[Quality assurance in therapy of chronic pain. Results obtained by a taskforce of the German Section of the Association for the Study of Pain on psychological assessment of chronic pain. V. Instruments for the assessment of pain-related cognitions and coping with pain.]

The present paper is one of a series of publications, reviewing German instruments for psychological assessment of pain. Their main focus is on the results of a task force on quality testing for each subject. This paper describes and comments on methods regarding self-reporting of pain cognitions and both cognitive and behavioral strategies for coping with pain. Concerning pain cognitions one focus is on patients' attributions of causes of pain and the modes of controlling pain (subjective pain model). The other focus is on instruments recording "pain beliefs" in the sense of dysfunctional congitions associated with the experience of pain. Each instrument was examined with reference to approved psychometric criteria, empirical foundation and clinical relevance. It was noted that several instruments are deficient in their psychometric criteria and their empirical foundations. We used these data as a basis to elaborate a specific and differential recommendation. A similar procedure was followed with instruments for the assessment of pain-related coping strategies. According to our research there are two subgroups of coping instruments, one more specifically for cognitive coping with pain, and the other combined with behavioral coping strategies. Once again, we elaborated a specific and differential recommendation, giving priority to instruments taking account of both cognitive and behavioral dimensions of coping with pain.

[Pain perception of adolescents with chronic functional pain : adaptation and psychometric validation of the Pain Perception Scale (SES) by Geissner]

BACKGROUND

Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects.

MATERIAL AND METHODS

Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed.

RESULTS

Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high.

CONCLUSION

With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.

[Assessment and measurement of pain]

BACKGROUND

The assessment and measurement of pain is essential in the implementation and control of pain relieving strategies. The measurement of pain in infants and children should be based on the consideration of age, cognitive level, psychological status, intercurrent diseases and the social context in order to register the child's individual situation and to avoid misinterpretation.

DIAGNOSIS

In the preverbal infant, behavioral and physiological cues have to be interpreted by the caregivers. For the assessment of pain in children of four and older who have at least a basic understanding of the pain concept self assessment methods (as rating scales, specific pain interviews, diaries and questionnaires) can be used. In any case the instruments used should be age appropriate. The instruments used for the different age groups are presented with comments on quality and clinical applicability.

[Therapy of headaches in childhood and adolescence]

BACKGROUND

Headaches are one of the most common health problems of children and adolescents, afflicting between 50-90% of the pediatric population in some form sometimes during their first two decades of life. Due to changing prevalence rates, more or less complex classification systems, inconsistent therapy responses with great inter- and intraindividual variabilities and high placebo response rates, pediatric headache syndromes are frequently thought to be too difficult for the outpatient evaluation and treatment in clinical practice.

THERAPY AND PROGNOSIS

However, with the introduction of the International Headache Society classification system, the continuously expanding knowledge about the pathophysiology of different headache syndromes and the development of new symptomatic as well as causative treatment options - covering both: pharmacologic and non-pharmacologic approaches - a pragmatic diagnostic work up and the development of specific treatment schedules for pediatric headache patients is now possible.

[Quality control in the therapy of chronic pain. Results obtained by a task force of the German Section of the International Association for the Study of Pain on psychological assessment of chronic pain. XI. Assessment and multiaxial classification of pain]

This paper reviews instruments in German language for the psychological assessment and classification of pain. Usually chronic pain syndromes are classified within the International Classification of Diseases (ICD). Instead of the psychiatric chapter of the ICD, it is possible to use the Diagnostic and Statistical Manual of Mental Disorders (DSM). The proposed classification system of the International Association of the Study of Pain (IASP) is based on a multiaxial solution. The numerous ways to classify chronic pain include many problems and limits, especially in the case of an interdisciplinary assessment. They provide no specific system for classifying pain syndromes. They are impractical to handle and restrict classifying pain as either somatogenic or psychogenic. It is not possible to describe both sides in one diagnosis without loss of information. As a result of this situation, a task force of the German Chapter of the International Association for the Study of Pain developed a Multiaxial Classification of Pain (Multiaxiale Schmerzklassifikation; MASK) as an advanced system of pain assessment and an alternative to the common classification systems. MASK embraces a somatic (MASK-S) and a psychological (MASK-P) part. Both parts constitute an 'interdisciplinary diagnosis'. MASK-S enables classifying a pain syndrome using hierarchical levels, with progredient specific degrees of differentiation. In addition there are 6 axes to describe pain syndromes qualitatively and quantitatively (e.g. localization, quality). The psychosocial part (MASK-P) embraces 5 main levels (1. behavioral, 2. emotional, 3. cognitive, 4. stress-related, 5. habitual personal factors) and 2 additional levels (6. functional coherence, 7. ICD/DSM-diagnosis additional). The MASK-P part of the diagnosis is composed of graduation on these levels. Differential axis of the pain syndromes are described phenomenologically and specifically. MASK provides the possibility of establishing an integrative, interdisciplinary diagnosis.

[Quality assurance in chronic pain therapy. Results obtained by a task force of the German Chapter of the International Association for the Study of Pain on psychological Assessment of chronic Pain. Psychological instruments for the assessment of pediatric pain]

The present paper is one in a series of publications reviewing German instruments for the psychological assessment of pain. Part X deals with pain measurement of acute and chronic pain in infants and children. German assessment instruments of pediatric pain together with frequently used instruments of American origin are examined and described. The survey contains self-report and behavioral pain measures. Multidimensional pain interviews for both children and parents, diaries and rating scales, as well as observation measures especially for infants, are examined. Since the selection of pain-assessment instruments is dependent on the age and cognitive level of the children, for each instrument a minimum age limit is given. In cases in which quantitative indices of reliability, validity and objectivity are still needed, the evaluation is based on qualitative quotations.

[Quality assurance in therapy of chronic pain. Results obtained by a task force of the German Section of the Association for the Study of Pain on psychological assessment of chronic pain. IX. Multidimensional instruments for the assessment of aspects relating to pain and recommendations on standard procedures for diagnosis]

Four multidimensional inventories used as instruments for the assessment of pain are examined: "Fragebogen zur Erfassung der Schmerzverarbeitung' [Questionnaire for Assessment of Level of Coping with Pain], "Kieler Schmerzverarbeitungs-Inventar' [Kiel Inventory of Coping with Pain], "Fragebogen zur Schmerzregulation' [Questionnaire on Pain Regulation], and the German version of the "Multidimensional Pain Inventory'. None of these questionnaires assesses all domains that are important in chronic pain. The recommended standardized assessment routine for pain centres includes the use of a diary, the rating of actual, average and maximum pain intensity, the application of the PDI, a measure of disability, and the FESV, which records cognitive processing and coping. As measures of general psychological dysfunction the ADS for the assessment of depression and the B-L, a symptom checklist, are suggested as instruments suitable for routine use in diagnosis and evaluation.

[Quality assurance in therapy of chronic pain. Results obtained by a taskforce of the German Section of the Association for the Study of Pain on psychological assessment of chronic pain : VI. Instruments for the assessment of disability VII. Psychological instruments for the assessment of pain relevant aspects of social interaction and communication.]

Disability is a central aspect in the assessment of chronic pain patients. Disability questionnaires in German (developed or adapted) are examined and selected for different purposes. The "Funktionsfragebogen Hannover" and the "Pain Disability Index" are recommended for both research and clinicalapplication while the "Sickness Impact Profile" is suitable only for research purposes.Four different German questionnaires for the assessment of social interaction and communication in pain patients and their significant others are examined in part VII. There are some empirical data for three of them. Only the "Inventory of Familial Adaptability and Cohesion" has achieved a certain degree of empirical maturity. Further research and developmental activity in this area of pain assessment are urgently needed.

Esophageal carcinoma: prognostic features and comparison between blunt transhiatal dissection and transthoracic resection

Among 86 patients who underwent resection for thoracic esophageal carcinoma between 1982 and 1989, 49 were resected by a transhiatal blunt esophagectomy (THE) and 37 underwent a transthoracic-abdominal esophagectomy (TTE). The two groups were statistically comparable with respect to preoperative characteristics. Overall morbidity and respiratory complications were high for both groups (71% vs 62% and 45% vs 46%; P = NS). The rate of cardiac, renal, neurological and bleeding complications, as well as recurrent nerve injuries was similar in both groups. An anastomotic leak occurred in 39% (19/49) of THE patients and in 11% (4/37) (P < 0.05) of TTE patients. Hospital mortality was 16% (8/49) in the THE group (4 resulting from cervical anastomotic leaks, 4 from respiratory complications) and 13% (5/37) in the TTE patients (1 from myocardial infarction, 4 from respiratory failures; P = NS). Actuarial survival curves for all THE and TTE patients (5-year survival rate: 20% vs 22%) and separate analysis for N0 and N1 tumors revealed no significant difference between these two techniques. Of the different preoperative variables, only tobacco addiction, beside lymph node involvement, was an independent predictor of outcome. Respiratory complications and hospital mortality were significantly lower for the non-smokers and long term survival was significantly higher for the N0 stages.

[Anus praeter--site, care and corrective possibilities]

BASIC REMARKS

The main indication for an colostomy is a carcinoma low down in the rectum. Apart from this, tumors in any part of the bowel or neighboring organs, and complications of inflammatory disease may make a diversion of feces necessary.

POINTS DISCUSSED

A stoma should be sited at a distance from skin folds, and bony protuberance, and should be readily visible for self-care. Temporary "continence" can be achieved with special stool regulatory measures (in particular irrigation), while the patient can make to with a stoma cap or a mini-bag. Many complications of stoma, in particular necrosis, parastomal hernias, prolapse, too large a stoma, stenosis and stomal recurrent tumor can usually be eliminated by surgery.

CONCLUSIONS

Today excellent possibilities of stomal care are available for a wide range of problems, which can be determined and applied in cooperation with the various specialists.

Presence of atrial natriuretic factor prohormone in enterochromaffin cells of the human large intestine

Atrial natriuretic factor is a hormone intimately involved in water and salt homeostasis. The heart constitutes the major but not exclusive site of synthesis of this hormone. Among other functions, the gastrointestinal tract has endocrine functions, plays an important role in volume regulation of the body, and seems to be a target organ for atrial natriuretic factor. Therefore, the presence of atrial natriuretic factor was investigated in the human gut. Immunoreactive atrial natriuretic factor was found in intraoperatively obtained samples of normal human colon. Acidic extracts of human large intestine contained about 0.4 pmol/g wet wt of atrial natriuretic factor. Analysis of atrial natriuretic factor immunoreactivity by gel-filtration and reverse-phase high-performance liquid chromatography showed that about 65% of the immunoreactivity corresponded to the atrial natriuretic factor phohormone and about 35% corresponded to the C-terminal ANF99-126. Immunohistochemistry showed atrial natriuretic factor prohormone location in enterochromaffin cells of the colon mucosa. Altogether, these findings show the presence of atrial natriuretic factor prohormone in enterochromaffin cells of the human large intestine and may suggest this organ as a site of atrial natriuretic factor synthesis in humans.

[Carcinoid tumor of the stomach--aspects of surgical therapy]

Carcinoid tumors of the stomach are rare (0.4% of all malignancies of the stomach). Long-lasting hypergastrinemia, most often due to chronic atrophic gastritis, leads to hyperplasia of ECL-cells in the gastric fundic mucosa with consequent dysplasia or neoplasia. Between 1974 and 1988 four patients underwent surgical treatment after diagnosis of a gastric carcinoid tumor. One patient was treated by local excision, two by subtotal resection and one patient underwent complete gastrectomy. None of the patients had local or distant metastases or died in the follow-up period due to tumor progression. The different approaches to surgical therapy are discussed.

Ifosfamide plus etoposide combined with regional hyperthermia in patients with locally advanced sarcomas: a phase II study

From July 1986 to July 1989, 40 patients (92% pretreated) with deep-seated, advanced soft tissue sarcomas (STS, 25 patients), Ewing's sarcomas (ES, eight patients), osteosarcomas (OS, three patients) and chondrosarcomas (ChS, four patients) were treated at the University of Munich in a protocol involving regional hyperthermia (RHT) combined with ifosfamide plus etoposide. A total of 265 RHT treatments (mean, 6.6 RHT per patient) were applied including 33 pelvic, four extremity, and three abdominal sites. The mean tumor volume was 537 cc (range, 50 to 2,980 cc). For systemic chemotherapy, all patients received ifosfamide (1.5 g/m2, days 1 to 5), etoposide (100 mg/m2, days 1, 3, and 5), and mesna (300 mg/m2 x 4, days 1 to 5) with RHT given only on days 1 and 5 in repeated cycles every 4 weeks. Acute toxicity consisted primarily of pain (57%) combined with local discomfort within the annular phased array applicator (AA) of the BSD hyperthermia system (BSD Medical Corp, Salt Lake City, UT). The average maximum systemic temperature was 37.4 +/- 0.5 degrees C, and there was no indication of enhanced bone marrow toxicity due to the addition of RHT to the systemic chemotherapy. Detailed thermal mapping by invasive thermometry was performed in all patients. In 38 assessable patients, the overall objective response rate was 37%: six complete responses (CRs), four partial responses (PRs), and four favorable histologic responses (FHRs) (95% confidence limits, 22% to 54%). Complete responders are alive and disease-free at 40, 35, 23, 19, 19, and 8 months. Of patients with PR and FHR, two died from metastatic disease after 4 and 17 months and one died from other disease after 27 months. The remaining five patients are stable at 37, 25, 21, 13, and 8 months. Eleven patients showed no change (NC), and 13 patients showed local tumor progression (PD). The mean observation time for all patients was 11.6 months. The time-averaged temperatures (Ts) of all RHT treatments calculated as 20% (T20), 50% (T50), or 90% (T90) of measured tumor sites differed significantly between responders and nonresponders (T20, P = .003; T50, P = .006; and T90, P = .004; respectively). These data support activity for ifosfamide-etoposide combined with RHT in pretreated patients with advanced sarcomas.

[Development of special electron applicators for intraoperative radiotherapy at the Grosshadern Clinic]

A specialized applicator system for intraoperative radiation therapy using high energy electrons of a linear accelerator has been developed and manufactured, regarding the specific situation that there is no dedicated linear accelerator available at the surgery facility. Additionally, long lasting interruptions of the daily routine irradiations are hardly tolerable. A significant improvement of the procedure could be achieved developing applicators, which are divided into two halves. Positioning the lower part of the applicator into the patient at the operating room already, the transportation and the irradiation of the closed patient is possible. Adapted to the linear accelerator in use, a Siemens Mevatron KD having electron energies in the range from 6 to 21 MeV, the dosimetric properties of the system have been optimized by iteration. Excess dose values near the applicator walls could be avoided completely. A rapid decrease of the leakage dose could be realized.

[Blunt injuries of the gastrointestinal tract]

This study represents our experience with severe blunt gastrointestinal injury in 29 polytrauma and 3 solitary trauma patients. The primary diagnosis was missed in intestinal perforation (4x) and mesenteric disrupture (1x). In 2 other patients contusion of the gastrointestinal wall led to postprimary perforation. The average mortality was 21.8%; only 2 patients died from abdominal sepsis. Blunt gastrointestinal trauma differs from penetrating injury as far as the diagnostic and therapeutic aspects are concerned. In some cases, explorative laparotomy alone leads to early diagnosis. For sufficient management, the blunt contusion/compression aspects must be taken into account.

[Intraoperative electron irradiation of malignant pancreatic tumors--initial experiences at Grosshadern]

15 patients with locally unresectable pancreatic carcinomas were treated by IORT and bypass surgery. 13 patients without distant metastases were additionally treated by external beam irradiation. Although only one patient had a local failure, the median survival was only eight months. Severe complications were seen in eight patients, gastrointestinal bleeding occurred in six patients and was the cause of death in three patients. The stop of weight loss and the impressive pain relief within ten days after IORT demonstrate the significance of this treatment modality with respect to palliative effects.

[Radioimmunoscintigraphy with monoclonal antibodies]

Radioimmunoscintigraphy is presented as a new imaging modality in nuclear medicine, using specific antigen-antibody interactions. Monoclonal antibodies to tumor-associated antigens facilitate the characterization of molecular differences between tumors and normal cells. Labelled with gamma-emitting radioisotopes like I-131, I-123, In-111, and Tc99M, these antibodies can be used for in-vivo imaging. Radioimmunoscintigraphy does not compete with morphological modalities like CT and ultrasound, but provides additional information based on its functional principle. Hidden lesions may be detected. Target-to-background ratios, however, are still rather low hampering scintigraphic imaging. The use of Single Photon Emissions Computed Tomography (SPECT) in addition to planar scintigraphy resolves background activities thus providing better visualization and localization of tumors, and increasing sensitivity. The high cost of these time-consuming studies is still a limiting factor to its wider use. Its preliminary indication is founded on the suspicion of tumor progression, based on clinical findings and/or increasing serum tumor markers (CEA, CA 19-9, CA 12-5). This paper provides an overview over possible applications of radioimmunoscintigraphy. Its clinical use is demonstrated by studies of malignant melanoma, colorectal cancer and ovarian cancer.

[Primary and secondary chylopericardium]

Primary chylopericardium proved to be the (rare) cause of chronic, symptom-poor pericardial effusion in a 19-year-old man. Echocardiography and pericardiocentesis provided a firm diagnosis. Lymphography demonstrated extravasation into the mediastinum but no direct connection into the pericardial sac. Ligation of the thoracic duct at diaphragmatic level and pericardiostomy achieved a cure. Secondary chylopericardium requires treatment of the underlying disease, e.g. mediastinal tumor. Chylopericardium after thoracic or cardiac operation without signs of tamponade is preferably treated conservatively by pericardiocentesis and diet.

[Results of repair and direct reconstructive procedures of the sphincter system]

Direct sphincter repair gives good surgical results. In 8 out of 10 patients operated on, incontinence was clearly improved. In 15 patients posterior repair was performed simultaneously with posterior rectosigmoidal resection because of rectal prolapse. 14 patients had been incontinent. Incontinence was improved clearly in 7 patients, remained unchanged in 4 and worsened in 3. However, the good clinical results did not correspond completely to those achieved by perfusion manometry.