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Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

Autosuggestion is a cognitive process that is believed to enable control over one’s own cognitive and physiological states. Despite its potential importance for basic science and clinical applications, such as in rehabilitation, stress reduction, or pain therapy, the neurocognitive mechanisms and psychological concepts that underlie autosuggestion are poorly defined. Here, by reviewing empirical data on autosuggestion and related phenomena such as mental imagery, mental simulation, and suggestion, we offer a neurocognitive concept of autosuggestion. We argue that autosuggestion is characterized by three major factors: reinstantiation, reiteration, and volitional, active control over one’s own physiological states. We also propose that autosuggestion might involve the ‘overwriting’ of existing predictions or brain states that expect the most common (but not desired) outcome. We discuss potential experimental paradigms that could be used to study autosuggestion in the future, and discuss the strengths and weaknesses of current evidence. This review provides a first overview on how to define, experimentally induce, and study autosuggestion, which may facilitate its use in basic science and clinical practice.

В огляді показана актуальність проблеми попереково-крижової радикулопатії. Наведені епідеміологічні дані, причини, механізми розвитку, клінічна картина і методи фармакотерапії при даній патології. Розглянуто рекомендації міжнародних організацій щодо лікування болю, що як терапію першої лінії рекомендують застосування прегабаліну. Ефективність та безпечність прегабаліну в лікуванні нейропатичного болю була вивчена в ряді клінічних рандомізованих досліджень, що продемонстрували не тільки знеболювальну дію препарату, а й регрес супутніх афективних розладів і інсомнії у пацієнтів із попереково-крижовою радикулопатією.

In the context of their offer of interdisciplinary multimodal pain therapy (day-patient and inpatient), hospitals repeatedly have to contend with strict detailed checks of the procedure codes (OPS 8-918.xx; 8-91c) by health insurers and the medical service. The necessity of day-patient or inpatient treatment in the respective sector, documented therapy components, and the qualifications of the therapists are regularly reviewed. On 27 October 2020, the Federal Social Court ruled on the specific qualification of psychological psychotherapists (BSG, 27 October 2020, Ref.: B 1 KR 25/19 R). The ruling and its potential impact are explained and discussed in this overview.

Was ist neu? Schmerzerfassung Das „Schmerzinterview für geriatrische Patienten“ gibt Vorschläge, wie wichtige Informationen zu Schmerzen bei älteren Patienten selbst mit kognitiven Beeinträchtigungen erfasst werden können, solange eine gewisse Kommunikationsfähigkeit erhalten ist. Zur Schmerzerfassung bei eingeschränkter Kommunikationsfähigkeit eignen sich Fremdbeobachtungsinstrumente für Schmerzen zur Ersterfassung und für den Verlauf von Schmerzen und somit auch zur Beurteilung der Schmerztherapie. PAIC-15 ist der jüngste Vorschlag, der auf der Grundlage bestehender Instrumente entwickelt wurde, allerdings noch nicht ausreichend auf Validität geprüft wurde. Therapie Schmerzedukation für Angehörige, Musiktherapie, Krafttraining und Ausdauertraining mildern Verhaltensauffälligkeiten bei Demenz. Die Wirksamkeit auf Schmerzen ist bei allen beschriebenen Verfahren unzureichend untersucht. Nur für Paracetamol gibt es auch bei Menschen mit Demenz und reduzierter Kommunikationsfähigkeit Erkenntnisse, die eine Schmerzlinderung nahelegen. Wahrscheinlich bewirkt die Summe der verabreichten Medikamente mit anticholinergen Nebenwirkungen (= anticholinerge Last) die mangelnde Verträglichkeit auch vieler Analgetika.

ZusammenfassungAkutschmerztherapie nach operativen oder interventionellen Eingriffen ist ein Pflichtbestandteil im modernen perioperativen Management. Ihr strukturierter Einsatz führt unmittelbar zu einer Verbesserung der Lebensqualität behandelter Patienten, mittelfristig zu einer objektivierbaren Reduktion der Morbidität, langfristig zu einer Verhinderung einer Schmerzchronifizierung und parallel stets auch zu einer darstellbaren ökonomischen Effizienz durch beschleunigte Mobilisation, Verkürzung der Krankenhausverweildauer und Vermeidung komplikationsimmanenter Folgekosten.

Patient's satisfaction with treatment is a fundamental indicator of the quality of medical care, which is especially important for assessing the effectiveness of therapy for musculoskeletal pain in rheumatic diseases (RD).Objective: to determine satisfaction of patients with RD with pain relief therapy and to analyze the factors influencing the subjective assessment of analgesic therapy.Patients and methods. Anonymous survey of 1040 patients (age 55.8±14.0 years, 76.8% were women) with RD, rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthritis, systemic connective tissue diseases and gout, was carried out. The presence of pain and its therapy, satisfaction with treatment, and patient's opinion about the reasons of low pain relief effectiveness were assessed. The dependence of the presence of dissatisfaction with treatment on a number of demographic and clinical factors was analyzed.Results and discussion. 71.5% of patients experienced pain in one or more joint areas and/or in the back. 70.6% of patients used non-steroidal antiinflammatory drugs (NSAIDs), 1.6% – paracetamol, 40.0% – non-drug modalities and methods of alternative medicine. 15.6% of the respondents were completely satisfied with the treatment, 64.0% were partially satisfied, and 20.4% were completely dissatisfied. The main subjective reasons for the insufficient effectiveness of analgesic therapy were: fear of taking prescribed medications due to possible complications (45.4%), low effectiveness of drugs (15.7%), insufficient attention of doctors (20.3%). Male gender, body mass index >30 kg/m2 , severe pain, pain in several areas, and the diagnosis of OA were statistically significantly associated with treatment dissatisfaction. In contrast, patients with RA showed greater satisfaction with treatment.Conclusion. Most patients with RD are dissatisfied with the results of pain therapy. Educational work with patients and a personalized approach to prescribing analgesic therapy is needed.

Pain is a complex perceptual phenomenon. Coordinated activity among local and distant brain networks is a central element of the neural underpinnings of pain. Brain oscillatory rhythms across diverse frequency ranges provide a functional substrate for coordinating activity across local neuronal ensembles and anatomically distant brain areas in pain networks. This review addresses parallels between insights from human and rodent analyses of oscillatory rhythms in acute and chronic pain and discusses recent rodent-based studies that have shed light on mechanistic underpinnings of brain oscillatory dynamics in pain-related behaviors. We highlight the potential for therapeutic modulation of oscillatory rhythms, and identify outstanding questions and challenges to be addressed in future research.

Chronic pain in older adults should be explained and treated on the basis of the biopsychosocial model. With its interdisciplinary and interprofessional approach, multimodal pain therapy is the method of choice. In old age freedom from pain is usually not the primary goal. It is more important to restore the quality of life of those affected and to maintain independence and autonomy with a versatile treatment offer. This article explains the basics of multimodal pain therapy and its special features in old age.

In this article we performed publication analysis devoted to pain medicine in oncology during anticancer therapy and in palliative setting. Until recently, the main WHO guidelines for pain management in oncology were the recommendations of 1996, which included only pain relievers, as well as adjuvant and symptomatic drugs, which were applied according to the WHO analgesic ladder. These recommendations were based on the collective expert opinion of leading clinicians and scientists. The new WHO clinical guidelines were published in 2019. They are based on the principles of evidence-based medicine, including modern concepts of the etiology and pathogenesis of tumor pain syndrome. This recommendations contain sections on the analgesic efficacy of radiation therapy and antitumor drug therapy. The new WHO recommendations have not yet been published in Russian and are not sufficiently available for a wide range of oncologists and palliative specialists in our country. The purpose of this publication is to present within one volume a concise but complete and comprehensible discussion of the latest trends in pain therapy in oncology, published by WHO experts.

The activation of Na/40Ca exchange in reverse (R) mode leading to neuronal swelling and muscle contraction has been suggested as a mechanism for generation of pain signals. However, the activation of R Na/45Ca exchange, having higher rate than R Na/40Ca exchange, brings to depression of pain sensation, the mechanism of which is not clear. The previous data that the 4 Hz mechanical vibration (MV) has pain-relieving effects by activation of cGMP-dependent Na/Ca exchange in forward (F) mode, which leads to muscle hydration and neuronal dehydration, as in case of R Na/45Ca exchange activation, allow us to suggest that the comparative study of the effects of 4 Hz MV and R Na/45Ca exchange on thermal pain thresholds, tissue hydrations in different experimental conductions will make it possible to evaluate the mechanisms of R Na/45Ca exchange-induced inhibition of pain sensation. The obtained data show that the R Na/45Ca exchange-induced depression of pain sensation is due to high [Ca2+]i-inactivation of Na/K pump which brings to further increase of [Ca2+]i, while 4 Hz MV-activated F Na/Ca exchange-induced pain-relieving effect is due to Na/K pump activation by low [Ca2+]i. It is suggested that the R Na/45Ca exchange inhibits pain sensation, which is due to high [Ca2+]i-induced depression inhibition of muscle contractility, while the 4 Hz MV-induced pain-relieving effect is due to activation of Na/K pump by cGMP-dependent decrease of [Ca2+]i leading to muscle relaxation and neuronal dehydration. Therefore, the 4 Hz MV has been suggested as a novel quantum-mechanical sensitive target for pain therapy.

Experiential avoidance is a core process variable in the concept of Acceptance and Commitment Theory (ACT) and has been connected to various disorders. A widely used instrument for the measurement of experiential avoidance is the Acceptance and Action Questionnaire II (AAQ-II). Recently, a pain-specific version for chronic pain patients was introduced in the Netherlands (AAQ-II‑P). High scores indicate strong pain-related experiential avoidance. The aim of the current study was to measure pain-related experiential avoidance in a sample of chronic pain patients using the German translation of the AAQ-II‑P and to analyze its psychometric qualities.After a forward-backward translation procedure of the AAQ-II and adaptation to the pain context, a sample of N = 168 patients from a multidisciplinary pain center answered the German version of the AAQ-II‑P. Additional questionnaires were administered to measure specific constructs of interest: chronic pain grade (CPG), pain catastrophizing (PCS), health-related quality of life (SF-12), psychopathology (HADS-D), personality (BFI‑K) and mindfulness (KIMS-S). Reliability, factorial validity and construct validity of the AAQ-II‑P were identified.The AAQ-II‑P had high internal consistency (α = 0.89) and the one-factor solution explained 61% of the total variance. Correlations to personality and mindfulness subscales were low (maxima: r = 0.44 with neuroticism and r = -0.43 with acceptance). High correlations were shown for catastrophizing (r = 0.75), depression (r = 0.73) and anxiety (r = 0.66). Also, there was a substantial correlation to health-related quality of life, specifically the psychological total scale (r = -0.58).The German AAQ-II‑P has good reliability. Regarding factorial structure and construct validity, it is highly comparable to the original version. Direction and magnitude of the relationship to adjacent constructs mostly measure up to our expectations. Chronic pain patients inclined to pain-related experiential avoidance tend to indicate more pain catastrophizing and show restricted quality of life regarding psychological variables. Apparently, pain-related experiential avoidance can be relevant for popular target variables in psychotherapy.EINLEITUNG UND FRAGESTELLUNG: Erlebensvermeidung („experiential avoidance“) stellt einen zentralen störungsrelevanten Prozess im Rahmen der Akzeptanz- und Commitment-Therapie (ACT) dar. Zur Erfassung wurde der Acceptance and Action Questionnaire II (AAQ-II) entwickelt und in den Niederlanden für eine Patientengruppe mit chronischem Schmerz adaptiert und validiert (AAQ-II‑P). Hohe Werte im AAQ-II‑P bedeuten hohe schmerzbezogene Erlebensvermeidung. Ziel unserer Untersuchung ist die Erfassung von schmerzbezogener Erlebensvermeidung mit einer deutschen Version des AAQ-II‑P bei chronischen Schmerzpatienten und die Prüfung psychometrischer Merkmale des Messverfahrens.Der AAQ-II wurde mittels eines Vorwärts-Rückwärts-Verfahrens ins Deutsche übersetzt, für chronischen Schmerz adaptiert (AAQ-II‑P) und von 168 Patienten einer universitären Schmerzambulanz beantwortet. Zusätzlich wurden Daten zu schmerzbedingter Beeinträchtigung (CPG: Schweregrad nach von Korff) und Schmerzkatastrophisieren (PCS) erhoben sowie zu gesundheitsbezogener Lebensqualität (SF-12), Angst und Depressivität (HADS-D). Ebenfalls erfasst wurden allgemeine Persönlichkeitsmerkmale (BFI‑K) und habituelle Achtsamkeit (KIMS-S). Ausgewertet wurden Reliabilität und faktorielle Validität des AAQ-II‑P sowie seine Beziehung zu den anderen psychometrischen Verfahren.Der AAQ-II‑P erzielte eine hohe interne Konsistenz mit α = 0,89 sowie eine eindimensionale Faktorenstruktur mit 61 % aufgeklärter Varianz. Geringe Korrelationen ergaben sich zu Persönlichkeitsdimensionen (maximal r = 0,44 zu Neurotizismus) und Achtsamkeit (maximal r = −0,43 zu Akzeptanz). Ein hoher Zusammenhang fand sich zu Schmerzkatastrophisieren (r = 0,75), Depression (r = 0,73) und Angst (r = 0,66). Die Beziehung zu Lebensqualität war am stärksten ausgeprägt auf der Psychischen Summenskala (r = −0,58).Die deutsche Version des AAQ-II‑P hat eine gute Reliabilität und weist hinsichtlich Zuverlässigkeit und Faktorenstruktur hohe Vergleichbarkeit mit der Originalversion auf. Die Beziehungen zu den Skalen der psychometrischen Verfahren sind zumeist in erwarteter Richtung und Höhe. Patienten mit chronischem Schmerz und hoher schmerzbezogener Erlebensvermeidung tendieren deutlich zum Schmerzkatastrophisieren und zeichnen sich durch schlechtere psychische Lebensqualität aus. Dies spricht für die Relevanz des Konstrukts hinsichtlich therapeutischer Zielvariablen.

Od kilku lat obserwujemy znaczny wzrost zainteresowania nową techniką neuromodulacyjną, tj. polaryzacją układu nerwowego. Polaryzacja opiera się na indukowaniu pól elektrycznych w obrębie wybranych elementów układu nerwowego, przez zewnętrznie umiejscowione elektrody polaryzujące, co skutkuje zwiększeniem bądź zmniejszeniem aktywności sieci neuronalnych w zależności od zastosowanego bieguna elektrody czynnej. Obecnie istnieją dwie podstawowe formy aplikowania polaryzacji: polaryzacja przezczaszkowa (tDCS) i polaryzacja przezrdzeniowa (tsDCS). Będąc bardziej rozpowszechnioną, tDCS jest szeroko stosowana jako wspomaganie terapii w szeregu schorzeń neurologicznych, od terapii poudarowej, do terapii bólu i terapii schorzeń psychiatrycznych kończąc. tsDCS jest znacznie rzadziej stosowana, a efekty jej działania na poszczególne elementy układu nerwowego są wciąż badane w celu znalezienia optymalnych i bezpiecznych warunków aplikacji. Celem tego artykułu jest przybliżenie zjawiska polaryzacji układu nerwowego i stosowanych technik polaryzacji, ze szczególnym uwzględnieniem techniki tsDCS, jak również analiza możliwych mechanizmów fizjologicznych leżących u podstaw działania polaryzacji. Ponadto artykuł wskazuje możliwe zastosowanie tsDCS w zakresie wspomagania treningu sportowego, jak i terapii chorób neurodegeneracyjnych.

In addition to other distressing symptoms, palliative patients often suffer from very severe pain. For this reason, a precise pain diagnosis is necessary in order to be able to initiate the necessary therapeutic measures. Pain therapy includes the medications specified in the World Health Organization (WHO) analgesic ladder as well as various supportive measures.

BackgroundThe Combined Mandibulectomy and Neck Dissection (COMMANDO) surgery results in severe postoperative pain and requires multimodal analgesia (MMA) for its management. We speculated that the erector spinae plane block (ESPB) which is the ultrasound (US)-guided regional technique and has been used in various types of surgeries due to its analgesic benefits could be used as an effective analgesic adjunct in COMMANDO surgery.Case presentationWe report a case of a 68-year-old female patient who underwent left side COMMANDO surgery for carcinoma cheek. She was given an ultrasound-guided left erector spinae plane block (ESPB) in the preoperative period with catheter insertion at T3 (3rd thoracic vertebral level). Two boluses of local anesthetic were given each with 10 ml 0.25% ropivacaine one before and one after surgery, and then, the infusion was started with a volumetric pump. The ESPB provided effective intraoperative as well as postoperative pain relief without any side effects.ConclusionUS-guided ESPB could be used as a potential opioid-sparing multimodal analgesic in head and neck surgeries based on the pain relief provided and the spread of contrast on imaging. This hypothesis needs to be explored in the form of case series and adequately powered randomized controlled trials.

This review examines the pain control options for geriatric trauma patients, who represent an increasing proportion of the trauma population. Current pain management of geriatric trauma patients has evolved to a multimodal pain approach including non-opioid medications and regional anesthesia, due to safety concerns with respiratory depression and delirium when using primarily opioid-based pain regimens. Ideal regimens incorporate treatment of multiple pain pathways to decrease the required dosages of all pain medicine to safer thresholds, especially in the geriatric patient population. Intravenous, oral, and transdermal adjunctive medications provide effective pain control for these patients. Regional anesthesia also improves pain control and decreases narcotic use, especially in the setting of rib and femoral fractures. The growing population of elderly trauma patients requires thoughtful multimodal pain therapy regimens tailored to injury type and personalized to the patient’s comorbidities to optimize outcomes and prevent complications.

Pain syndrome is commonly a leading syndrome of oncological and oncohematological diseases in children. Whether the condition is curable or not, the pain syndrome can almost always be controlled that can significantly improve the quality of life of young patients and their families. The presented article highlights the causes and the mechanism of the pain syndrome development in children with oncological and oncohematological diseases. Adequate identification of pathogenetic mechanisms and assessment of pain syndrome is the main goal of the initial assessment of the patient's condition, taking into account the psychosocial characteristics of the patient and his family, thus it is important for clinicians to include these criteria in initial and follow-up examinations of patients in order to provide appropriate therapeutic management. We stress on the comprehensive understanding of the aetiology and pathogenetic mechanisms of the pain syndrome in children with oncological diseases, which directly affect the strategy of overcoming the pain associated with the tumour process, treatment, and carrying out medical and diagnostic manipulations in such children. It is important for specialists in paediatric oncology and oncohematology to diagnose the general pain syndrome, which accompanies cancerous diseases. Effective analgesia requires careful monitoring of the patient’s condition and his/ her syndromic reactions during treatment. The comprehensive assessment of the pain syndrome should include a discussion of the purpose and expectations of pain therapy, changes in pain intensity, characteristics and location. The article presents the basic principles of overcoming the pain syndrome, a three-step approach to the treatment of pain syndrome in children with oncological diseases and the main characteristics and combinations of analgesic groups for pain management.

Michael Richter,1 Christian Rauscher,2 Alexander Kluttig,3 Joachim Mallwitz,4 Karl-Stefan Delank5 1Physiotherapie Am Michel, Hamburg, Germany; 2Rückenzentrum St. Georg, Asklepios Klinik St. Georg, Hamburg, Germany; 3Institute for Medical Epidemiology, Biometrics and Informatics, Interdisciplinary Center for Health Sciences, Martin-Luther-University, Halle-Wittenberg, Halle, Germany; 4Rückenzentrum Am Michel, Praxis Für Orthopädie, Hamburg, Germany; 5Universitätsklinikum (Halle), Department Für Orthopädie, Unfall- Und Wiederherstellungschirurgie, Martin-Luther-Universität, Halle-Wittenberg, Halle, GermanyCorrespondence: Alexander KluttigMartin-Luther-University, Halle-Wittenberg, Institute for Medical Epidemiology, Biometrics and Informatics, Halle (Saale) 06097, GermanyTel +49 (0)345 557-3570Fax +49 (0)345 557-3580Email alexander.kluttig@uk-halle.dePurpose: Interdisciplinary multimodal pain therapy (IMPT) programs for chronic back pain are effective and recommended. The patient-centered and biopsychosocial nature of IMPT is grounded in contemporary understanding that chronic pain states reflect heightened sensitization of the nervous system rather than an issue in the tissue. Teaching patients about pain is part of IMPT programs, though a clinical guideline is lacking. This study aims to answer the following question: Does the addition of an evidence-based pain neuroscience education (PNE) lecture for patients, into an IMPT program, produce superior results than the IMPT program itself?Patients and Methods: A non-randomized, controlled intervention study was performed with 179 back pain patients indicated for IMPT. Intervention group (N=102) received a four-week IMPT program, which contained 4 one-hour sessions PNE. Control group (N=77) received the same IMPT without the additional PNE. Primary outcome was current pain after intervention. Pain knowledge, physical function, depression, anxiety, stress, quality of life and fear-avoidance were analyzed as secondary outcomes. Outcomes were defined as change of the parameter measured before and immediately after the four-week IMPT. For each outcome, linear regression models were used to estimate the raw and adjusted (sex, age and BMI) effect of additional PNE.Results: Despite improvement in all outcomes for both groups during the treatment phase, the implemented PNE did not result in additional pain reduction (regression coefficient for PNE effect on pain level 0.34; 95% CI − 6.23– 6.97). Between-group differences could only be shown for pain-related knowledge in favor for the intervention group (0.78; 95% CI 0.35– 1.20).Conclusion: The additional PNE lecture did not lead to pain reduction beyond the usual IMPT. However, the PNE did increase pain-related knowledge and, therefore, might be helpful in coping with pain after the IMPT program.Keywords: interdisciplinary multimodal pain therapy, pain neuroscience education, chronic back pain, neurophysiology of pain, pain management

Pain is a challenge to rheumatologists. Not only patients with active arthritis but also patients with a good therapeutic response and even in remission complain of persistent joint pain. It has been proposed that a chronic pain stimulus may have a greater impact in a chronic inflammatory state, and the process towards a pain condition may be influenced by individual predisposition for development of chronic pain. In addition, features of peripheral pain processing may be exacerbated by inflammation, and disturbed pain processing may be a feature contributing to widespread pain. Furthermore, a neuropathic component may be part of the total pain experience of our patients. There are many different strategies of pain therapy in patients with rheumatic diseases, such as pharmacological and non- pharmacological modalities.

It is estimated that one-third of oncologic patients in the USA do not receive analgesia proportional to or adequate for the intensity of their pain. A mechanism-based approach to oncologic pain therapy is critical to ensure that analgesia regimens are individualized and effective. Since the mechanisms that lead to cancer pain are complex, healthcare providers must be willing to elicit and recognize the symptoms of each individual patient since these factors influence both the experience of pain and response to treatment. This process is centered on the use of detailed history in order to understand symptom expression in the context of primary tumor diagnosis and progression, history of cancer pain, psychological distress, sleep disturbances, cognitive function, and addictive behavior. Incorporating all of these factors into the assessment of a patient’s pain condition can facilitate management decisions and help predict patient response to treatment.

Due to the COVID-19 pandemic, elective medical services have had to be reduced to a minimum, which has also affected care in pain medicine. Following these drastic cutbacks, a cautious resumption of elective care is planned. This also applies to the delivery of inpatient and day-care interdisciplinary multimodal pain therapy (IMPT). Since the majority of pain medicine centers have been closed to date, the question has arisen as to whether a resumption of regular care can be easily provided under the required protective measures. To answer this question, the authors conducted a survey among patients that were in a position to make a direct comparison between IMPT under normal conditions as well as under the currently required protective measures. The survey recorded the level of disruption caused by the different protective measures in the various treatment modules. An evaluation of the questionnaires, which were completed by two patient groups and all therapists involved, revealed that interdisciplinary multimodal pain therapy is possible without significant impairments even under the required protective measures. In particular, wearing protective masks proved to be the protective measure with the greatest negative impact. However, options like the use of protective visors or relocating treatment modules to the outdoors offer practicable alternative solutions for protection. Both patient and therapist satisfaction was high despite these constraints, and personal concern regarding possible infection low.

Background: Pay for Quality (P4Q) is being discussed as an incentive to ensure high quality standards despite cost pressure in healthcare. However, P4Q can also have adverse effects, and the evidence for its effectiveness is limited, especially regarding chronic conditions and multimorbidity. For the treatment of the latter, specific evaluation criteria were defined. Whether these are feasible in the context of costs and remunerations is analyzed in this study using the German DRG system as an example. The aim is to show conditions under which P4Q can be effective. Methods and Results: Costs and remuneration for hospitals were compared for an exemplary geriatric indication, with and without complex treatment. Doing so, cost weights were shown to be more than triple for the latter. The results are applicable to health care systems with P4Q or similar approaches. Conclusion: Introducing complex treatments poses higher and costly demands regarding structure, processes, and interdisciplinary cooperation in organizations. Additional average costs can be calculated by comparison to regular treatment. Covering the extra costs creates the necessary conditions for P4Q and makes the implementation of complex treatments more likely. As high standards have to be guaranteed for complex treatments and patient satisfaction rises when these are introduced, quality improvements can be assumed. This study can inform Health policy (incentive models) medical societies, give impulses for quality management, and healthcare research (patient-oriented health, e.g. consumer-driven health care, shared decision-making). Future studies should report patient-related outcomes and investigate further diagnoses.

In 2017, the Neurosciences section of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy published a national survey on postoperative care and treatment circuits in neurosurgery. The survey showed that practices vary widely, depending on the centre, the anaesthesiologist and the pathology of the patient. There is currently no standard postoperative circuit for cranial neurosurgical procedures in Spanish hospitals, and there is sufficient evidence to show that not all patients undergoing elective craniotomy should be routinely admitted to a postsurgical critical care unit. The aim of this study is to perform a narrative review of postoperative circuits in elective craniotomy in order to standardise clinical practice in the light of published studies. For this purpose, we searched MEDLINE (PubMed) to retrieve studies published in the last ten years, up to November 2019, using the keywords neurosurgery and postoperative care, craniotomyand postoperative care.

ZusammenfassungInsuffizienzfrakturen des Os sacrum werden in letzter Zeit immer häufiger detektiert, wobei aufgrund der steigenden Lebenserwartung die Inzidenz weiter zunehmen wird. Ein Teil der Patienten ist, bedingt durch die starken Frakturschmerzen, invalidisiert und lässt sich durch eine konservative Behandlung nicht suffizient therapieren. Mittels Zementeinbringung in die entsprechende Frakturzone lässt sich eine deutliche Schmerzreduktion und klinische Verbesserung herbeiführen. Ziel dieser Übersichtsarbeit ist eine Darstellung der unterschiedlichen Zementaugmentationsverfahren Ballon-, Radiofrequenz-, Vertebro- und Zementsakroplastie hinsichtlich der richtigen Indikation, der technischen Durchführbarkeit, den möglichen Komplikationen und des klinischen Outcomes. Die Grenzen der Sakroplastie und die Indikation zur Durchführung unterschiedlicher Osteosyntheseverfahren werden aufgezeigt.Eine Literaturrecherche in PubMed und GoogleScholar wurde zu den Stichworten durchgeführt: Beckeninsuffizienzfraktur, Fragilitätsfrakturen des Beckenrings, sacrale Insuffizienzfraktur, Os sacrum, Osteoporose, interventionelle Schmerztherapie, Sakroplastie, Zementaugmentation und Beckenosteosynthesen. Erfahrungen aus der seit Jahren bestehenden eigenen interdisziplinären und multizentrischen Arbeitsgruppe wurden mitberücksichtigt.Neue Klassifikationen in der Einteilung von Beckeninsuffizienzfrakturen sind bei der Festlegung des therapeutischen Vorgehens unter Beachtung der individuellen Klinik zu berücksichtigen. Eine konservative Therapie steht zunächst im Vordergrund, jedoch werden hier nicht alle Patienten schmerzfrei und lassen sich nicht adäquat mobilisieren, konsekutiv folgen Komorbiditäten und eine erhöhte Mortalität. Bei nichtdislozierten Frakturen lässt sich mittels Sakroplastie eine schnelle und nachhaltige Schmerzreduktion herbeiführen. Hinsichtlich der Zementaugmentation lassen sich osteoplastische Verfahren wie die Ballon-, Radiofrequenz- und Zementsakroplastie von dem nichtosteoplastischen Verfahren der Vertebrosakroplastie unterscheiden. Bei der Vertebrosakroplastie muss man mit einer höheren Zementleckagerate rechnen. Die komplexe sacrale Anatomie, die osteopene Knochenstruktur, die Ausrichtung der Frakturzonen, das unterschiedlich technische Vorgehen, die Eigenschaften der Zemente und die Erfahrung des Operateurs haben einen Einfluss auf das Auftreten möglicher Komplikationen.Wenn konservative Maßnahmen zu keiner klinischen Verbesserung führen, profitieren Patienten mit schmerzhaften, nichtdislozierten sacralen Insuffizienzfrakturen von einer Zementaugmentation effektiv und nachhaltig. Durch den Einsatz von individuell anzupassenden Sakroplastieverfahren sind relevante Komplikationen insgesamt sehr selten. Patienten mit instabilen Frakturen profitieren von einer rechtzeitig durchgeführten Osteosynthese.

In den letzten Jahrzehnten hat die Forschung zu Schmerz und Placeboanalgesie sowohl in wissenschaftlicher als auch klinischer Hinsicht deutlich an Relevanz gewonnen. In diesem Beitrag werden die aktuellen Erkenntnisse und Forschungsschwerpunkte dargestellt. Die Bedeutung der Placeboforschung fur die wissenschaftliche Beurteilung der Wirksamkeit von Schmerzmedikamenten wird erlautert. Aus den psychologischen und neurobiologischen Mechanismen, die der Placeboanalgesie zugrunde liegen, ergeben sich Implikationen fur theoretische Modelle und auch fur klinisch relevante Alltagsinterventionen. Der Ausblick zeigt, dass viele Placebophanomene noch nicht vollstandig verstanden sind und weiter untersucht werden mussen, um das Potenzial des Placeboeffekts komplett auszuschopfen. Hierbei werden interindividuelle Unterschiede und deren Einbezug in die Behandlung eine grose Rolle spielen.

Background The devastating effects of the opioid epidemic are well documented. We implemented a surgeon/pharmacist opioid reduction initiative at an academic medical center that incorporated multimodal pain therapy in an attempt to reduce total inpatient opioids prescribed. We hypothesized that less opioids would be used postoperatively without affecting pain scores or length of stay. Methods This single-center observational cohort analysis included patients admitted to the acute general surgical service and had one of 10 emergent general surgical (nontrauma) procedures. Patients who underwent surgery before the opioid reduction initiative were compared with patients who underwent surgery postinitiative. The primary objective was to evaluate differences in daily oral morphine equivalents and average pain scores in patients before and after implementation of the surgeon/pharmacist initiative. Results Eighty-three patients in the preopioid reduction initiative group and 92 patients in the postopioid reduction initiative group met inclusion criteria. Oral morphine equivalents were significantly different at 24 h before discharge when comparing across both year (P = 0.032) and number of procedures (P = 0.013). Our results showed decreased opioid utilization in the postopioid reduction initiative group on all observed postoperative days with unaffected pain scores. Conclusions An opioid reduction initiative showed promise in lowering the number of opioids used during inpatient admission without affecting pain scores in emergent general surgical procedures. This initiative can be easily reproduced at other institutions to help combat the opioid epidemic.

ZusammenfassungDieser Beitrag bietet einen Überblick zu Basiswissen in medikamentöser Schmerztherapie in der Palliativsituation. Schmerz ist eines der führenden Symptome bei 60–90 % aller Krebspatienten. Schmerzen entstehen auch bei neurologischen oder anderen Krankheiten, die am Lebensende auftreten. Um dieses Symptom zu behandeln, ist eine ganzheitliche Strategie vonnöten, die alle körperlichen, psychologischen, sozialen und spirituellen Aspekte der multidimensionalen Schmerzerfahrung („Total Pain“-Konzept) umfasst.Die Behandlung von Krebsschmerzen basierte viele Jahre auf einem Stufenschema, beginnend mit nichtopioiden Analgetika, gefolgt von mittelstarken und starken Opioiden. Im Gegensatz dazu wird die heutige Schmerzbehandlung mehr von der tatsächlichen Intensität dieses aversiven Ereignisses bestimmt.Die Schmerzbeurteilung sollte darauf zugeschnitten sein, eine nozizeptive vs. neuropathische Schmerzkomponente zu identifizieren, die durch die geeignete Arzneimitteltherapie gelindert werden muss. Nichtopioid-Analgetika sind ideale Substanzen zur Linderung nozizeptiver Schmerzen. Antidepressiva und Antikonvulsiva reduzieren die Intensität neuer neuropathischer Schmerzen. Opioide sind für alle Arten von Schmerzen geeignet, sollten jedoch als zweite Wahl eingesetzt werden. Tilidin und Tramadol sind Prodrugs, die erst nach Aktivierung in der Leber schmerzlindernd wirken. Arzneimittelwechselwirkungen können diese Aktivierung blockieren. Schnellwirksame Opioide sollten bei Tumor-Durchbruchschmerzen eingesetzt werden. Transdermale Opioid-Anwendungen werden bei Schluckstörungen empfohlen, normalerweise jedoch nicht, um die Schmerzkontrolle einzuleiten. Wenn Nebenwirkungen wie Halluzinationen für das ausgewählte Opioid auftreten, kann ein Opioid-Wechsel durchgeführt werden.

Die modernen Konzepte wie „patient empowerment“ stehen dafur, dass wir unter wissenschaftlichen Aspekten geeignete begleitende Therapieverfahren auswahlen und in die Hand des Patienten geben und so seine Eigenverantwortung fordern und fordern. Es ist wichtig die Begriffe komplementare und/oder alternative Medizin zu trennen. Betrachtet man die Motivation der Patienten zum Einsatz von komplementaren und/oder alternativen Verfahren, so teilt sich dies einmal in den Wunsch direkt etwas gegen den Tumor zu tun und auf der anderen Seite korpereigene Krafte zu starken, das Immunsystem zu unterstutzen und konkret Nebenwirkungen zu vermindern. Die Crux der modernen Onkologie ist, dass viele Facharzte nicht mehr genug Zeit fur ausfuhrliche Aufklarungsgesprache und wiederholte gute Arzt-Patienten-Gesprache haben. Der Stellenwert der komplementaren Medizin neben Ernahrung und Bewegung liegt vor allen Dingen im gezielten Einsatz als begleitende supportive Therapie. Komplementare Medizin bietet v. a. die Chance, dem Wunsch der Betroffenen nach einer aktiven Beteiligung an der Therapie zu entsprechen.

There is no “gold standard” for the treatment of postoperative pain. According to statistics, from 30 to 75% of patients in the surgical departments continue to suffer from severe pain.Objective. To assess the practical relevance and quality of postoperative pain management using advanced standard operating procedure techniques. Material and methods. Evaluation of performance, safety and pharmacoeconomic feasibility was carried out in accordance with the standard operating procedure (SOP.01-03). Results and discussion. The “GarvisTM Clinic” has introduced a multimodal approach to pain therapy, which is based on the use of paracetamol (infulgan). This drug is characterized by the best price-quality ratio., Актуальность. На сегодня не существует “золотого стандарта” для лечения послеоперационной боли. От выраженного болевого синдрома, по статистике, продолжают страдать от 30 до 75 % пациентов хирургических отделений.Цель. Оценить практическую значимость и качество послеоперационного обезболивания путем использования усовершенствованных методик стандартной операционной процедуры.Материал и методы. Оценка показателей эффективности, безопасности и фармакоэкономической целесообразности проводилась согласно стандартной операционной процедуре (СОП УП.01-03).Результаты и обсуждение. В медицинском центре “GarvisТМ” внедрен мультимодальный подход в терапии боли, в основе которого лежит применение парацетамола (Инфулган). Данный препарат характеризуется лучшим соотношением “цена – качество”., Актуальність. На сьогодні не існує “золотого стандарту” для лікування післяопераційного болю. Від вираженого больового синдрому, за статистикою, продовжують страждати від 30 до 75 % пацієнтів хірургічних відділень.Мета. Оцінити практичну значимість і якість післяопераційного знеболювання шляхом використання вдосконалених методик стандартної операційної процедуриМатеріал і методи. Оцінка показників ефективності, безпеки та фармакоекономічної доцільності проводилася згідно зі стандартною операційною процедурою (СОП УП.01-03).Результати й обговорення. У медичному центрі “GarvisТМ” впроваджено мультимодальний підхід у терапії болю, в основі якого лежить застосування парацетамолу (Інфулган). Даний препарат характеризується найкращим співвідношенням “ціна – якість”.

Absztrakt: A perioperatív fájdalomcsillapítás kérdésköre jelentős kihívás az egészségügyi ellátást végzők számára. A nem jól ellenőrzött, műtét utáni fájdalom szövődményekhez vezethet. A világszerte elterjedt szervezési módszer, az ’Acute Pain Service’ teamek kialakítása bizonyítottan növeli a posztoperatív fájdalomcsillapítás eredményességét. Összefoglalónk célja, hogy közlemények alapján leírja az akutfájdalom-kezelő szolgálat fogalmát, szervezeti struktúráját, minőségi kritériumait és a külföldön történt bevezetés modelljeit. Több adatbázisban történt keresés után PICO-technikával szisztematikusan áttekintettük az irodalmat, és 263 absztrakt került értékelésre. A világ számos országában működtetik a szolgálatot, alapvetően háromféle működési struktúrában. A személyzet aneszteziológusból és fájdalomterápiára specializálódott ápolószemélyzetből áll. A teamek működésének leírására 5 minőségi kritériumot hoztak létre, de fontos szerepe van a szolgálatnak a betegek és a személyzet oktatásában és a fájdalomterápiás protokollok kialakításában. Javasoljuk, hogy hazánkban is készüljön felmérés a szolgálatok működéséről és a minőségi kritériumok érvényesüléséről a posztoperatív fájdalomcsillapítási ellátás terén. Orv Hetil. 2020; 161(15): 575–581.

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Zusammenfassung Hintergrund Der Bregmatest (BT) als Untersuchung sensomotorischer Defizite wurde bislang nicht in der Breite angewandt. Er gilt als ein Test zur Darstellung allgemeiner sensomotorischer Fähigkeiten im Stand. Schmerzpatienten zeigen häufig Körperwahrnehmungs- und Bewegungsstörungen. Ziel der Arbeit Gibt es Unterschiede in der Punktprävalenz beim Bregmatest bei Patienten (mit und ohne die Diagnose F45.41) bzw. Gesunden. In einem zweiten Teil wird die Entwicklung pathologischer BT-Werte im Rahmen einer interdisziplinären multimodalen Schmerztherapie (IMST) beobachtet. Material und Methoden Punktprävalenz pathologischer Testergebnisse in 3 Gruppen, insgesamt n = 218. Verlaufsbeobachtung im Rahmen einer IMST zu Beginn und am Ende eines tagesklinischen Settings, n = 60. Ergebnisse Gesunde und „Nicht-F45.41-Patienten“ zeigen 50 %. Im Rahmen einer IMST ließen sich die pathologischen Bewegungsausführungen auf ca. 33 % absenken. Diskussion Gehäufte Körperwahrnehmungsstörungen sind für chronische Schmerzpatienten bekannt. Der Bregmatest ist in der Lage, zumindest einen Teil der Patienten, die sensomotorische Defizite haben, zu detektieren. Chronische Schmerzpatienten unterscheiden sich hier signifikant von Gesunden oder anderen Patientengruppen. Die Defizite in der Ansteuerbarkeit myofaszialer Gewebe (Koordination) sind auch im Rahmen einer vierwöchigen IMST besserbar.

Pectus excavatum is a congenital chest wall deformity characterized by a sternal depression, which typically begins at the manubrium and ends toward the xiphoid. At young age, the pectus excavatum causes no complaints, but as children become more active when they grow up, symptoms of shortness of breath on exertion, lack of endurance, and exercise tolerance appears. A frequent reason to seek medical attention is cosmetic concern. The most common surgical treatments are the Nuss procedure and the Ravitch procedure. Several modifications of the original operation exists. Compared with the Ravitch operation, the Nuss operation duration is much shorter and had lower blood loss. Length of hospital stay was similar. The overall anesthesia and surgery-related complication rate of the Nuss procedure is between 15% and 20%. A common complication is a small pneumothorax and pleural effusion. Chest tube drainage is not always necessary. Life-threatening complications are estimated to be 0.1%. The most devastating complication, cardiac perforation, is rather seldom. Anesthesiologists should be aware of this. Adequate pain therapy is essential to prevent discomfort and allow coughing, which is important to prevent pulmonary complications. Thoracic epidural is most frequently used as a primary analgesic modality. Compared with Ravitch, Nuss patients also had higher average daily pain scores and received more opioids, although both groups received an thoracic epidural. It is unique that a minimally invasive technique produces more pain. Many alternative pain therapies are possible. A hospital protocol should be established for optimal postoperative care.

Cannabis is probably the best-known drug worldwide. Δ9-THC and 11-OH-Δ9-THC are the essential components that are responsible for the intoxicating and psychoactive effects. A general approval for pain therapy has been discussed for years. The analytical determination of low concentrations of Δ9-THC and its metabolites is therefore increasingly important. Quantitative tests in saliva, blood or urine require extensive analytical procedures including suitable sample preparation.

Background: Due to the growing interest in regional anesthesia (RA) techniques and the realization of the need for formalized education in them, the Greek Chapter of the European Society of Regional Anesthesia and Pain Therapy (ESRA-Hellas) has established a structured hands-on training course held annually since 2009, which is quite popular in the community of Greek anesthesiologists. The aim of the current survey was twofold: first, to provide an overview of the current practice of RA in Greece, secondly, to evaluate the effect the aforementioned training course has on participants’ knowledge and attitude towards RA. Methods: An electronic questionnaire was uploaded on SurveyMonkey and a link giving access to the questionnaire was forwarded via email to a mailing list of 825 practicing Greek anesthesiologists held in the electronic database of ESRA Hellas. The survey was totally anonymous and no identifying information was collected throughout. It contained questions relating to the anesthesiologists’ demographic characteristics, their RA practice, and information pertaining to the RA training course. Results: A total of 424 fully completed questionnaires were received, representing an overall response rate of 51.4%. Attendants of the course are more familiar than non-attendants with the performance of peripheral nerve blocks with neurostimulation and/or ultrasound guidance (p &lt, 0.001). Attendants are also less likely to practice exclusively general anesthesia, more likely to use peripheral blocks for lower limb surgery, and more likely to consider taking the European Diploma of RA in comparison to non-attendants (p &lt, 0.001, p = 0.018 and p = 0.002, respectively). Both cohorts consider the course of value and agree that the main reason to use regional techniques is to ensure optimal postoperative analgesia, while the main hindrance to RA practice is the lack of relevant education in the techniques, especially those under ultrasound guidance. Regarding improvement of the course, most participants suggested devoting ampler time in hands-on ultrasound practice and application. Conclusion: Greek anesthesiologists seek educational activities in the field of RA and the course seems to fulfil the majority of attendants’ expectations. There will be further effort by the organizers to improve weaknesses of the current course and undertake further educational initiatives in the field of RA according to international recommendations.

Understanding neuropathic pain presents several challenges, given the various mechanisms underlying its pathophysiological classification and the lack of suitable tools to assess its diagnosis. Furthermore, the response of this pathology to available drugs is still often unpredictable, leaving the treatment of neuropathic pain still questionable. In addition, the rise of personalized treatments further extends the ramified classification of neuropathic pain. While a few authors have focused on neuropathic pain clustering, by analyzing, for example, the presence of specific TRP channels, others have evaluated the presence of alterations in microRNAs to find tailored therapies. Thus, this review aims to synthesize the available evidence on the topic from a clinical perspective and provide a list of current demonstrations on the treatment of this disease.

Pain management for patients with chest trauma in aeromedical prehospital and retrieval medicine is important in order to maintain respiratory function. However, it can be challenging to achieve with opioids alone due to side effects including sedation, respiratory depression, and nausea.Reported are two trauma patients with uncontrolled pain despite multiple doses of opioids managed with a single-injection erector spinae plane block (ESB).The sono-anatomy and performance of the block, indications, and possible complications associated with the ESB are described.An ultrasound-guided ESB is useful for multimodal pain therapy following chest trauma in aeromedical retrieval medicine.