Publications by authors named "Kris C Vissers"

118 Publications

"No One Can Tell Me How Parkinson's Disease Will Unfold": A Mixed Methods Case Study on Palliative Care for People with Parkinson's Disease and Their Family Caregivers.

J Parkinsons Dis 2021 Sep 15. Epub 2021 Sep 15.

Department of Anesthesiology, Radboud University Medical Center, Pain and Palliative Care, Nijmegen, The Netherlands.

Background: Palliative care for persons with Parkinson's disease (PD) is developing. However, little is known about the experiences of patients with PD in the palliative phase and of their family caregivers.

Objective: To explore needs of patients with PD in the palliative phase and of their family caregivers.

Methods: A mixed methods case study design. Health care professionals included patients for whom the answer on the question "Would you be surprised if this patient died in the next 12 months?" was negative. At baseline, and after six and twelve months, we conducted semi-structured interviews with patients and caregivers. Participants completed questionnaires on quality of life, disease burden, caregiver burden, grief, and positive aspects of caregiving. We analyzed quantitative data using descriptive statistics, while we used thematic analysis for qualitative data.

Results: Ten patients and eight family caregivers participated, of whom five patients died during the study period. While the quantitative data reflected a moderate disease burden, the qualitative findings indicated a higher disease burden. Longitudinal results showed small differences and changes in time. Patients reported a diverse range of symptoms, such as fatigue, immobility, cognitive changes, and hallucinations, which had a tremendous impact on their lives. Nevertheless, they rated their overall quality of life as moderate to positive. Family caregivers gradually learned to cope with difficult situations such delirium, fluctuations in functioning and hallucinations. They had great expertise in caring for the person with PD but did not automatically share this with health care professionals. Patients sensed a lack of time to discuss their complex needs with clinicians. Furthermore, palliative care was rarely discussed, and none of these patients had been referred to specialist palliative care services.

Conclusion: Patients with PD experienced many difficulties in daily living. Patients seems to adapt to living with PD as they rated their quality of life as moderate to positive. Family caregivers became experts in the care for their loved one, but often learned on their own. An early implementation of the palliative care approach can be beneficial in addressing the needs of patients with PD and their family caregivers.
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http://dx.doi.org/10.3233/JPD-212742DOI Listing
September 2021

Postoperative pain reduction by pre-emptive N-acetylcysteine: an exploratory randomized controlled clinical trial.

Reg Anesth Pain Med 2021 11 26;46(11):960-964. Epub 2021 Aug 26.

Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Gelderland, The Netherlands.

Background: A new potential target for multimodal pain management is the group-II metabotropic glutamate receptor subtypes, which can be activated by N-acetylcysteine. We investigated whether pre-emptive administration of N-acetylcysteine leads to a reduction in postoperative pain after laparoscopic inguinal hernia repair.

Methods: Sixty American Society of Anesthesiologists I-II patients scheduled for elective inguinal hernia repair were randomized to receive either N-acetylcysteine (150 mg/kg) or placebo intravenously 1 hour before surgery. The primary outcome was the visual analogue score during movement in the morning (approximately 24 hours) after surgery. Among secondary outcomes were postoperative opioid consumption and safety of intravenous N-acetylcysteine.

Results: In total, 23 patients were analyzed per group. Pain scores were similar at all timepoints with a 24 hours median score of 34 (IQR of 19.0 to 42.5) in the N-acetylcysteine group and a median score of 26 (16.0 to 50.0) in the placebo group. The percentage of patients using opioids after surgery was 22% versus 39% day 1 (p=0.63); 9% versus 26% day 2 (p=0.14); 9% versus 17% day 3 (p=0.35) in the N-acetylcysteine group compared with placebo group. Side effects resembling anaphylactoid reactions in response to the administration of N-acetylcysteine were present in more than half of the patients.

Conclusions: Without finding important differences between N-acetylcysteine and placebo group in pain scores postoperatively, but with a high percentage of bothersome side effects for the N-acetylcysteine group, we would not recommend the use of pre-emptive intravenous N-acetylcysteine to reduce postoperative pain in laparoscopic inguinal hernia repair patients based on this study.

Trial Registration Number: NCT03354572.
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http://dx.doi.org/10.1136/rapm-2021-102884DOI Listing
November 2021

Identification of preoperative predictors for acute postsurgical pain and for pain at three months after surgery: a prospective observational study.

Sci Rep 2021 08 12;11(1):16459. Epub 2021 Aug 12.

Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, intern 714, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.

Identifying patients at risk is the start of adequate perioperative pain management. We aimed to identify preoperative predictors for acute postsurgical pain (APSP) and for pain at 3 months after surgery to develop prediction models. In a prospective observational study, we collected preoperative predictors and the movement-evoked numerical rating scale (NRS-MEP) of postoperative pain at day 1, 2, 3, 7, week 1, 6 and 3 months after surgery from patients with a range of surgical procedures. Regression analyses of data of 2258 surgical in- and outpatients showed that independent predictors for APSP using the mean NRS-MEP over the first three days after surgery were hospital admittance, female sex, higher preoperative pain, younger age, pain catastrophizing, anxiety, higher score on functional disability, highest categories of expected pain, medical specialty, unknown wound size, and wound size > 10 cm compared to wound size ≤ 10 cm (RMSE = 2.11). For pain at three months, the only predictors were preoperative pain and a higher score on functional disability (RMSE = 1.69). Adding pain trajectories improved the prediction of pain at three months (RMSE = 1.37). Our clinically applicable prediction models can be used preoperatively to identify patients at risk, as well as in the direct postoperative period.
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http://dx.doi.org/10.1038/s41598-021-95963-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361098PMC
August 2021

Pandemic ICU triage challenge and medical ethics.

BMJ Support Palliat Care 2021 Jun 4;11(2):133-137. Epub 2021 Feb 4.

Anaesthesiology Department, Radboud University Medical Center, Nijmegen, The Netherlands.

The COVID-19 pandemic has made unprecedented global demands on healthcare in general and especially the intensive care unit (ICU). the virus is spreading out of control. To this day, there is no clear, published directive for doctors regarding the allocation of ICU beds in times of scarcity. This means that many doctors do not feel supported by their government and are afraid of the medicolegal consequences of the choices they have to make. Consequently, there has been no transparent discussion among professionals and the public. The thought of being at the mercy of absolute arbitrariness leads to fear among the population, especially the vulnerable groups.
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http://dx.doi.org/10.1136/bmjspcare-2020-002793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868132PMC
June 2021

Dorsal Root Ganglion Stimulation Normalizes Measures of Pain Processing in Patients with Chronic Low-Back Pain: A Prospective Pilot Study using Quantitative Sensory Testing.

Pain Pract 2021 06 28;21(5):568-577. Epub 2021 Jan 28.

The Spine & Pain Institute of New York, New York City, New York, U.S.A.

Background: Dorsal root ganglion stimulation (DRG-S) is used as a treatment for chronic low-back pain (CLBP), although its underlying mechanisms remain elusive. CLBP patients have been found to have reduced mechanoreceptive perception, reduced endogenous analgesia, as well as deep-tissue hyperalgesia when compared with healthy controls. Using quantitative sensory testing (QST), we studied if DRG-S in CLBP patients results in changes in pain processing.

Methods: Quantitative sensory testing was performed in patients before trial implantation of a DRG-S system for CLBP and just before the trial lead removal or at 1-month follow-up after the permanent implant. We determined the pressure pain threshold (PPT) and mechanical detection threshold (MDT) at the most painful lower-back location. PPT was also measured on the contralateral shoulder as a control. We obtained a measure of endogenous inhibitory pain modulation using conditioned pain modulation (CPM).

Results: We enrolled 11 patients (60 ± 16 years). Pain decreased from 8.5 ± 1.0 at baseline to 2.0 ± 1.5 on a 0-10 numerical rating scale with DRG-S (P < 0.01). From baseline to with DRG-S, PPT on the most painful location on the low back increased from 28.7 ± 13.6 to 43.4 ± 17.2 N/cm (P < 0.01). MDT on the same location decreased from 8.1 ± 10.4 to 3.4 ± 4.7 mN (P = 0.07). PPT on the control location and CPM did not change significantly.

Conclusions: Our results suggest that DRG-S in CLBP patients reduces deep-tissue hyperalgesia in the low back, while improving mechanoreceptive perception. These changes in both neuropathic and nociceptive components of CLBP were accompanied by clinical improvements in pain and function.
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http://dx.doi.org/10.1111/papr.12992DOI Listing
June 2021

Inappropriate end-of-life cancer care in a generalist and specialist palliative care model: a nationwide retrospective population-based observational study.

BMJ Support Palliat Care 2020 Dec 22. Epub 2020 Dec 22.

Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands.

Objectives: To evaluate the impact of provision and timing of palliative care (PC) on potentially inappropriate end-of-life care to patients with cancer in a mixed generalist-specialist PC model.

Method: A retrospective population-based observational study using a national administrative health insurance database. All 43 067 adults in the Netherlands, who were diagnosed with or treated for cancer during the year preceding their death in 2017, were included. Main exposure was either generalist or specialist PC initiated >30 days before death (n=16 967). Outcomes were measured over the last 30 days of life, using quality indicators for potentially inappropriate end-of-life care.

Results: In total, 14 504 patients (34%) experienced potentially inappropriate end-of-life care; 2732 were provided with PC >30 days before death (exposure group) and 11 772 received no PC or ≤30 days before death (non-exposure group) (16% vs 45%, p<0.001). Most patients received generalist PC (88%). Patients provided with PC >30 days before death were 5 times less likely to experience potentially inappropriate end-of-life care (adjusted OR (AOR) 0.20; (95% CI 0.15 to 0.26)) than those with no PC or PC in the last 30 days. Both early (>90 days) and late (>30 and≤90 days) PC initiation had lower odds for potentially inappropriate end-of-life care (AOR 0.23 and 0.19, respectively).

Conclusion: Timely access to PC in a mixed generalist-specialist PC model significantly decreases the likelihood of potentially inappropriate end-of-life care for patients with cancer. Generalist PC can play a substantial role.
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http://dx.doi.org/10.1136/bmjspcare-2020-002302DOI Listing
December 2020

Qualitative Evaluation of the Influence of Acute Oxaliplatin-Induced Peripheral Neuropathy on Quality of Life and Activities of Daily Life.

Pain Pract 2021 06 19;21(5):513-522. Epub 2021 Jan 19.

Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands.

Introduction/aims: Oxaliplatin often causes acute or chronic peripheral neuropathy in patients with an intestinal or pancreatic tumor, but in-depth insights in its influence on quality of life (QoL) are lacking. We explored the influence of acute oxaliplatin-induced peripheral neuropathy (OIPN) on daily QoL in these patients.

Methods: We performed semistructured interviews with a purposive sample of patients receiving oxaliplatin and possibly experiencing acute OIPN. Interviews were audio-recorded, transcribed verbatim, and coded by two researchers. Data were analyzed by using the constant comparative method for content analysis with ATLAS.ti software.

Results: After nine patients, saturation took place. In total, 11 patients were interviewed. Four themes were extracted from the data: (1) adverse effects, (2) physical (un)well-being, (3) emotional aspects, and (4) treatment aspects. All participants were suffering from acute OIPN to a certain extent, leading to restrictions in daily activities such as household chores, but also to a decrease in mobility and independency. Other adverse effects such as general malaise and gastrointestinal side effects also influenced the participants' well-being, as did the diagnosis and prognosis of their disease.

Conclusion: Acute OIPN, together with other side effects of chemotherapeutic treatment and the difficulties that come with the diagnosis of cancer and its prognosis, largely influences patients' daily QoL. Managing expectations (by patient education) seems important.
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http://dx.doi.org/10.1111/papr.12981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247978PMC
June 2021

Views of patients suffering from Failed Back Surgery Syndrome on their health and their ability to adapt to daily life and self-management: A qualitative exploration.

PLoS One 2020 7;15(12):e0243329. Epub 2020 Dec 7.

Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: The clinical outcomes of Spinal Cord Stimulation (SCS) therapy in patients with a Failed Back Surgery Syndrome (FBSS) is mostly done by standardized pain and quality of life measurements instruments and hardly account for personal feelings and needs as a basis for a patient-centred approach and shared decision making.

Objectives: The objective of this study is to explore perspectives on personal health and quality of life (QoL) in FBSS patients concerning their physical-, psychological and spiritual well-being prior to receiving an SCS system.

Methods: We performed face-to-face, semi-structured, in-depth interviews to obtain descriptive and detailed data on personal health, guided by the Web diagram of Positive Health (Huber et al.) and a topic list. The following main topics were assessed qualitatively: 1) Bodily functioning, 2) Mental function and perception 3) Spiritual dimension, 4) Quality of life, 5) Social and societal participation and 6) Daily functioning.

Results: Seventeen FBSS patients (eight male, nine female) were included from April-November 2019 at the department of pain medicine in the Albert Schweitzer Hospital in the Netherlands. Median age 49 years; range 28 to 67 years, and patients underwent between one and five lumbar surgical operations. The duration of their chronic pain was between four and 22 years. After analyzing the interviews, three themes emerged: 1) dealing with chronic pain, 2) the current situation regarding aspects of positive health, and 3) future perspectives on health and quality of life. These themes arose from eleven categories and a hundred ninety codes.

Conclusion: This qualitative study explored FBSS patients 'views on their health and the ability to adapt to daily life having complex chronic pain, and showed that patients experienced shortcomings in daily life within the six dimensions of the Web diagram of Positive Health before the SCS implant.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243329PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721158PMC
January 2021

Very Low Frequencies Maintain Pain Relief From Dorsal Root Ganglion Stimulation: An Evaluation of Dorsal Root Ganglion Neurostimulation Frequency Tapering.

Neuromodulation 2021 Jun 23;24(4):746-752. Epub 2020 Nov 23.

Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA.

Background: Dorsal root ganglion neurostimulation (DRG-S) is effective in treating various refractory chronic pain syndromes. In preclinical studies, DRG-S at very low frequencies (<5 Hz) reduces excitatory output in the superficial dorsal horn. Clinically, we have also observed the effectiveness of DRG-S at low frequencies. We conducted a case series to describe the effect of very low-frequency DRG-S stimulation on clinical outcomes.

Materials And Methods: DRG-S for refractory low back pain was initiated at parameters consistent with published values. Thereafter, the stimulation frequency of DRG-S was reduced in a stepwise fashion to the lowest frequency that maintained pain relief. Pain intensity, disability, and general health status data were collected at baseline, prior to initiation of tapering, and at four weeks after each patient's lowest effective stimulation frequency was reached.

Results: After device activation (N = 20), DRG-S frequency was tapered from 16 to 4 Hz over a 4- to 17-week period, reducing charge-per-second by nearly two-thirds. Even so, pain relief was maintained at more than 75%, with consistent findings in the other measures.

Conclusion: DRG-S may have utility in treating chronic pain at lower stimulation frequencies than previously recognized. We have previously theorized that the mechanism of action may involve preferential recruitment of low-threshold mechanoreceptor fibers via the endogenous opioid system. Of clinical relevance, lower frequency stimulation maintains DRG-S efficacy regarding improvements in pain, disability, and quality of life. It can extend battery life and may potentially lead to the development of smaller implantable pulse generators.
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http://dx.doi.org/10.1111/ner.13322DOI Listing
June 2021

Experiences From the Patient Perspective on Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Qualitatively Driven Mixed Method Analysis.

Neuromodulation 2021 Jan 23;24(1):112-125. Epub 2020 Sep 23.

Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.

Introduction: When neither pharmacological therapies nor alternative interventions provide sufficient pain relief, spinal cord stimulation (SCS) can be used to treat Failed Back Surgery Syndrome (FBSS). Although it seems reasonable that quality of life (QoL)- and psychosocial-related factors contribute to the outcome of SCS since pain is a multidimensional experience, few qualitative studies have explored the expectations of SCS and experiences on SCS to treat FBSS from the patient perspective.

Objectives: The aim of this study was to qualitatively and quantitatively map the FBSS patients' experiences with SCS and the effects of SCS on low back pain caused by FBSS.

Materials And Methods: A qualitative study with in-depth semi-structured interviews, assisted by the Brief Pain Inventory (BPI)-questionnaire.

Results: Seven themes regarding patients' experiences, subdivided into 15 categories, were identified, including an understudied theme within this field of research, Spiritual Well-Being. "Acceptance" and "coping" emerged as pre-eminent motifs throughout these themes. Moreover, the realization of patients' expectations were variable throughout the presented themes. According to the BPI Questionnaire, four out of 13 patients (31%) had significant pain relief (≥50%). Seven out of 13 (54%) reported a ≥50% increase regarding enjoyment of life.

Conclusion: Multiple QoL- and psychosocial-related themes are related to SCS-outcomes. In order to improve SCS-outcomes for both short- and long-term, these themes should be implemented as a multidimensional approach, both prior to implantation as during follow-up.
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http://dx.doi.org/10.1111/ner.13277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891647PMC
January 2021

Decreased costs and retained QoL due to the 'PACE Steps to Success' intervention in LTCFs: cost-effectiveness analysis of a randomized controlled trial.

BMC Med 2020 09 22;18(1):258. Epub 2020 Sep 22.

Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.

Background: The number of residents in long-term care facilities (LTCFs) in need of palliative care is growing in the Western world. Therefore, it is foreseen that significantly higher percentages of budgets will be spent on palliative care. However, cost-effectiveness analyses of palliative care interventions in these settings are lacking. Therefore, the objective of this paper was to assess the cost-effectiveness of the 'PACE Steps to Success' intervention. PACE (Palliative Care for Older People) is a 1-year palliative care programme aiming at integrating general palliative care into day-to-day routines in LTCFs, throughout seven EU countries.

Methods: A cluster RCT was conducted. LTCFs were randomly assigned to intervention or usual care. LTCFs reported deaths of residents, about whom questionnaires were filled in retrospectively about resource use and quality of the last month of life. A health care perspective was adopted. Direct medical costs, QALYs based on the EQ-5D-5L and costs per quality increase measured with the QOD-LTC were outcome measures.

Results: Although outcomes on the EQ-5D-5L remained the same, a significant increase on the QOD-LTC (3.19 points, p value 0.00) and significant cost-savings were achieved in the intervention group (€983.28, p value 0.020). The cost reduction mainly resulted from decreased hospitalization-related costs (€919.51, p value 0.018).

Conclusions: Costs decreased and QoL was retained due to the PACE Steps to Success intervention. Significant cost savings and improvement in quality of end of life (care) as measured with the QOD-LTC were achieved. A clinically relevant difference of almost 3 nights shorter hospitalizations in favour of the intervention group was found. This indicates that timely palliative care in the LTCF setting can prevent lengthy hospitalizations while retaining QoL. In line with earlier findings, we conclude that integrating general palliative care into daily routine in LTCFs can be cost-effective.

Trial Registration: ISRCTN14741671 .
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http://dx.doi.org/10.1186/s12916-020-01720-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507669PMC
September 2020

Is Preoperative Quantitative Sensory Testing Related to Persistent Postsurgical Pain? A Systematic Literature Review.

Anesth Analg 2020 10;131(4):1146-1155

From the Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.

Persistent postsurgical pain (PPSP) is a common complication of surgery that significantly affects quality of life. A better understanding of which patients are likely to develop PPSP would help to identify when perioperative and postoperative pain management may require specific attention. Quantitative sensory testing (QST) of a patient's preoperative pain perception is associated with acute postoperative pain, and acute postoperative pain is a risk factor for PPSP. The direct association between preoperative QST and PPSP has not been reviewed to date. In this systematic review, we assessed the relationship of preoperative QST to PPSP. We searched databases with components related to (1) preoperative QST; (2) association testing; and (3) PPSP. Two authors reviewed all titles and abstracts for inclusion. Inclusion criteria were as follows: (1) QST performed before surgery; (2) PPSP assessed ≥3 months postoperatively; and (3) the association between QST measures and PPSP is investigated. The search retrieved 905 articles; 24 studies with 2732 subjects met inclusion criteria. Most studies (22/24) had moderate to high risk of bias in multiple quality domains. Fourteen (58%) studies reported a significant association between preoperative QST and PPSP. Preoperative temporal summation of pain (4 studies), conditioned pain modulation (3 studies), and pressure pain threshold (3 studies) showed the most frequent association with PPSP. The strength of the association between preoperative QST and PPSP varied from weak to strong. Preoperative QST is variably associated with PPSP. Measurements related to central processing of pain may be most consistently associated with PPSP.
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http://dx.doi.org/10.1213/ANE.0000000000004871DOI Listing
October 2020

Severe mental illness and palliative care: patient semistructured interviews.

BMJ Support Palliat Care 2020 Aug 11. Epub 2020 Aug 11.

Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.

Objectives: To explore perceptions, experiences and expectations with respect to palliative care of patients with severe mental illness (SMI) and an incurable, life-limiting chronic illness.

Methods: Face-to-face semistructured interviews were conducted with 12 patients (10 of them living in a mental healthcare institution) with severe mental and physical health issues in the Netherlands. A semistructured interview guide was used to elicit perceptions of, experiences with and expectations regarding palliative care. Data were analysed using inductive content analysis.

Results: Analysis of the data revealed eight categories: perceptions on health and health issues, coping with illness and symptoms, experiences with and wishes for current healthcare, contact with relatives and coresidents, experiences with end of life of relatives and coresidents, willingness to discuss end of life and death, wishes and expectations regarding one's own end of life and practical aspects relating to matters after death. These categories were clustered into two separate themes: current situation and anticipation of end of life. Interviewees with SMI appeared not accustomed to communicate about end-of-life issues, death and dying due to their life-threatening illness. They tended to discuss only their current situation and, after further exploration of the researcher, the terminal phase of life. They seemed not engaged in their future palliative care planning.

Conclusions: Findings of this study highlight inadequacies in advance care planning for patients with SMI. Results suggest using values, current and near wishes, and needs as a starting point for establishing a gradual discussion concerning goals and preferences for future medical and mental treatment and care.
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http://dx.doi.org/10.1136/bmjspcare-2019-002122DOI Listing
August 2020

Translation, Cross-Cultural Adaptation, and Validation of the Pain Sensitivity Questionnaire in Dutch Healthy Volunteers.

Pain Res Manag 2020 23;2020:1050935. Epub 2020 Jul 23.

Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands.

An increased sensitivity to painful stimuli has been proposed to be related to the development of chronic pain. Therefore, assessment of individual pain sensitivity is useful in clinical practice. However, experimental pain testing may be uncomfortable for patients and requires specific equipment. The Pain Sensitivity Questionnaire (PSQ) has been developed to facilitate assessment of pain sensitivity. In this study, we aimed to translate and cross-culturally adapt the PSQ from its published German and English versions into the Dutch language and to assess validity of the PSQ in healthy volunteers. After translation and cross-cultural adaptation of the PSQ following international guidelines, we validated the PSQ in 394 healthy volunteers by comparing the PSQ-values with two different experimental pain tests: electrical pain tolerance (EPT) and pressure pain threshold (PPT). In addition, ratings of pain intensity during these tests were obtained on the numerical rating scale (NRS, 0-10). We found that the reliability of the PSQ based on internal consistency was good (Cronbach's alpha 0.90). PSQ-scores, adjusted for age and sex, were statistically significant and weakly inversely correlated to EPT (PSQ-moderate: rho = -0.24, =0.007; PSQ-total: rho = -0.22, =0.016). No statistically significant correlation between PSQ-scores and PPT was found. Concerning the pain scores, PSQ-scores were weakly to moderately correlated to EPT-NRS (PSQ-minor: rho = 0.21, =0.021; PSQ-moderate: rho = 0.22, =0.016; PSQ-total: rho = 0.23, =0.009) as well as PPT-NRS (PSQ-minor: rho = 0.32, < 0.001; PSQ-moderate: rho = 0.36, < 0.001; PSQ-total: rho = 0.37, < 0.001). Therefore, we concluded that the Dutch version of the PSQ is culturally appropriate for assessing self-reported pain sensitivity in healthy volunteers.
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http://dx.doi.org/10.1155/2020/1050935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397447PMC
November 2020

Acute Cytokine Response During Breast Cancer Surgery: Potential Role of Dexamethasone and Lidocaine and Relationship with Postoperative Pain and Complications - Analysis of Three Pooled Pilot Randomized Controlled Trials.

J Pain Res 2020 27;13:1243-1254. Epub 2020 May 27.

Department of Anesthesiology, Pain and Palliative Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands.

Purpose: An imbalance in perioperative cytokine response may cause acute pain and postoperative complications. Anesthetic drugs modulate this cytokine response, but their role in non-major breast cancer surgery is unclear. In an exploratory study, we investigated whether intravenous lidocaine and dexamethasone could modulate the cytokine response into an anti-inflammatory direction. We also evaluated interrelationships between cytokine levels, pain scores and postoperative complications. Our goal is to develop multimodal analgesia regimens optimizing outcome after breast cancer surgery.

Patients And Methods: Forty-eight patients undergoing a lumpectomy were randomly assigned to placebo or lidocaine (1.5 mg⋅kg followed by 2 mg⋅kg⋅hour) supplemented by dexamethasone zero, 4 or 8 mg, yielding six groups of eight patients. Interleukin (IL)-1β, IL-1Ra, IL-6, IL-10 levels and pain scores were measured at baseline and four hours postoperatively. We assessed postoperative complications occurring within 30 days. We noted persistent pain and infections as potential immune-related complications (PIRC). We used multiple regression to disentangle the effects of the individual study drugs (given by their partial regression coefficients (b)). Odds ratios (OR) estimated the link between pain scores and complications.

Results: Dexamethasone 8 mg increased IL-10 (b=12.70 (95% CI=8.06-17.34), <0.001). Dexamethasone 4 mg and 8 mg decreased the ratio IL-6/IL-10 (b=-2.60 (-3.93 to -1.26), <0.001 and b=-3.59 (-5.04 to -2.13), <0.001, respectively). We could not show modulatory effects of lidocaine on cytokines. High pain scores were linked to the occurrence of PIRC's (OR=2.028 (1.134-3.628), =0.017). Cytokine levels were not related either to acute pain or PIRC.

Conclusion: Dexamethasone modulated the perioperative cytokine response into an anti-inflammatory direction. An overall lidocaine effect was not found. Patients with higher pain scores suffered from more 30-day PIRCs. Cytokine levels were not associated with pain or more postoperative complications, even not with PIRC. Larger studies in breast cancer surgery are needed to confirm these explorative results.
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http://dx.doi.org/10.2147/JPR.S252377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266394PMC
May 2020

The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment.

Neuromodulation 2021 Jun 23;24(4):610-621. Epub 2020 Apr 23.

Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA.

Background: Dorsal root ganglion stimulation (DRG-S) is a novel approach to treat chronic pain. Lead placement at L2 has been reported to be an effective treatment for axial low back pain (LBP) primarily of discogenic etiology. We have recently shown, in a diverse cohort including cases of multilevel instrumentation following extensive prior back surgeries, that DRG-S lead placement at T12 is another promising target. Local effects at the T12 DRG, alone, are insufficient to explain these results.

Materials And Methods: We performed a literature review to explore the mechanisms of LBP relief with T12 DRG-S.

Findings: Branches of individual spinal nerve roots innervate facet joints and posterior spinal structures, while the discs and anterior vertebrae are carried via L2, and converge in the dorsal horn (DH) of the spinal cord at T8-T9. The T12 nerve root contains cutaneous afferents from the low back and enters the DH of the spinal cord at T10. Low back Aδ and C-fibers then ascend via Lissauer's tract (LT) to T8-T9, converging with other low back afferents. DRG-S at T12, then, results in inhibition of the converged low back fibers via endorphin-mediated and GABAergic frequency-dependent mechanisms. Therefore, T12 lead placement may be the optimal location for DRG-S to treat LBP.
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http://dx.doi.org/10.1111/ner.13150DOI Listing
June 2021

Development and Performance of a Web-Based Tool to Adjust Urine Toxicology Testing Frequency: Retrospective Study.

JMIR Med Inform 2020 Apr 22;8(4):e16069. Epub 2020 Apr 22.

The Spine & Pain Institute of New York, New York, NY, United States.

Background: Several pain management guidelines recommend regular urine drug testing (UDT) in patients who are being treated with chronic opioid analgesic therapy (COAT) to monitor compliance and improve safety. Guidelines also recommend more frequent testing in patients who are at high risk of adverse events related to COAT; however, there is no consensus on how to identify high-risk patients or on the testing frequency that should be used. Using previously described clinical risk factors for UDT results that are inconsistent with the prescribed COAT, we developed a web-based tool to adjust drug testing frequency in patients treated with COAT.

Objective: The objective of this study was to evaluate a risk stratification tool, the UDT Randomizer, to adjust UDT frequency in patients treated with COAT.

Methods: Patients were stratified using an algorithm based on readily available clinical risk factors into categories of presumed low, moderate, high, and high+ risk of presenting with UDT results inconsistent with the prescribed COAT. The algorithm was integrated in a website to facilitate adoption across practice sites. To test the performance of this algorithm, we performed a retrospective analysis of patients treated with COAT between June 2016 and June 2017. The primary outcome was compliance with the prescribed COAT as defined by UDT results consistent with the prescribed COAT.

Results: 979 drug tests (867 UDT, 88.6%; 112 oral fluid testing, 11.4%) were performed in 320 patients. An inconsistent drug test result was registered in 76/979 tests (7.8%). The incidences of inconsistent test results across the risk tool categories were 7/160 (4.4%) in the low risk category, 32/349 (9.2%) in the moderate risk category, 28/338 (8.3%) in the high risk category, and 9/132 (6.8%) in the high+ risk category. Generalized estimating equation analysis demonstrated that the moderate risk (odds ratio (OR) 2.1, 95% CI 0.9-5.0; P=.10), high risk (OR 2.0, 95% CI 0.8-5.0; P=.14), and high risk+ (OR 2.0, 95% CI 0.7-5.6; P=.20) categories were associated with a nonsignificantly increased risk of inconsistency vs the low risk category.

Conclusions: The developed tool stratified patients during individual visits into risk categories of presenting with drug testing results inconsistent with the prescribed COAT; the higher risk categories showed nonsignificantly higher risk compared to the low risk category. Further development of the tool with additional risk factors in a larger cohort may further clarify and enhance its performance.
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http://dx.doi.org/10.2196/16069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203611PMC
April 2020

RADPAC-PD: A tool to support healthcare professionals in timely identifying palliative care needs of people with Parkinson's disease.

PLoS One 2020 21;15(4):e0230611. Epub 2020 Apr 21.

Department of Anesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Parkinson's disease (PD) is a progressive degenerative disease without curative treatment perspectives. Even when palliative care for people with PD seems to be beneficial, the need for palliative care is often not timely recognized.

Aim: Our aim was to develop a tool that can help healthcare professionals in timely identifying palliative care needs in people with PD.

Design: We used a mixed-methods design, including individual and focus group interviews and a three-round modified Delphi study with healthcare professionals from a multidisciplinary field.

Results: Data from the interviews suggested two distinct moments in the progressive PD trajectory: 1) an ultimate moment to initiate Advance Care Planning (ACP); and 2) the actual start of the palliative phase. During the Delphi process, six indicators for ACP were identified, such as presence of frequent falls and first unplanned hospital admission. The start of the palliative phase involved four indicators: 1) personal goals have started to focus on maximization of comfort; 2) care needs have changed; 3) PD drug treatment has become less effective or an increasingly complex regime of drug treatments is needed; and 4) specific PD-symptoms or complications have appeared, such as significant weight loss, recurrent infections, or progressive dysphagia. Indicators for both moments are included in the RADboud indicators for PAlliative Care Needs in Parkinson's Disease (RADPAC-PD) tool.

Conclusion: The RADPAC-PD may support healthcare professionals in timely initiating palliative care for persons with PD. Identification of one or more indicators can mark the need for ACP or the palliative phase. We expect that applying the RADPAC-PD, for example on an annual basis throughout the PD trajectory, can facilitate identification of the palliative phase in PD patients in daily practice. However, further prospective research is needed on the implementation of the RADPAC-PD.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230611PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173770PMC
July 2020

Peripheral Nerve Field Stimulation for Chronic Back Pain: Therapy Outcome Predictive Factors.

Pain Pract 2020 06 24;20(5):522-533. Epub 2020 Mar 24.

Medtronic International Trading Sarl, Tolochenaz, Switzerland.

Objective: To identify variables that influence pain reduction following peripheral nerve field stimulation (PNFS) in order to identify a potential responder profile.

Methods: Exploratory univariate and multivariate (random forest) analyses were performed separately on 2 randomized controlled trials and a registry; all included patients with chronic back pain, mainly failed back surgery syndrome. An international expert panel judged the clinical relevance of variables to identify responders by consensus.

Results: Variables identified that may help predict PNFS success in patients with back pain include patient and pain characteristics (age, time since onset of pain and spinal surgery, pain medication history, position and size of pain area, pain severity, mixed nociceptive/neuropathic pain, health-related quality of life, depression, functional disability, and leg pain status), implant procedure variables (the number and position of leads, paresthesia coverage, and amount of pain relief during the trial), and programming (number of programs, cathodes, and anodes; pulse rate; pulse width; and percentage of device usage).

Conclusions: While these analyses are exploratory and restricted to a limited sample size, they suggest variables that may play a role in predicting a therapeutic response. These results, however, are informative only and should be cautiously interpreted. Future research to validate the variables in a clinical study is needed.
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http://dx.doi.org/10.1111/papr.12880DOI Listing
June 2020

Invasive Motor Cortex Stimulation Influences Intracerebral Structures in Patients With Neuropathic Pain: An Activation Likelihood Estimation Meta-Analysis of Imaging Data.

Neuromodulation 2020 Jun 6;23(4):436-443. Epub 2020 Feb 6.

Department of Anatomy, Radboud University Medical Center, Nijmegen, The Netherlands.

Objective: Invasive motor cortex stimulation (iMCS) has been proposed as a treatment for intractable neuropathic pain syndromes. Although the mechanisms underlying the analgesic effect of iMCS remain largely elusive, several studies found iMCS-related changes in regional cerebral blood flow (rCBF) in neuropathic pain patients. The aim of this study was to meta-analyze the findings of neuroimaging studies on rCBF changes to iMCS.

Methods: PubMed, Embase, MEDLINE, Google Scholar, and the Cochrane Library were systematically searched for retrieval of relevant scientific papers. After initial assessment of relevancy by screening title and abstract by two investigators, independently, predefined inclusion and exclusion criteria were used for final inclusion of papers. Descriptive results were statistically assessed, whereas coordinates were pooled and meta-analyzed in accordance with the activation likelihood estimation (ALE) methodology.

Results: Six studies were included in the systematic narrative analysis, suggesting rCBF increases in the cingulate gyrus, thalamus, insula, and putamen after switching the MCS device "ON" as compared to the "OFF" situation. Decreases in rCBF were found in for example the precentral gyrus and different occipital regions. Two studies did not report stereotactic coordinates and were excluded from further analysis. ALE meta-analysis showed that, after switching the iMCS electrode "ON," increased rCBF occurred in the (1) anterior cingulate gyrus; (2) putamen; (3) cerebral peduncle; (4) precentral gyrus; (5) superior frontal gyrus; (6) red nucleus; (7) internal part of the globus pallidus; (8) ventral lateral nucleus of the thalamus; (9) medial frontal gyrus; (10) inferior frontal gyrus; and (11) claustrum, as compared to the "OFF" situation. Reductions in rCBF were found in the posterior cingulate gyrus when the iMCS electrode was turned "OFF."

Conclusions: These findings suggested that iMCS induces changes in principal components of the default mode-, the salience-, and sensorimotor network.
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http://dx.doi.org/10.1111/ner.13119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317964PMC
June 2020

Lumbar Transgrade Dorsal Root Ganglion Stimulation Lead Placement in Patients with Post-Surgical Anatomical Changes: A Technical Note.

Pain Pract 2020 04 6;20(4):399-404. Epub 2019 Dec 6.

The Spine & Pain Institute of New York, New York, New York, U.S.A.

Background: Stimulation of the dorsal root ganglion (DRG-S) has been shown to be an efficacious treatment option for refractory neuropathic pain syndromes. However, placement of the percutaneous leads for trial implantation can be challenging in patients with prior spinal surgical interventions resulting in anatomical changes and adhesions.

Methods: This technical report describes the transgrade placement of DRG-S leads in 4 patients with back pain surgery histories in whom secondary to specific anatomical pathologies the traditional anterograde placement of DRG-S leads was not feasible.

Results: We used a transgrade placement approach, entering superior and contralateral to the target level of placement, resulting in uncomplicated and effective placement of DRG-S leads.

Conclusions: Transgrade lead placement for DRG-S may be an efficacious alternative to traditional anterograde DRG lead placement in cases where interlaminar access below the level of the DRG is not available, or desirable. Further studies are needed to clarify the safety and applicability of this approach.
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http://dx.doi.org/10.1111/papr.12859DOI Listing
April 2020

T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: A Case Series.

Neuromodulation 2020 Feb 6;23(2):203-212. Epub 2019 Oct 6.

The Spine & Pain Institute of New York, New York City, NY, USA.

Introduction: Dorsal root ganglion stimulation (DRG-S) is a neuromodulation technique for treating neuropathic pain syndromes. Research has demonstrated DRG-S to be more effective than conventional SCS in treating RSD/CRPS, particularly of the lower extremities. Results from recent case series and prospective studies suggest that DRG-S may be effective in treatment of pain syndromes considered to have non-neuropathic components and characteristics (e.g. nociceptive). There have been multiple, small studies demonstrating efficacy of DRG-S for axial low back pain. There has, however, been no consensus regarding the best location for DRG lead placement in the treatment of low back pain.

Methods: Patients presenting with refractory low back pain in a private pain management practice were considered for DRG-S. Patients were provided a trial stimulator prior to potential implantation. Per standard practice, pain intensity, disability, general health status, and quality of life were followed using the visual analog scale (VAS), Oswestry Disability Index, EQ-5D index, and the SF-36 survey, respectively. Data were collected prior to implantation and at variable follow-ups after DRG-S initiation.

Results: Seventeen consecutive patients presented with predominantly axial low back pain with/without a secondary component of lower extremity pain. All were trialed and subsequently implanted for DRG-S. Leads were placed at T12 to target the low back. Stimulation levels were set very low, below that of which patients experienced paresthesias. Last follow-up times averaged 8.3 months. More than half of the patients experienced pain relief ≥80%, with an average low back pain relief of 78% at last follow-up. Additionally, substantial improvements in physical and mental functioning, disability, and quality of life were reported.

Conclusions: T12 DRG-S can be an effective treatment for chronic axial low back pain. Stimulation results in reduced pain and disability, while improving quality of life. These outcomes can be achieved without paresthesias.
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http://dx.doi.org/10.1111/ner.13047DOI Listing
February 2020

Cost-Effectiveness Analysis of Peripheral Nerve Field Stimulation as Add-On Therapy to Spinal Cord Stimulation in the Treatment of Chronic Low Back Pain in Failed Back Surgery Syndrome Patients.

Neuromodulation 2020 Jul 18;23(5):639-645. Epub 2019 Aug 18.

Department of Anesthesiology, Pain Medicine and Palliative Care, Radboud University Medical Centre, The Netherlands.

Objective: Presently, there is only limited evidence about the cost-effectiveness of peripheral nerve field stimulation (PNFS) and no evidence to date on the cost-effectiveness of PNFS as an add-on therapy to spinal cord stimulation (SCS). In a multicenter randomized controlled trial, PNFS as add-on therapy to SCS demonstrated clinical effectiveness in treating chronic low back pain in failed back surgery syndrome (FBSS) patients. We report here the cost-effectiveness of PNFS as additional therapy.

Materials And Methods: Cost-effectiveness analysis was performed from a health-care perspective using the general principles of cost-utility analysis, using empirical data from our multicenter randomized controlled trial on the effectiveness of hybrid SCS + PNFS on low back pain in FBSS patients, who were back pain non-responders to initial SCS-therapy, over a time-horizon of three months. Outcome measures were costs and quality-adjusted life-years (QALYs). Cost and QALYs were integrated using the net monetary benefit (NMB). Differences in costs, effects, and NMB were analyzed using multilevel regression. Uncertainty surrounding the NMB was presented by cost-effectiveness acceptability curves.

Results: A total of 52 patients implanted with both SCS and PNFS, randomly assigned to a group with PNFS either activated or inactive, completed the controlled part of the study. With mean total costs for the SCS + active PNFS group of €1813.86 (SD €109.78) versus €1103.64 (SD €123.43) for the SCS + inactive PNFS group at three months, we found an incremental cost-utility ratio of €25.311 per QALY gained and a probability being cost-effective of more than 80% given a willingness to pay for a QALY of about €40.000.

Conclusions: From a Dutch national health-care context, when the willingness to pay threshold is up to 60.000 Euros per QALY, PNFS as an add-on therapy to SCS for the treatment of low back pain in FBSS patients has a high probability of being cost-effective.
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http://dx.doi.org/10.1111/ner.13032DOI Listing
July 2020

Unpredictable Injectate Spread of the Erector Spinae Plane Block in Human Cadavers.

Anesth Analg 2019 11;129(5):e163-e166

From the Departments of Anesthesiology, Pain and Palliative Medicine.

We performed bilateral ultrasound-guided erector spinae plane blocks at the second and eighth thoracic vertebrae in 11 fresh frozen cadavers. Methylene blue dye spread variably and extensively deep to the erector spinae muscles fascia with involvement of the spinal rami and paravertebral space in 1 of 11 cadavers when injected at the eighth thoracic vertebra, and in 4 of 11 cadavers at the second thoracic vertebra, with crossover to the contralateral side of the spine. Our study demonstrates that in cadavers, an erector spinae plane block follows the fascial planes with unpredictable spread, which might explain its varying clinical efficacy.
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http://dx.doi.org/10.1213/ANE.0000000000004187DOI Listing
November 2019

Simple surface EMG recording as a noninvasive screening method for the detection of acute oxaliplatin-induced neurotoxicity: a feasibility pilot study.

Neurosci Lett 2019 04 10;699:184-188. Epub 2019 Feb 10.

Donders Institute for Brain Cognition and Behavior, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands.

Objectives: Oxaliplatin-induced neurotoxicity can be a dose-limiting side effect to effective chemotherapy. Acute hyperexcitability causes cold-evoked sensory and motor symptoms, which resemble neuromyotonia. An accessible and non-invasive technique for early detection could help select patients for potential treatments. We assessed the use of a simple surface electromyography (sEMG) in patients directly after oxaliplatin infusion.

Methods: In patients with colorectal cancer, acute neurotoxicity was evaluated by means of a physical examination, a questionnaire, and sEMG directly after the second and fourth cycle of oxaliplatin. Questionnaires were also assessed 1 day after infusion.

Results: 14 patients were measured after the second cycle and 8 patients were also measured after the fourth cycle of oxaliplatin. All patients reported to a variable degree oxaliplatin induced neurotoxicity symptoms: sensitivity to touching cold or swallowing cold items were reported as most severe. Clinical signs of hyperexcitability were observed in 55% of the measurements. Spontaneous activity compatible with neuromyotonia was observed in 82% of the sEMG recordings.

Conclusions: Patient reported symptoms, physical examination and simple sEMG are complementary measurements to detect acute oxaliplatin induced neurotoxicity. After further validation, sEMG recording can be used as a simple objective screenings tool to detect nerve hyperexcitability directly after oxaliplatin administration.
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http://dx.doi.org/10.1016/j.neulet.2019.02.014DOI Listing
April 2019

Technical-efficiency analysis of end-of-life care in long-term care facilities within Europe: A cross-sectional study of deceased residents in 6 EU countries (PACE).

PLoS One 2018 25;13(9):e0204120. Epub 2018 Sep 25.

Radboud University Medical Center, Department of Anesthesiology, Pain and Palliative Medicine, Nijmegen, The Netherlands.

Background: An ageing population in the EU leads to a higher need of long-term institutional care at the end of life. At the same time, healthcare costs rise while resources remain limited. Consequently, an urgency to extend our knowledge on factors affecting efficiency of long-term care facilities (LTCFs) arises. This study aims to investigate and explain variation in technical efficiency of end-of-life care within and between LTCFs of six EU countries: Belgium (Flanders), England, Finland, Italy, the Netherlands and Poland. In this study, technical efficiency reflects the LTCFs' ability to obtain maximal quality of life (QoL) and quality of dying (QoD) for residents from a given set of resource inputs (personnel and capacity).

Methods: Cross-sectional data were collected by means of questionnaires on deceased residents identified by LTCFs over a three-month period. An output-oriented data-envelopment analysis (DEA) was performed, producing efficiency scores, incorporating personnel and capacity as input and QoL and QoD as output. Scenario analysis was conducted. Regression analysis was performed on explanatory (country, LTCF type, ownership, availability of palliative care and opioids) and case mix (disease severity) variables.

Results: 133 LTCFs of only one type (onsite nurses and offsite GPs) were considered in order to reduce heterogeneity. Variation in LTCF efficiency was found across as well as within countries. This variation was not explained by country, ownership, availability of palliative care or opioids. However, in the 'hands-on care at the bedside' scenario, i.e. only taking into account nursing and care assistants as input, Poland (p = 0.00) and Finland (p = 0.04) seemed to be most efficient.

Conclusions: Efficiency of LTCFs differed extensively across as well as within countries, indicating room for considerable efficiency improvement. Our findings should be interpreted cautiously, as comprehensive comparative EU-wide research is challenging as it is influenced by many factors.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204120PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6155520PMC
March 2019

Avoiding Catch-22: validating the PainDETECT in a in a population of patients with chronic pain.

BMC Neurol 2018 Jun 29;18(1):91. Epub 2018 Jun 29.

Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Huispost 549, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.

Background: Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system and is a major therapeutic challenge. Several screening tools have been developed to help physicians detect patients with neuropathic pain. These have typically been validated in populations pre-stratified for neuropathic pain, leading to a so called "Catch-22 situation:" "a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule". The validity of screening tools needs to be proven in patients with pain who were not pre-stratified on basis of the target outcome: neuropathic pain or non-neuropathic pain. This study aims to assess the validity of the Dutch PainDETECT (PainDETECT) in a large population of patients with chronic pain.

Methods: A cross-sectional multicentre design was used to assess PainDETECT validity. Included where patients with low back pain radiating into the leg(s), patients with neck-shoulder-arm pain and patients with pain due to a suspected peripheral nerve damage. Patients' pain was classified as having a neuropathic pain component (yes/no) by two experienced physicians ("gold standard"). Physician opinion based on the Grading System was a secondary comparison.

Results: In total, 291 patients were included. Primary analysis was done on patients where both physicians agreed upon the pain classification (n = 228). Compared to the physician's classification, PainDETECT had a sensitivity of 80% and specificity of 55%, versus the Grading System it achieved 74 and 46%.

Conclusion: Despite its internal consistency and test-retest reliability the PainDETECT is not an effective screening tool for a neuropathic pain component in a population of patients with chronic pain because of its moderate sensitivity and low specificity. Moreover, the indiscriminate use of the PainDETECT as a surrogate for clinical assessment should be avoided in daily clinical practice as well as in (clinical-) research. Catch-22 situations in the validation of screening tools can be prevented by not pre-stratifying the patients on basis of the target outcome before inclusion in a validation study for screening instruments.

Trial Registration: The protocol was registered prospectively in the Dutch National Trial Register: NTR 3030 .
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http://dx.doi.org/10.1186/s12883-018-1094-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026336PMC
June 2018

Long-Term Effect of Peripheral Nerve Field Stimulation as Add-On Therapy to Spinal Cord Stimulation to Treat Low Back Pain in Failed Back Surgery Syndrome Patients: A 12-Month Follow-Up of a Randomized Controlled Study.

Neuromodulation 2019 Dec 2;22(8):970-977. Epub 2018 Apr 2.

Department of Anesthesiology, Pain Medicine and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands.

Objective: Different approaches in neuromodulation have been used to treat chronic low back pain in failed back surgery syndrome (FBSS) patients. We previously randomized 52 FBSS patients to be treated with spinal cord stimulation (SCS) and additional peripheral nerve field stimulation (PNFS) or SCS alone. At three months, we found a significant reduction of back pain in the PNFS-SCS group compared to the SCS group. In the subsequent open phase part of the study, all patients received optimal SCS and PNFS simultaneously. Here, we present the 12-month follow-up data on back and leg pain.

Materials And Methods: Data regarding back and leg pain, function, quality of life, patient satisfaction, anxiety and depression, and use of medication were collected by analyzing patients' questionnaires at 12 months and compared with data collected at baseline. Data were analyzed using multilevel regression models.

Results: A combined group of 50 subjects completed the 12-month follow-up. Back pain, measured on a 100-mm visual analog scale (VAS), significantly decreased over this period by 30.0 mm (95% CI: [-37.7/-22.4]; p < 0.001), while leg pain decreased by 43.7 mm (95% CI: [-51.5/-36.2]; p < 0.001). We observed statistically significant improvement in almost all secondary outcome measurements.

Conclusions: At 12-month follow-up, PNFS in addition to SCS continues to provide a statistically significant and clinically relevant relief of low back pain in FBSS patients in whom SCS alone is effective for relief of leg pain only.
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http://dx.doi.org/10.1111/ner.12776DOI Listing
December 2019

Predicting Persistent Pain After Surgery: Can Predicting the Weather Serve as an Example?

Anesth Analg 2018 11;127(5):1264-1267

From the Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

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http://dx.doi.org/10.1213/ANE.0000000000003318DOI Listing
November 2018
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