Der Schmerz
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This is the first in a series of publications presenting the results of a taskforce on quality assurance in psychological assessment of chronic pain. The initiative was motivated by the increasing and confusing variety of newly developed German instruments and/or translations of Anglo-American instruments. Our main work was therefore concentrated on the collection of existing German assessment instruments, on summarizing the essentials in a documentary sheet, and on examining their objectivity, reliability, validity, clinical relevance, economy and degree of empirical foundation. For each diagnostic domain we thus elaborated specific differential recommendations for those working in psychological pain research and clinical practice, in an attempt to devise criteria enabling them to choose the optimal instrument or test battery for their needs and conditions.
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In this paper morphological and physiological experiments are described that refer to the concept of neurogenic inflammation of meningeal structures as a putative source of migrainous pain and other headaches. The main emphasis of this study carried out on the duramater encephali of the rat was the functional role of calcitonin generelated peptide (CGRP), a vasodilatory neuropeptide of fine afferent nerve fibres. Immunocytochemical preparations showed that the parietal dura mater was densely innervated by CGRP immunoreactive nerve fibres, the distribution and ultrastructure of which were examined by ligh and electron microscopy. ⋯ This increase was inhibited in a dose-dependent manner by the competitive CGRP antagonist CGRP(8-37), which shows an involvement of CGRP in the regulation of meningeal blood flow. We conclude that stimulation of trigeminal afferents innervating the dura mater releases CGRP from peptidergic afferent terminals, thereby causing vasodilatation and increasing the meningeal blood flow, an important component of neurogenic inflammation. The preparation decribed will be used for further studies on basic mechanisms of neurogenic inflammation and nociception in meningeal structures.
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The adequate use of opioids in the treatment of chronic cancer pain requires sound knowledge of selection criteria for the various opioids, the routes of administration, dosages, dosing schemes and possible side effects. Drug selection depends on the intensity of pain rather than on the specific pathophysiology. Mild to moderate pain can often be treated effectively by so-called "weak" opioids. ⋯ True dependence or psychological addiction rarely occurs in patients with chronic cancer pain. In most cases, progression of the underlying disease associated with increasing tissue damage and increasing pain is found. Fear of dependence and addiction often contributes to undertreatment of patients suffering from chronic cancer pain.
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Effective treatment of patients with trigeminal neuralgia is often a long and complicated procedure. The symptoms of trigeminal neuralgia are clearly defined in most cases. Sudden and brief episodes of severe and stabbing pain (tic douloureux) occur, with pain usually starting from a trigger point. Recent reports suggest 80-90% suppression of pain with various treatment regimens, which seems to indicate that the diagnosis and successful treatment of the disorder are no longer a major problem. In fact, however, the intense suffering of patients and isolated reports in the literature suggest that there are still considerable diagnostic difficulties. Patients are referred from one specialist to another, in most cases without the necessary interdisciplinary cooperation, and countless interventions and attempts at therapy not only remain unsuccessful, but may cause serious adverse effects. ⋯ Apparently there is a considerable need for more information about the clinical symptoms, cause, diagnosis and therapy of trigeminal neuralgia, especially as the symptoms are often no longer typical because they have become chronic or are the result of previous treatment. This is needed by all specialists involved, including dentists and general practitioners. In patients in whom clinical criteria suggest the diagnosis of trigeminal neuralgia, drug treatment should be initiated immediately in consultation with the neurologist or neurosurgeon. For cases in which drug treatment fails or resistance to the drug develops surgical treatments are available, such as non-destructive microvascular decompression or thermocoagulation of the gasserian ganglion.