). Lidocaine 5% patches are a new treatment option currently licensed for the treatment of postherpetic neuralgia. However, these patches can also be used for the treatment of different types of superficial NeP syndromes, such as diabetic polyneuropathy. Their therapeutic success, however, largely depends on the correct identification of appropriate patients and pain syndromes. This manuscript outlines the correct identification of patients and proper use of these patches in order to ensure as much as possible the therapeutic efficacy of this new treatment option.

Management of neuropathic pain after surgical and non-surgical trauma with lidocaine 5% patches: study of 40 consecutive cases

OBJECTIVE

To determine the efficacy of lidocaine 5% patches [Versatis, commercialised by Grünenthal GmbH, Aachen, Germany] in patients with PNCCP.

BACKGROUND

This study focuses on chronic pain states of a neuropathic nature, located at the scar or over a larger area of the skin around the scar. This post-operative/post-traumatic neuropathic chronic cutaneous pain (PNCCP) may be a side-effect of any incision of the skin in the context of a surgical procedure or a traumatic event.

RESEARCH DESIGN AND METHODS

A single-centre, open, non-randomised, prospective study was performed in a university hospital referral centre for patients with chronic neuropathic pain after surgical or non-surgical trauma. Forty consecutive patients with chronic PNCCP, a VAS score > or =5, a LANSS score > or =12, and a stable consumption of pain medication were prospectively evaluated. All patients were given lidocaine 5% patches, following a 12 h on/off schedule.

MAIN OUTCOME MEASURES

Visual analogue scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scorings were performed pretreatment (day 0), on the 28th day (4 weeks), and after 84 days (12 weeks).

RESULTS

The mean pretreatment VAS score (VAS(0)) was 7.225 +/- 1.209, and the mean pretreatment LANSS score (LANSS(0)) was 18.60 +/- 2.610. The number of patients with a VAS score <5 at the latest follow-up (VAS(84)) was 21 (52.5%). Mean VAS(84) was 4.625 +/- 1.675. Seventeen patients (42.5%) had a LANSS score <12 at the latest follow-up. Overall mean LANSS(84) was 12.85 +/- 3.093.

CONCLUSION

Lidocaine 5% patches seem to be an effective treatment of post-surgical and post-traumatic pain. These results should be supported with randomised and placebo-controlled studies with larger sample sizes and longer follow-ups.

Transdermal buprenorphine - a critical appraisal of its role in pain management

This paper reviews the current clinical data for the role of transdermal buprenorphine (BUP TDS) in the treatment of diverse acute and chronic pain syndromes. Literature searches were carried out using PubMed (1988 to June 2009). The published findings seem to support hypotheses regarding the rather unique analgesic mechanisms of buprenorphine as compared with pure μ-opioids like morphine and fentanyl. However, the exact mechanism of this analgesic efficacy still remains largely unknown despite recent advances in preclinical pharmacological studies. Such assessments have demonstrated the sustained antihyperalgesic effect of buprenorphine in diverse animal pain models. These findings are supported in a growing number of clinical studies of oral, intrathecal, intravenous, and Bup TDS. This review paper focuses almost entirely on the clinical experience concerning the transdermal administration of buprenorphine, although preclinical aspects are also addressed in order to provide a complete picture of the unique pharmacological properties of this analgesic drug. Mounting evidence indicates the appropriateness of Bup TDS in the treatment of diverse acute and chronic pain syndromes which have been less or not responsive to other opioids. Additionally, BUP TDS seems to hold great promise for other difficult-to-treat (pain) conditions, such as patients in the intensive care setting. However, its use is somewhat tempered by the occurrence of local skin reactions which have been shown to be often therapy resistant. Further studies are certainly warranted to identify even more precisely the clinical syndromes that are most sensitive to buprenorphine treatment, and to compare buprenorphine to other opioids in head-to-head trials of acute and chronic pain conditions.

Topical 5% lidocaine (lignocaine) medicated plaster treatment for post-herpetic neuralgia: results of a double-blind, placebo-controlled, multinational efficacy and safety trial

BACKGROUND AND OBJECTIVE

Post-herpetic neuralgia (PHN) is a distressing neuropathic pain condition mainly affecting elderly patients. Neuropathic pain symptoms can be of a burning, shooting and stabbing nature, and may continue for prolonged periods and are often poorly controlled by polymedication. The aim of this study was to evaluate the analgesic efficacy and safety of topical analgesic treatment (5% lidocaine [lignocaine] medicated plaster) compared with placebo plaster in patients with PHN.

METHODS

This was a double-blind, placebo plaster-controlled, parallel-group, multicentre study employing enriched enrolment with randomized withdrawal methodology. After an initial 8-week open-label, active run-in phase, responders entered a 2-week randomized, double-blind, placebo-controlled phase. The study was conducted at 33 outpatient investigational centres in 12 European countries. Patients with PHN were selected who were aged >/=50 years, had experienced neuropathic pain persisting for >/=3 months after rash healing, and had a mean pain intensity of >/=4 on an 11-point numerical rating scale. A total of 265 patients entered the open-label phase and subsequently a pre-defined number of 71 patients entered the randomized phase. Patients applied up to three 5% lidocaine medicated plasters for up to 12 hours per day. The primary endpoint of the study was time-to-exit due to a >/=2-point reduction in pain relief on two consecutive days of plaster application using a 6-point verbal rating scale.

RESULTS

Of the 265 patients entering the run-in phase, 51.7% achieved at least moderate pain relief. In the double-blind phase (full analysis set, n = 71), median times-to-exit were 13.5 (range 2-14) and 9.0 (range 1-14) days for lidocaine and placebo plaster groups, respectively (p = 0.151). For per-protocol patients (n = 34), median time-to-exit was 14.0 (range 3-14) and 6.0 (range 1-14) days for lidocaine and placebo plaster groups, respectively (p = 0.0398). Drug-related adverse events occurred in 13.6% of patients. Treatment with 5% lidocaine medicated plaster was associated with improvements in pain, allodynia, quality of life and sleep measures.

CONCLUSIONS

This study adds to a growing body of evidence that the 5% lidocaine medicated plaster can be considered a valuable treatment option for patients with PHN, providing beneficial effects on pain, allodynia, quality of life and sleep, with minimal adverse effects.