Association of Perioperative Regional Analgesia with Postoperative Patient-Reported Pain Outcomes and Opioid Requirements: Comparing 22 Different Surgical Groups in 23,911 Patients from the QUIPS Registry

(1) Background: In many surgical procedures, regional analgesia (RA) techniques are associated with improved postoperative analgesia compared to systemic pain treatment. As continuous RA requires time and experienced staff, it would be helpful to identify settings in which continuous RA has the largest benefit. (2) Methods: On the basis of 23,911 data sets from 179 German and Austrian hospitals, we analyzed the association of perioperative RA with patient-reported pain intensity, functional impairment of movement, nausea and opioid use for different surgeries. Regression analyses adjusted for age, sex and preoperative pain were performed for each surgery and the following groups: patients receiving continuous RA (surgery and ward; RA++), RA for surgery only (RA+−) and patients receiving no RA (RA−−). (3) Results: Lower pain scores in the RA++ compared to the RA−− group were observed in 13 out of 22 surgeries. There was no surgery where pain scores for RA++ were higher than for RA−−. If maximal pain, function and side effects were combined, the largest benefit of continuous RA (RA++) was observed in laparoscopic colon and sigmoid surgery, ankle joint arthrodesis, revision (but not primary) surgery of hip replacement, open nephrectomy and shoulder surgery. The benefit of RA+− was lower than that of RA++. (4) Discussion: The additional benefit of RA for the mentioned surgeries is larger than in many other surgeries in clinical routine. The decision to use RA in a given surgery should be based on the expected pain intensity without RA and its additional benefits

Accuracy of standard clinical 3T prostate MRI for pelvic lymph node staging: Comparison to 68Ga-PSMA PET-CT

The aim was to assess the performance of prostate 3T MRI for pelvic lymph node (LN) staging in prostate cancer (PCa), in comparison to 68Gallium-prostate specific membrane antigen PET-CT (68Ga-PSMA PET-CT) as reference standard for LN detection. 130 patients with PCa underwent non-contrast-enhanced multiparametric prostate 3T MRI and 68Ga-PSMA-PET-CT within 180 days at our institution. Overall, 187 LN metastases (n = 43 patients) detected by 68Ga-PSMA-PET-CT were characterized by calculating maximum standardized uptake value (SUVmax), area, diameter and anatomical location including iliac, obturator, presacral and inguinal region. MRI achieved an overall sensitivity, specificity, positive and negative predictive value of 81.6% (CI 71.1-88.9%), 98.6% (CI 97.6-99.2%), 73.5% (CI 52.1-87.6%) and 99.5% (CI 98.8-99.8%), respectively. On a region-based analysis, detection rates differed non-significantly (ps > 0.12) in the anatomical regions. On a size-dependent analysis, detection of LN > 10 mm did not differ significantly (ps > 0.09) from LN ≤ 10 mm. In comparison to single T1 sequence evaluation, additional use of the T2 weighted sequences did not improve the overall performance significantly (p > 0.05). 3T prostate MRI represented an accurate tool for the detection of LN compared to 68Ga-PSMA-PET-CT. Especially for LN metastases smaller than 10 mm, MRI was less accurate compared to 68Ga-PSMA-PET-CT

Desire to Receive More Pain Treatment: A Relevant Patient-Reported Outcome Measure to Assess Quality of Post-Operative Pain Management? Results From 79,996 Patients Enrolled in the Pain Registry QUIPS from 2016 to 2019

Acute postoperative pain is frequently evaluated by pain intensity scores. However, interpretation of the results is difficult and thresholds requiring treatment are notwell defined. Additional patientreported outcome measures (PROMs) might be helpful to better understand individual pain experience and quality of pain management after surgery.We used data from the QUIPS pain registry for a cross-sectional study in order to investigate associations between the desire to receive more pain treatment (D2RMPT) with pain intensity ratings and other PROMs. Responses from 79,996 patientswere analyzed, of whom 10.7% reported D2RMPT. A generalized estimating equation Poisson model showed that women had a lower risk ratio (RR) to answer this question with “yes” (RR: .92, P < .001). Factors that increased the risk most were “maximal pain intensity ≥ 6/10 on a numerical rating scale” (RR: 2.48, P < .001) and “any pain interference” (RR: 2.48, P < .001). The largest reduction in risk was observed if patients were “allowed to participate in pain treatment decisions” (RR: .41, P < .001) and if they felt that they “received sufficient treatment information” (RR: .58, P < .001). Our results indicate that the (easily assessed) question D2RMPT gives additional information to other PROMs like pain intensity. The small proportion of patients with D2RMPT (even for high pain scores) opens the discussion about clinicians’ understanding of over- und under-treatment and questions the exclusive use of pain intensity as quality indicator. Future studies need to investigatewhether asking about D2RMPT in clinical routine can improve postoperative pain outcome. Perspective: This article presents characteristics of the patient-reported outcome measure “Desire to receive more pain treatment.” This measure could be used to apply pain treatment in a more individualized way and lead to improved treatment strategies and quality

Structural characteristics and contractual terms of specialist palliative homecare in Germany

Background Multi-professional specialist palliative homecare (SPHC) teams care for palliative patients with complex symptoms. In Germany, the SPHC directive regulates care provision, but model contracts for each federal state are heterogeneous regarding staff requirements, cooperation with other healthcare providers, and financial reimbursement. The structural characteristics of SPHC teams also vary. Aim We provide a structured overview of the existing model contracts, as well as a nationwide assessment of SPHC teams and their structural characteristics. Furthermore, we explore whether these characteristics serve to find specifc patterns of SPHC team models, based on empirical data. Methods This study is part of the multi-methods research project “SAVOIR”, funded by the German Innovations Fund. Most model contracts are publicly available. Structural characteristics (e.g. number, professions, and affiliations of team members, and external cooperation) were assessed via an online database (“Wegweiser Hospiz- und Palliativversorgung”) based on voluntary information obtained from SPHC teams. All the data were updated by phone during the assessment process. Data were descriptively analysed regarding staff, cooperation requirements, and reimbursement schemes, while latent class analysis (LCA) was used to identify structural team models. Results Model contracts have heterogeneous contract partners and terms related to staff requirements (number and qualifications) and cooperation with other services. Fourteen reimbursement schemes were available, all combining different payment models. Of the 283 SPHC teams, 196 provided structural characteristics. Teams reported between one and 298 members (mean: 30.3, median: 18), mainly nurses and physicians, while 37.8% had a psychosocial professional as a team member. Most teams were composed of nurses and physicians employed in different settings; for example, staff was employed by the team, in private practices/nursing services, or in hospitals. Latent class analysis identified four structural team models, based on the team size, team members’ affiliation, and care organisation. Conclusion Both the contractual terms and teams’ structural characteristics vary substantially, and this must be considered when analysing patient data from SPHC. The identified patterns of team models can form a starting point from which to analyse different forms of care provision and their impact on care quality

[Organisation of Perioperative Pain Management]

ZusammenfassungOrganisatorische Aspekte der postoperativen Schmerztherapie werden oft vernachlässigt – dabei sind sie ebenso wichtig wie Details zu pharmakologischen oder regionalanalgetischen Verfahren. Anhand virtueller Fragen und Erfahrungen eines Assistenzarztes beleuchten wir in diesem Artikel die „Organisation der perioperativen Schmerztherapie“: Schmerzerfassung und Dokumentation, Patienteninformation und -edukation, Aufgaben eines Akutschmerzdienstes.</jats:p

The Quality of Postoperative Pain Therapy in German Hospitals.

BACKGROUND Many patients in German hospitals complain of inadequate treatment of their postoperative pain. Hospital-related structural and procedural variables may affect pain perception and patient satisfaction. We studied the association of individual variables with outcome quality. METHODS Data from the years 2011 to 2014 from the world's largest acute pain registry (QUIPS) were evaluated. The analysis was performed with mixed linear regression models. RESULTS We studied registry data from 138 German hospitals concerning four commonly performed types of operations (total number of operations, 21 114) and found that the intensity of pain, functional impairment, and satisfaction with postoperative pain therapy were all highly variable from one hospital to another. Patients in university hospitals complained more often than those in standard care facilities of highly intense pain (odds ratio [OR] 2.44; 95% con - fidence interval [CI] [1.18; 5.04]) and dissatisfaction (OR 3.58 [1.85; 6.93]). In specialized centers as well, pain intensity (OR 1.39 [1.06; 1.83]) and dissatisfaction (OR 1.59 [1.25; 2.02]) were higher. Pain-related limitation of movement was also reported more commonly in university hospitals (OR 2.12 [0.87; 5.16]) and specialized centers (OR 1.87 [1.33; 2.65]) than in standard care facilities. Less pain-related limitation of movement and higher satisfaction were reported in hospitals in which pain was documented in the patients' charts and the patients felt adequately informed about the treatment options. CONCLUSION The current state of postoperative pain therapy leaves much room for improvement. Quality indicators in the field of acute pain medicine might help improve patient care

The effect of adjuvant oral application of honey in the management of postoperative pain after tonsillectomy in adults: A pilot study.

OBJECTIVE:To analyze the effect of adjuvant oral application of honey for treating postoperative pain after tonsillectomy. DESIGN:Single centre prospective cohort study. SETTING:Two cohorts of patients after tonsillectomy. PARTICIPANTS:56 patients treated with honey 8 times per day (honey group), 18 patients treated without honey (control group); baseline analgesia were non-steroidal anti-inflammatory drugs (NSAID) or coxibs; opioids were used as pro re nata (PRN) medication; mean age 34.4 ± 13.4 years; 36% women. MAIN OUTCOME MEASURES:On first to fifth postoperative day, patients rated their pain using the validated questionnaire of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale (NRS, 0-10) for determination of patient's pain. QUIPS allows standardized assessment of patients' characteristics andpain-associated patient-reported outcomes (PROs). The influence of preoperative and postoperative parameters on patients' postoperative pain were estimated by univariate and multivariate statistical analysis. RESULTS:Average pain in activity in the control group was greater than 4 (NRS 4.4 ± 2.4) during the first five postoperative days, with a renewed increase in pain intensity on the fifth day (4.3 ± 2.5). In the honey group, the pain in activity decreased without any further pain increase and was only higher than 4 on the first three postoperative days (4.3 ± 2.1, all p>0.05). However; neither minimal nor maximal pain were significantly different between both groups on the first postoperative day (p = 0.217, p = 0.980). Over the five postoperative days, the minimal and maximal pain in the honey group decreased continuously and faster than in the control group. With regard to pain-related impairments on the first day, the honey group reported less pain-related sleep disturbance (p = 0.026), as well as significantly fewer episodes of postoperative oral bleeding (p = 0.028) than the control group. Patients without honey consumption had on the first and fifth postoperative day a higher risk of increased minimal pain (OR = -2.424, CI = -4.075 --0.385). Gender was an independent factor for compliance of honey consumption on the second postoperative day (p = 0.037). Men had a lower probability for compliance of honey consumption (OR = -0.288, CI = -2.863 --0.090). CONCLUSION:There was a trend of reduced postoperative pain after oral honey application. Honey also seems to reduce pain-related impairments. The need for additional opioids on the first day could be reduced. A larger controlled trial is now needed to varify the effect of honey on pain after tonsillectomy. CLINICAL TRIAL REGISTRATION NUMBER:German Clinical Trials Register DRKS00006153. The authors confirm that all ongoing and related trials for this drug/intervention are registered

Pain on the first postoperative day after tonsillectomy in adults: A comparison of metamizole versus etoricoxib as baseline analgesic.

ObjectiveTo compare the effect of metamizole versus etoricoxib as baseline analgesic for treating postoperative pain after tonsillectomy.DesignSingle centre prospective cohort study.SettingTwo consecutive cohorts of tonsillectomy patients.Participants124 patients (n = 55 treated with etoricoxib, n = 69 with metamizole); median age 30.5 years; 50% women.Main outcome measuresPatients rated their pain on first postoperative day using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including numeric rating scales (NRS, 0-10) for pain determination. The influence of preoperative and postoperative parameters on patients' pain was estimated by univariate and multivariate statistical analysis.ResultsThe demographic parameters showed no differences between the patients in the metamizole group and the etoricoxib group (all p>0.05) with one exception: Patients in the metamizole group had significantly more preoperative pain than patients in the etoricoxib group (p = 0.001). The metamizole group had a mean postoperative pain in activity of 4.4 ± 2.1 and the etoricoxib group of 4.5 ± 2.2. Maximal pain for the metamizole group and the etoricoxib group were 5.6 ± 2.2 and 6.1 ± 1.9, respectively. Pain in activity, maximal pain and minimal pain were not different between both groups (p = 0.652, p = 0.113, p = 0.276, respectively). Patients of the etoricoxib group received more frequently piritramide in recovery room as demand medication (p = 0.046). In the whole cohort, patients with peritonsillar abscess had more preoperative pain in comparison to chronic tonsillitis (pConclusionEtoricoxib does not have an advantage as baseline analgesic for post tonsillectomy pain in comparison to metamizole