Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system

OBJECTIVE

Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation.

METHODS

This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project.

RESULTS

A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor.

CONCLUSION

This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Objectively measured activity is not associated with average pain intensity 1 week after surgery: A cross-sectional study

BACKGROUND

Measures of physical activity and pain-related patient-reported outcomes are important components of patient recovery after surgery. However, little is known about their association in the early post-operative period. This study aims to increase this knowledge. Our primary objective was to determine the association between average pain intensity and activity (in steps) 1 week after surgery. Secondary objectives were the association of activity with other patient-reported outcomes, age, sex, comorbidities and body mass index.

METHODS

Data were obtained from the PROMPT sub-project of IMI-PainCare. Patients after breast and endometriosis-related surgery, sternotomy and total knee arthroplasty completed pain-related outcomes questionnaires and wore an ActiGraph activity-tracking device. We correlated steps with average pain intensity on post-operative days 6 and 7. Secondary analyses were done using correlations and t-tests.

RESULTS

In 284 cases, there was no statistically significant correlation between steps and average pain intensity. In addition, none of the 28 secondary analyses showed a statistically significant result.

CONCLUSIONS

Pain-related patient-reported outcome measures and physical activity are separate entities. Both should be measured after surgery to assess patient recovery and to identify treatment deficiencies.

SIGNIFICANCE STATEMENT

Measuring recovery is a multi-dimensional challenge. After surgery, clinicians need to be aware that neither pain intensity nor activity levels tell the whole story. Each can hint to problems and treatment requirements.

Implementation of a piritramide based patient-controlled analgesia (PCA) as a standard of care for pain control in late abortion induction: A prospective cohort study from a patient perspective

Objective

To assess whether the implementation of patient-controlled analgesia (PCA) with piritramide using an automatic pump system under routine conditions is effective to reduce pain in late abortion inductions.

Study design

Prospective observational cohort study.

Setting

Patients requiring medically indicated abortion induction from 14 weeks of pregnancy onwards between July 2019 and July 2020 at the department of Obstetrics and Prenatal Medicine of the Bonn University Hospital in Germany.

Methods

Evaluation of pain management after implementation of a PCA system compared with previous nurse-controlled tramadol-based standard under routine conditions. Patients answered a validated pain questionnaire and requirement of rescue analgesics was assessed. Pain intensity and satisfaction were measured on a ten-point numeric rating scale. Main Outcome Measure Maximal pain intensity.

Results

Forty patients were included. Patients using Piritramide-PCA complained of higher pain sores than those in the standard group (6.90 (± 2.34) vs. 4.83 (± 2.87), (p < 0.05)). In both groups the level of satisfaction with the analgesia received was comparable (8.00 (± 2.45) vs 7.67 (± 2.62), (p = 0.7)). Patients in the PCA group suffered more nausea (63.2 % vs 30 % respectively, OR 4.0, 95 % CI 1.05-15.20, p < 0.05) and expressed more the desire for more analgesic support compared to the control group (OR 5.7 (1-33.25), p = 0.05).

Conclusion

Women with abortion induction after 14 weeks of gestation suffer from relevant severe pain, which requires adequate therapy. However, addition of PCA does not seem to bring any advantage in patients undergoing this procedure.

DYRK1B regulates Hedgehog-induced microtubule acetylation

The posttranslational modification (PTM) of tubulin subunits is important for the physiological functions of the microtubule (MT) cytoskeleton. Although major advances have been made in the identification of enzymes carrying out MT-PTMs, little knowledge is available on how intercellular signaling molecules and their associated pathways regulate MT-PTM-dependent processes inside signal-receiving cells. Here we show that Hedgehog (Hh) signaling, a paradigmatic intercellular signaling system, affects the MT acetylation state in mammalian cells. Mechanistically, Hh pathway activity increases the levels of the MT-associated DYRK1B kinase, resulting in the inhibition of GSK3β through phosphorylation of Serine 9 and the subsequent suppression of HDAC6 enzyme activity. Since HDAC6 represents a major tubulin deacetylase, its inhibition increases the levels of acetylated MTs. Through the activation of DYRK1B, Hh signaling facilitates MT-dependent processes such as intracellular mitochondrial transport, mesenchymal cell polarization or directed cell migration. Taken together, we provide evidence that intercellular communication through Hh signals can regulate the MT cytoskeleton and contribute to MT-dependent processes by affecting the level of tubulin acetylation.

Epidural needle insertion : A large registry analysis

BACKGROUND

Dural puncture, paraesthesia and vascular puncture are the most common complications of epidural catheter insertion. Their association with variation in midline needle insertion depth is unknown.

OBJECTIVE

This study evaluated the risk of dural and vascular punctures and the unwanted events paraesthesia and multiple skin punctures related to midline needle insertion depth.

MATERIAL AND METHODS

A total of 14,503 epidural catheter insertions including lumbar (L1-L5; n = 5367), low thoracic (T7-T12, n = 8234) and upper thoracic (T1-T6, n = 902) insertions, were extracted from the German Network for Regional Anaesthesia registry between 2007 and 2015. The primary outcomes were compared with logistic regression and adjusted (adj) for confounders to determine the risk of complications/events. Results are presented as odds ratios (OR, [95% confidence interval]).

MAIN RESULTS

Midline insertion depth depended on body mass index, sex, and spinal level. After adjusting for confounders increased puncture depth (cm) remained an independent risk factor for vascular puncture (adjOR 1.27 [1.09-1.47], p = 0.002) and multiple skin punctures (adjOR 1.25 [1.21-1.29], p < 0.001). In contrast, dural punctures occurred at significantly shallower depths (adjOR 0.73 [0.60-0.89], p = 0.002). Paraesthesia was unrelated to insertion depth. Body mass index and sex had no influence on paraesthesia, dural and vascular punctures. Thoracic epidural insertion was associated with a lower risk of vascular puncture than at lumbar sites (adjOR 0.39 [0.18-0.84], p = 0.02).

CONCLUSION

Variation in midline insertion depth is an independent risk factor for epidural complications; however, variability precludes use of depth as a reliable guide to insertion in individual patients.

Dipyrone is the preferred nonopioid analgesic for the treatment of acute and chronic pain. A survey of clinical practice in German-speaking countries

PURPOSE

Nonopioid analgesics are frequently used for the treatment of acute and chronic pain. Dipyrone is an alternative to NSAIDs and paracetamol, however, data on the frequency of its usage by anaesthesiologists in the perioperative and chronic pain setting are lacking and its adverse reactions are a matter of debate.

METHODS

The link to a questionnaire on the use of nonopioid analgesics (NSAIDs, COX-2 inhibitors, paracetamol, dipyrone) and the safety of dipyrone in the perioperative and chronic pain setting was mailed to anaesthesiologists and pain physicians.

RESULTS

A total of 2237 responses were analysed. About 97.4% of the respondents used nonopioid analgesics for the treatment of acute pain, with 93.8% administering dipyrone, 54.0% NSAIDs, 41.8% COX-2 inhibitors and 49.2% paracetamol. Nonopioid analgesics were administered preoperatively by 22.3%, intraoperatively by 86.1% and postoperatively by 73.0% of the respondents. For chronic pain management, 76.7% of the respondents prescribed oral dipyrone in combination with other nonopioid analgesics; 19.9% used dipyrone as sole nonopioid, whereas 2.9% denied its use. Cases of dipyrone-associated agranulocytosis were observed by 3.5% of the respondents of the acute and 1.5% of the chronic pain questionnaire, respectively. The majority of respondents (acute pain: 73.0%, chronic pain 59.3%) performed no blood cell counts to monitor dipyrone therapy. Patients were rarely informed about possible adverse drug reactions.

CONCLUSIONS

Dipyrone is the preferred nonopioid analgesic in the perioperative and chronic pain setting. Although cases of agranulocytosis occur, benefits apparently outweigh the risks according to anaesthesiologists. Measures like patient information may improve safety.

SIGNIFICANCE

A survey of anaesthesiologist in German-speaking countries revealed dipyrone as preferred nonopioid analgesic for the treatment of acute and chronic pain. Benefits seem to outweigh the risks, specifically the risk of agranulocytosis. Information of medical staff and patients on adverse drug reactions and symptoms of agranulocytosis should be implemented.

Pain after orthopaedic surgery: differences in patient reported outcomes in the United States vs internationally. An observational study from the PAIN OUT dataset

BACKGROUND

A previous PAIN OUT study found that American orthopaedic-surgical patients rated 'worst pain' higher than did similar European patients. This study aims to confirm these findings in a larger, international patient sample, explore whether risk factors for greater postoperative pain exist disproportionately in the American population, and confirm the findings for one procedure.

METHODS

Surveyors collected patient reported outcomes (PROs) and perioperative pain management practices using PAIN OUT methodology. Most PROs used 11-point numerical rating scales (0=null, 10=worst possible). Risk factors included: female gender, younger age, high BMI, chronic pain, and opioid use before surgery. Initial analysis used a mixed patient cohort. A secondary analysis used only patients undergoing total knee replacement (TKR). Inference was based primarily on effect size using Cohen's d.

RESULTS

13,770 patients in 13 European and non-European countries (international ) and 564 patients from the United States (US) contributed data on the 1st postoperative day. Three of 11 PROs differed between the cohorts: 'worst pain' {US 7.5 (2.5) vs international 5.6 (2.8); d=0.66 [confidence interval (CI) 0.58-0.75]}; proportion 'receiving information about treatment options' [US 0.86 vs international 0.66; d=0.53 (CI 0.39-0.66)]; reporting adverse effects and their severity [US 0.87 vs international 0.73; d=0.52 (CI 0.38-0.66)]. Risk factors did not differ between the two cohorts. PROs and management patterns in TKR patients were similar to the mixed cohort.

CONCLUSIONS

Three PROs differed between international and US patients, with higher 'worst pain' for US patients. Neither risk factors, nor patient mix accounted for the observed differences for 'worst pain'.

CLINICAL TRIAL REGISTRATION

NCT 02083835.

Chronic intensive care-related pain: Exploratory analysis on predictors and influence on health-related quality of life

BACKGROUND

There is growing evidence for the development of chronic pain after intensive care. Nonetheless, there is only limited knowledge about factors leading to chronic intensive care-related pain (CIRP). Thus, the primary objective was the identification of predictors of CIRP. Moreover, we aimed to assess the impact of CIRP on patients' health-related quality of Life (HRQOL).

METHODS

Comprehensive information on patients' pain before ICU admission and present pain was collected longitudinally by means of the German Pain Questionnaire 6 and 12 months after ICU discharge (ICU_DC ). In addition, a subsample of patients underwent Quantitative Sensory Testing (QST). We used Generalized Estimating Equations to identify predictors of CIRP with logistic regression models.

RESULTS

In total, 204 patients (197/159 at 6/12 months after ICU_DC ) were available for the analyses. In the multivariate models, moderate to severe average pain in the 4 weeks after ICU_DC , lower age, female sex, increased inflammation and chronic pain conditions and increased levels of anxiety before ICU admission were predictive for CIRP. In addition, small fibre deficits and lower disease severity were associated with CIRP in the QST subsample (81 patients, 77/55 at 6/12 months after ICU_DC ). Patients with CIRP reported significantly lower HRQOL than patients without CIRP.

CONCLUSIONS

Chronic intensive care-related pain is associated with specific decrements in HRQOL. Knowledge about the identified predictors is of clinical and scientific importance and might help to reduce the incidence of CIRP.

SIGNIFICANCE

Chronic intensive care-related pain is associated with specific decrements in health-related quality of life. While most of the identified predictors for CIRP can only be considered as risk factors, especially adequate (post-) acute pain management should be studied as preventive strategy.

[Postoperative pain therapy in Germany. Status quo]

A great deal of progress has been made in the field of postoperative pain therapy in the last 20 years. Beginning from clinical trials on the effectiveness of individual procedures, such as epidural anesthesia and patient-controlled analgesia, a wide range of healthcare services research as well as basic research with human and animal experiments has been established. Whereas health services research in the 1980s and 1990s focused more on the implementation of acute pain services, outcome-oriented research approaches are nowadays the center of attention. Acute pain registries and pain certification projects initiated in Germany have to be mentioned particularly in this respect. Basic research papers from recent years increasingly address specific aspects of acute postoperative pain and have provided translational approaches that are applied around the world for studying neurobiological mechanisms of postoperative pain. At the same time, interdisciplinary cooperation in research projects has led to a better understanding of complex correlations regarding predictors and mechanisms (including psychosocial aspects) of acute and in recent times also chronic pain after surgery. In parallel, evidence-based medicine has found its way into acute pain medicine in Germany. In 2007, clinical acute pain therapy in Germany was enhanced by S3 level guidelines for the first time; however, the implementation is still incomplete. In future, questions concerning mechanism-based therapy of acute pain need to be equally in the center of attention of research, such as prevention of persisting pain after surgery and acute pain of different origins.

Perceived cognitive impairments after critical illness: a longitudinal study in survivors and family member controls

BACKGROUND

Many former intensive care unit (ICU) patients report difficulties in cognitive functions especially in their daily life. We aimed to measure perceived cognitive impairments in daily life in survivors of critical illness and their family member controls (FMC).

METHODS

Perceived cognitive impairments were assessed two times after ICU discharge using an adapted German version of the "Functional Assessment of Cancer Therapy - Cognitive Function" questionnaire. After 3 months, 127 former patients and 52 FMC participated and 103/127 patients and 36/52 FMC were followed up after 6 months. Baseline information was obtained retrospectively.

RESULTS

We found no significant differences between the patient sample and FMC, 3 and 6 months after ICU discharge. Based on questionnaire ratings, cluster analysis divided patients and FMC into a cognitively 'impaired' and a 'non-impaired' cluster. Questionnaire scales differed significantly prior to ICU admission as well as 3 and 6 months after ICU discharge between both clusters. While differences between patients and FMC were less pronounced in the 'non-impaired' cluster, patients were significantly more impaired than FMC at 3 and 6 months after ICU discharge in the 'impaired' cluster.

DISCUSSION

A substantial part of former patients were affected by post-ICU cognitive impairment in daily life. Pre-existing cognitive impairments were a risk factor. These patients would probably profit from tailored neurorehabilitative therapy. Therefore, an efficient tool to identify potential patients for neurorehabilitation is needed. The questionnaire revealed good psychometric properties. We recommend a comprehensive validation of the questionnaire in this patient population.

Tunnelling of thoracic epidural catheters is associated with fewer catheter-related infections: a retrospective registry analysis

BACKGROUND

Catheter-related infections are a serious complication of continuous thoracic epidural analgesia. Tunnelling catheters subcutaneously may reduce infection risk. We thus tested the hypothesis that tunnelling of thoracic epidural catheters is associated with a lower risk of catheter-related infections.

METHODS

Twenty-two thousand, four hundred and eleven surgical patients with continuous thoracic epidural analgesia included in the German Network for Regional Anaesthesia registry between 2007 and 2014 were grouped by whether their catheters were tunnelled (n=12 870) or not (n=9541). Catheter-related infections in each group were compared with Student's unpaired t and χ(2) tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic regression, adjusting for potential confounding factors, including age, ASA physical status score, use of catheter for ≥4 days, multiple skin puncture, hospital, and surgical department.

RESULTS

There were fewer catheter-related infections in patients with tunnelled catheters (4.5 vs 5.5%, P<0.001). Mild infections were also less common (4.0 vs 4.6%, P=0.009), as were moderate infections (0.4 vs 0.8%, P<0.001). After adjustment for potential confounding factors, tunnelling remained an independent prevention for any grade of infection (adjusted OR 0.51, 95% CI 0.42-0.61, P<0.001) and for mild infections (adjusted OR 0.54, 95% CI 0.43-0.66, P<0.001) and moderate and severe infections (adjusted OR 0.44, 95% CI 0.28-0.70, P=0.001).

CONCLUSION

Tunnelling was associated with a lower risk of thoracic epidural catheter-related infections.

Effects of N-, P/Q- and L-type Calcium Channel Blockers on Nociceptive Neurones of the Trigeminal Nucleus with Input from the Dura

In anaesthetized rats, extracellular recordings were made from neurones of the spinal trigeminal nucleus, involved in the processing of nociceptive input from the dura. Blockers of voltage-gated calcium channels (VGCCs) were administered topically to the exposed brainstem. Blockade of N-type (CaV2.2) channels reduced spontaneous activity and responses of the neurones to cold and chemical stimuli applied to the dura, suggesting that N-type channels regulate excitatory synaptic activation. Blockade of L-type (CaV1) channels enhanced spontaneous discharges of the neurones. Blockade of P/Q-type (CaV2.1) channels slightly decreased responses to chemical and cold stimuli but markedly increased spontaneous activity, an effect which was absent during concomitant application of GABA to the brainstem. The data suggest that P/Q-type VGCCs regulate a tonic synaptic inhibitory control of the brainstem neurones. The risk of migraine by genetic modifications of P/Q-type channels may thus be sought in disturbed inhibition in the network that processes nociceptive dura input.

[QUIPSambulant. An instrument for quality assurance in acute pain therapy after outpatient operations]

BACKGROUND AND OBJECTIVES

Up until recently no tool for quality assurance (QA) of outpatient pain therapy after outpatient surgery, which currently constitutes one third of all operations, was available with benchmarking capacity. The QUIPS (German abbreviation for quality assurance in postoperative pain therapy) questionnaire, that had primarily been developed and established for inpatient postoperative pain therapy, was to be optimized to not only incorporate the issues with regard to outpatient operations but also a revision for use in the clinical routine.

MATERIAL AND METHODS

An interdisciplinary task force reviewed and optimized the QUIPS questionnaire. The optimized questionnaire was then used within the scope of outpatient surgery in their clinics. A total of 121 patients and 12 surgeons received a questionnaire on the first postoperative day containing questions on acceptance and understandability of the QUIPS patient outcome questionnaire.

RESULTS

Of the patients 12 (9.9 %) did not understand the original question on special pain therapy procedures stated during the preoperative counseling. For 15 patients (12.4 %) the original questions on chronic or pre-existing pain were misleading and 4 out of the 12 surgeons (33 %) did not conclusively understand these questions. The optimized questionnaire modified the questions in the preoperative counseling in the segment of postoperative pain as follows: question E1 was changed to a yes/no answer. Question E13 was modified to "how content were you with respect to your post-operative pain therapy?" Question E14 was modified to "did you suffer from other pain prior to the operation, hence pain that continued in addition to the postoperative pain?" These changes improved the understandability of the QUIPS patient outcome questionnaire. Surgeons required on average 9.7 min (SD ±3.2 min) to complete the QUIPS documentation sheets and 83 % of the surgeons rated the optimized QUIPS module as usable in the daily routine. The new module QUIPSambulant will soon be available for download on the QUIPS internet website.

DISCUSSION

By reducing items on the QUIPS documentation sheets with respect to items relevant for outpatient surgery and redesigning three questions in the patient outcome questionnaire, a new QUIPS module for the QA of postoperative pain in an ambulatory setting is now available for both patients and surgeons. The necessity for quality management (QM) with regard to postoperative pain therapy after outpatient surgery can be considered assured. To what extent the newly adapted QM tool QUIPSambulant will be deemed suitable in a routine hospital setting remains to be seen and requires ongoing investigation.

The inverse agonist DG172 triggers a PPARβ/δ-independent myeloid lineage shift and promotes GM-CSF/IL-4-induced dendritic cell differentiation

The stilbene derivative (Z)-2-(2-bromophenyl)-3-{[4-(1-methylpiperazine)amino]phenyl}acrylonitrile (DG172) was developed as a highly selective inhibitory peroxisome proliferator-activated receptor (PPAR)β/δ ligand. Here, we describe a novel PPARβ/δ-independent, yet highly specific, effect of DG172 on the differentiation of bone marrow cells (BMCs). DG172 strongly augmented granulocyte-macrophage-colony-stimulating factor (GM-CSF)-induced differentiation of primary BMCs from Ppard null mice into two specific populations, characterized as mature (CD11c(hi)MHCII(hi)) and immature (CD11c(hi)MHCII(lo)) dendritic cells (DCs). IL-4 synergized with DG172 to shift the differentiation from MHCII(lo) cells to mature DCs in vitro. The promotion of DC differentiation occurred at the expense of differentiation to granulocytic Gr1(+)Ly6B(+) cells. In agreement with these findings, transcriptome analyses showed a strong DG172-mediated repression of genes encoding neutrophilic markers in both differentiating wild-type and Ppard null cells, while macrophage/DC marker genes were up-regulated. DG172 also inhibited the expression of transcription factors driving granulocytic differentiation (Cebpe, Gfi1, and Klf5), and increased the levels of transcription factors promoting macrophage/DC differentiation (Irf4, Irf8, Spib, and Spic). DG172 exerted these effects only at an early stage of BMC differentiation induced by GM-CSF, did not affect macrophage-colony-stimulating factor-triggered differentiation to macrophages and had no detectable PPARβ/δ-independent effect on other cell types tested. Structure-function analyses demonstrated that the 4-methylpiperazine moiety in DG172 is required for its effect on DC differentiation, but is dispensable for PPARβ/δ binding. Based on these data we developed a new compound, (Z)-2-(4-chlorophenyl)-3-[4-(4-methylpiperazine-1-yl)phenyl]acrylonitrile (DG228), which enhances DC differentiation in the absence of significant PPARβ/δ binding.

Mixed-polarization phenotype of ascites-associated macrophages in human ovarian carcinoma: correlation of CD163 expression, cytokine levels and early relapse

Ovarian cancer is typically accompanied by the occurrence of malignant ascites containing large number of macrophages. It has been suggested that these tumor-associated macrophages (TAMs) are skewed to alternative polarization (M2) and thereby play an essential role in therapy resistance and metastatic spread. In our study, we have investigated the nature, regulation and clinical correlations of TAM polarization in serous ovarian cancer. Macrophage polarization markers on TAMs and ascites cytokine levels were analyzed for 30 patients and associated with relapse-free survival (RFS) in a prospective study with 20 evaluable patients. Surface expression of the M2 marker CD163 on TAMs was inversely associated with RFS (p < 0.01). However, global gene expression profiles determined for 17 of these patients revealed a mixed-polarization phenotype unrelated to the M1/M2 classification. CD163 surface expression also correlated with the ascites levels of IL-6 and IL-10 (p < 0.05), both cytokines induced CD163 expression, and their ascites levels showed a clear inverse association with RFS (p < 0.01). These findings define a subgroup of patients with high CD163 expression, high IL-6 and/or IL-10 levels and poor clinical outcome.

Regulation of TAK1/TAB1-mediated IL-1β signaling by cytoplasmic PPARβ/δ

The peroxisome proliferator-activated receptor subtypes PPARα, PPARβ/δ, PPARγ are members of the steroid hormone receptor superfamily with well-established functions in transcriptional regulation. Here, we describe an unexpected cytoplasmic function of PPARβ/δ. Silencing of PPARβ/δ expression interferes with the expression of a large subset of interleukin-1β (IL-1β)-induced target genes in HeLa cells, which is preceded by an inhibition of the IL-1β-induced phosphorylation of TAK1 and its downstream effectors, including the NFκBα inhibitor IκBα (NFKBIA) and the NFκBα subunit p65 (RELA). PPARβ/δ enhances the interaction between TAK1 and the small heat-shock protein HSP27, a known positive modulator of TAK1-mediated IL-1β signaling. Consistent with these findings, PPARβ/δ physically interacts with both the endogenous cytoplasmic TAK1/TAB1 complex and HSP27, and PPARβ/δ overexpression increases the TAK1-induced transcriptional activity of NFκB. These observations suggest that PPARβ/δ plays a role in the assembly of a cytoplasmic multi-protein complex containing TAK1, TAB1, HSP27 and PPARβ/δ, and thereby participates in the NFκB response to IL-1β.

[Evaluation of the "initiative pain-free clinic" for quality improvement in postoperative pain management. A prospective controlled study]

AIM

Demonstration of improved postoperative pain management by implementation of the S3 guidelines on treatment of acute perioperative and posttraumatic pain, by the integrated quality management concept "quality management acute pain" of the TÜV Rheinland or by participation in the benchmark project "Quality improvement in postoperative pain management" (QUIPS).

METHODS

A prospective controlled study (pre-post design) was carried out in hospitals with various levels of care comparing three hospital groups (n = 17/7/3, respectively). Group 1: participation in the QUIPS project (intraclinic and interclinic comparison of outcome data of postoperative pain treatment), group 2: participation in the quality management acute pain program (certified by TÜV Rheinland), group 3: control group with no involvement in either of the two concepts. In all three groups, an anonymous data collection was performed consisting of patient-reported pain intensity, side effects, pain disability and patient satisfaction. Pain therapy intervention was carried out only in group 2 by an integrated quality management concept (certification project: Quality management acute pain) with a package of measures to improve structure, process and outcome quality.

RESULTS

The TÜV Rheinland certified clinics (group 2) showed a significant improvement in the pre-post comparison (before versus after certification) in the areas maximum pain (from visual analogue scale VAS 4.6 to 3.7), stress pain (5.3 to 3.9), pain-related impairment (proportion of patients with pain-linked decreased mobility and movement 26% to 16.1%, coughing and breathing 23.1% to 14.3%) and patient satisfaction (from 13.2 to 13.7; scale 0 completely unsatisfied, 15 very satisfied). The clinics with participation in QUIPS for 2 years also showed a significant improvement in stress pain (numeric rating scale NRS for pain 4.5 to 4.2), pain-linked-limitation of coughing and breathing (28% to 23.6%), and patient satisfaction (from 11.9 to 12.4). There were no differences in postoperative nausea and vomiting between any of the groups.

CONCLUSIONS

The main objective of the certification concept quality management acute pain as a tool for the successful implementation of the S3 guidelines on treatment of acute perioperative and posttraumatic pain, led to a significant improvement in patient outcome. Participation in QUIPS is an ideal supplement to TÜV Rheinland certification and can be recommended as a benchmarking tool to evaluate outcome.

Microbiological stability of solutions containing local anesthetics and opioids in closed infusion systems used for epidural analgesia

Nine solutions containing opiod analgesics and local anesthetics as typically use in epidural catheters were tested for antimicrobial stability. Administration via a pefusor syringe requires several refill processes. It was shown that repetitive refilling of the syringes did not result in any microbiological contamination.

Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods

BACKGROUND

Cut-off points (CPs) of the numeric rating scale (NRS 0-10) are regularly used in postoperative pain treatment. However, there is insufficient evidence to identify the optimal CP between mild and moderate pain.

METHODS

A total of 435 patients undergoing general, trauma, or oral and maxillofacial surgery were studied. To determine the optimal CP for pain treatment, four approaches were used: first, patients estimated their tolerable postoperative pain intensity before operation; secondly, 24 h after surgery, they indicated if they would have preferred to receive more analgesics; thirdly, satisfaction with pain treatment was analysed, and fourthly, multivariate analysis was used to calculate the optimal CP for pain intensities in relation to pain-related interference with movement, breathing, sleep, and mood.

RESULTS

The estimated tolerable postoperative pain before operation was median (range) NRS 4.0 (0-10). Patients who would have liked more analgesics reported significantly higher average pain since surgery [median NRS 5.0 (0-9)] compared with those without this request [NRS 3.0 (0-8)]. Patients satisfied with pain treatment reported an average pain intensity of median NRS 3.0 (0-8) compared with less satisfied patients with NRS 5.0 (2-9). Analysis of average postoperative pain in relation to pain-related interference with mood and activity indicated pain categories of NRS 0-2, mild; 3-4, moderate; and 5-10, severe pain.

CONCLUSIONS

Three of the four methods identified a treatment threshold of average pain of NRS≥4. This was considered to identify patients with pain of moderate-to-severe intensity. This cut-off was indentified as the tolerable pain threshold.

Genomewide analyses define different modes of transcriptional regulation by peroxisome proliferator-activated receptor-β/δ (PPARβ/δ)

Peroxisome proliferator-activated receptors (PPARs) are nuclear receptors with essential functions in lipid, glucose and energy homeostasis, cell differentiation, inflammation and metabolic disorders, and represent important drug targets. PPARs heterodimerize with retinoid X receptors (RXRs) and can form transcriptional activator or repressor complexes at specific DNA elements (PPREs). It is believed that the decision between repression and activation is generally governed by a ligand-mediated switch. We have performed genomewide analyses of agonist-treated and PPARβ/δ-depleted human myofibroblasts to test this hypothesis and to identify global principles of PPARβ/δ-mediated gene regulation. Chromatin immunoprecipitation sequencing (ChIP-Seq) of PPARβ/δ, H3K4me3 and RNA polymerase II enrichment sites combined with transcriptional profiling enabled the definition of 112 bona fide PPARβ/δ target genes showing either of three distinct types of transcriptional response: (I) ligand-independent repression by PPARβ/δ; (II) ligand-induced activation and/or derepression by PPARβ/δ; and (III) ligand-independent activation by PPARβ/δ. These data identify PPRE-mediated repression as a major mechanism of transcriptional regulation by PPARβ/δ, but, unexpectedly, also show that only a subset of repressed genes are activated by a ligand-mediated switch. Our results also suggest that the type of transcriptional response by a given target gene is connected to the structure of its associated PPRE(s) and the biological function of its encoded protein. These observations have important implications for understanding the regulatory PPAR network and PPARβ/δ ligand-based drugs.

[Estimation of postoperative pain after tonsillectomy in adults using QUIPS: an instrument to improve postoperative pain management]

BACKGROUND

Tonsillectomy leads to strong postoperative pain. Pain management often is not optimal after tonsillectomy. To date, there exists no clear guideline for pain management after tonsillectomy.

METHODS

In a prospective study 65 tonsillectomy patients were examined at the first postoperative day within the QUIPS project. This allowed a standardised assessment of patients' characteristics, pain parameters, outcome and process parameters. The influence of these parameters on the patients' postoperative pain was estimated with univariate and multivariate statistic analysis.

RESULTS

All patients report of constant slight pain during the first postoperative day after tonsillectomy. Although maximal pain intensity was moderate, overall, patients were satisfied with the pain management. Pain management did not result in relevant side effects. Younger patients suffered significantly more from maximal pain than older patients. The same was obvious for patients who needed pain killers already prior to surgery. Perioperative antibiotic treatment and specific counselling about the possibilities of postoperative pain management reduced pain intensity highly significant in univariate and multivariate analysis. Patients receiving opioids on the ward postoperatively had significantly less pain.

DISCUSSION

QUIPS is a very good tool to evaluate the quality of postoperative pain management in one's own hospital. Next step, a detailed comparison to the best practise of other hospitals participating at QUIPS will follow in order to improve and standardize pain management for adult tonsillectomy patients.

EGF-dependent induction of BCL-xL and p21CIP1/WAF1 is highly variable in HNSCC cells--implications for EGFR-targeted therapies

The anti-apoptotic protein BCL-x(L) and the cell cycle inhibitor p21(CIP1/WAF1) were previously implicated in head and neck cancer. Several reports point to a role of the epidermal growth factor receptor (EGFR, ErbB-1, HER1) in regulating their expression. In the present study, we investigated the influence of EGFR on these tumor-associated factors. HNSCC cell lines were incubated with EGF or with the EGFR-specific kinase inhibitor AG1478. Western blot analysis and quantitative reverse transcription-polymerase chain reaction (qRT-PCR) were deployed to measure BCL-x(L) and p21(CIP1/WAF1) protein and mRNA levels. A dose-dependent rise of BCL-x(L) as well as p21(CIP1/WAF1) protein was noted after incubation with EGF, whereas inhibition with AG1478 reduced basal expression levels. No influence on BCL-2 was seen. Interestingly, qRT-PCR revealed that p21(CIP1/WAF1) but not BCL-x(L) transcript levels were induced after EGF treatment. Taken together, it can be stated that p21(CIP1/WAF1) and BCL-x(L) but not BCL-2 levels are tightly regulated by EGFR in HNSCC cell lines. BCL-x(L) induction appears to be due to protein stabilization rather than transcriptional activation, which is the likely cause of p21(CIP1/WAF1) induction. The noted variability in EGF response of HNSCC cells could reflect frequently observed variations in clinical response rates after implementation of anti-EGFR therapies.

Reverse crosstalk of TGFβ and PPARβ/δ signaling identified by transcriptional profiling

Previous work has provided strong evidence for a role of peroxisome proliferator-activated receptor β/δ (PPARβ/δ) and transforming growth factor-β (TGFβ) in inflammation and tumor stroma function, raising the possibility that both signaling pathways are interconnected. We have addressed this hypothesis by microarray analyses of human diploid fibroblasts induced to myofibroblastic differentiation, which revealed a substantial, mostly reverse crosstalk of both pathways and identified distinct classes of genes. A major class encompasses classical PPAR target genes, including ANGPTL4, CPT1A, ADRP and PDK4. These genes are repressed by TGFβ, which is counteracted by PPARβ/δ activation. This is mediated, at least in part, by the TGFβ-induced recruitment of the corepressor SMRT to PPAR response elements, and its release by PPARβ/δ ligands, indicating that TGFβ and PPARβ/δ signals are integrated by chromatin-associated complexes. A second class represents TGFβ-induced genes that are downregulated by PPARβ/δ agonists, exemplified by CD274 and IL6, which is consistent with the anti-inflammatory properties of PPARβ/δ ligands. Finally, cooperative regulation by both ligands was observed for a minor group of genes, including several regulators of cell proliferation. These observations indicate that PPARβ/δ is able to influence the expression of distinct sets of both TGFβ-repressed and TGFβ-activated genes in both directions.

Transcriptional profiling identifies functional interactions of TGF β and PPAR β/δ signaling: synergistic induction of ANGPTL4 transcription

Peroxisome proliferator-activated receptors (PPARs) not only play a key role in regulating metabolic pathways but also modulate inflammatory processes, pointing to a functional interaction between PPAR and cytokine signaling pathways. In this study, we show by genome-wide transcriptional profiling that PPARβ/δ and transforming growth factor-β (TGFβ) pathways functionally interact in human myofibroblasts and that a subset of these genes is cooperatively activated by TGFβ and PPARβ/δ. Using the angiopoietin-like 4 (ANGPTL4) gene as a model, we demonstrate that two enhancer regions cooperate to mediate the observed synergistic response. A TGFβ-responsive enhancer located ∼8 kb upstream of the transcriptional start site is regulated by a mechanism involving SMAD3, ETS1, RUNX, and AP-1 transcription factors that interact with multiple contiguous binding sites. A second enhancer (PPAR-E) consisting of three juxtaposed PPAR response elements is located in the third intron ∼3.5 kb downstream of the transcriptional start site. The PPAR-E is strongly activated by all three PPAR subtypes, with a novel type of PPAR response element motif playing a central role. Although the PPAR-E is not regulated by TGFβ, it interacts with SMAD3, ETS1, RUNX2, and AP-1 in vivo, providing a possible mechanistic explanation for the observed synergism.

Long-term efficacy and safety of combined prolonged-release oxycodone and naloxone in the management of non-cancer chronic pain

OBJECTIVE

The aim of this study was to assess safety and efficacy of fixed combination oxycodone prolonged release (PR)/naloxone PR in terms of both analgesia and improving opioid-induced bowel dysfunction (OIBD) and associated symptoms, such as opioid-induced constipation (OIC), in adults with chronic non-cancer pain.

STUDY DESIGN

These were open-label extension studies in which patients who had previously completed a 12-week, double-blind study received oxycodone PR/naloxone PR for up to 52 weeks. The analgesia study assessed pain using the modified Brief Pain Inventory-Short Form (BPI-SF). The bowel function study assessed improvements in constipation using the Bowel Function Index (BFI).

RESULTS

At open-label baseline in the analgesia study (n = 379), mean score [+/- standard deviation (SD)] for the BPI-SF item 'average pain over the last 24 h' was 3.9 +/- 1.52, and this remained low at 6 months (3.7 +/- 1.59) and 12 months (3.8 +/- 1.72). Mean scores for BPI-SF item 'sleep interference', and the BPI-SF 'pain' and 'interference with activities' subscales also remained low throughout the 52-week study. In the bowel function study (n = 258), mean BFI score (+/- SD) decreased from 35.6 +/- 27.74 at the start of the extension study to 20.6 +/- 24.01 after 12 months of treatment with oxycodone PR/naloxone PR. Pain scores also remained low and stable during this study. Adverse events in both extension phases were consistent with those associated with opioid therapy; no additional safety concerns were observed.

CONCLUSION

Results from these two open-label extension studies demonstrate the long-term efficacy and tolerability of fixed combination oxycodone PR/naloxone PR in the treatment of chronic pain. Patients experienced clinically relevant improvements in OIBD while receiving effective analgesic therapy.

Room for improvement: nurses' and physicians' views of a post-operative pain management program

BACKGROUND

The practice of post-operative pain therapy continues to be a problem. We conducted a survey among nurses and physicians about their views of an established post-operative pain management program.

METHODS

A questionnaire was sent to all nurses and physicians of nine surgical wards (general, trauma, cardio-thoracic and oromaxillofacial surgery and gynecology). Questions were developed from qualitative interviews with staff. Patient data were derived from a post-operative pain registry.

RESULTS

Seventy-eight physicians and nurses answered; the overall response rate was 23%. Post-operative pain therapy had high personal priority on an 11-point numeric rating scale (mean 9.08+/-1.27 standard deviation), but the success of pain management on the ward was rated as 7.32+/-1.37. Staff rating of success tended to correspond with patients' actual pain ratings. Knowledge of pain therapy was assessed as 6.85+/-1.82; nurses consistently rated levels higher than physicians. Staff over- or underestimated the painfulness of typical procedures and females rated procedures as more painful than men. There was considerable confusion about responsibilities and duties. 10.7% of staff perceived time delays exceeding 6 h between a request for acute pain services (APS) consultation and administration of medication to the patient. Invited comments suggested improvement in personnel education, team coordination, communication with patients and speed of action to increase the quality of pain therapy.

CONCLUSION

Despite staff's high personal priority and well-established APS and pain management program, post-operative pain therapy still leaves room for improvement. Considerable confusion about responsibilities and duties underlines the importance of better organizational approaches.