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Biomedical subjects

B Zernikow

Publications and source records attributed to B Zernikow.

At least 19 recordsLinked to original sources
PubMed2006

[Buprenorphine in children. A clinical and pharmacological review].

There is a paucity of relevant pediatric data on buprenorphine, especially with respect to the long-term application in children suffering chronic pain or to pediatric pharmacokinetic as well as pharmacodynamic data after repeated sublingual or long-term transdermal administration. Compared to adults, after single-dose buprenorphine, children seem to exhibit a larger clearance related to body weight and a longer duration of action. If combined with other opioids or sedatives or if the metabolite norbuprenorphine cumulates, it is difficult to estimate the risk of respiratory depression. Clear-cut evidence is missing that in children there is a ceiling of buprenorphine-induced respiratory depression. Due to its various application routes, long duration of action, and metabolism largely independent of renal function buprenorphine is of special clinical interest in pediatrics, especially for postoperative pain and cancer pain control. There is no reason to expect effects fundamentally different from those in adults.

Adult↗
PubMed2006

[Three-week multimodal inpatient treatment of children with chronic pain. First results of the long-term follow-up].

OBJECTIVE: In children and adolescents we investigated the impact of a 3-week inpatient multimodal pain therapy on subjective burden of life, pain intensity, and number of days off from school 3, 6, or 12 months later. METHODS: At the beginning of therapy (inpatient setting) and 3, 6, and 12 months thereafter (outpatient setting) we collected the respective data using standardized questionnaires. For statistical analysis we used Wilcoxon's signed rank test. A p <0.05 was regarded as statistically significant. RESULTS: A total of 72 patients aged 7.5-18.2 years suffering daily pain entered the study, most of them being diagnosed with somatoform pain disease. After 3, 6, and 12 months, 65, 27, and 30 patients could be reevaluated. Mean pain intensity of the week before data acquisition was significantly less than at the beginning (2.9, 2.3, and 2.9 vs 6.3) as was the mean number of days off from school due to pain during the 4-week period before each day of data acquisition (1.8, 1.5, and 1.4 vs 9.2). Mean subjective burden of life was significantly less than at the beginning (24.5, 22.0, and 25.8 vs 37.8). CONCLUSION: Outpatient multimodal pain therapy has a sustained impact on children and adolescents suffering from chronic pain.

Adolescent↗
PubMed2006

[Unique children -- unique headaches. Case reports of pediatric headache patients from an outpatient children's pain department].

In the industrialized nations headache prevalence is increasing in children and adolescents. The nosologic classification determines the therapeutic strategy to follow. Three case reports illustrate the optimal cooperation of both a pediatric outpatient pain clinic and a pediatric psychosomatic pain clinic. We report on (1) a girl aged 2 years and 7 months with a 4-month history of headache episodes lasting about 15 min each with concomitant symptoms; (2) an 11-year-old boy with Schimmelpenning-Feuerstein-Mims syndrome, symptomatic focal epilepsy, psychomotor retardation, mild postinfectious internal hydrocephalus, and repeated heat-triggered episodes of right-sided headache beginning suddenly with a duration of 5-30 min and concomitant flush of his hemiface; and (3) a 12-year-old boy who for about 2 years has suffered from "migraine" 3 times a week, significantly impairing his quality of life. We discuss the patients' courses, diagnostic pitfalls, and therapeutic options. For the optimal treatment of children with headache not easily fitting into one of the categories, with significant comorbidity present, or if there is no adequate response to therapy conforming with guidelines, the help of an interdisciplinary pediatric pain clinic is invaluable.

Amines↗
PubMed2006

[Practical pain control in pediatric oncology. Recommendations of the German Society of Pediatric Oncology and Hematology, the German Association for the Study of Pain, the German Society of Palliative Care, and the Vodafone Institute of Children's Pain Therapy and Palliative Care].

In pediatric oncology, optimal pain control is still a challenge. A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in the prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented toward the WHO multistep therapeutic schedule. On no account should the pediatric patient have to climb up the "analgesic ladder" - strong pain requires the primary use of strong opioids. Give opioids preferably by the oral route and by the clock - short-acting opioids should be used to treat breakthrough pain. Alternatives are i.v. infusion, patient-controlled analgesia, and transdermal applications. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of pediatric nurses is of the utmost importance in pediatric pain control. Nurses deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses' task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our guideline we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.

Analgesics↗
PubMed2005

[Long-term pediatric opioid based pain control. Case reports].

Based on 4 case reports we focus on the peculiarities of long-term pediatric opioid based pain control. Case report #1, emphasizing the importance of adequate opioid dosing with reference to body weight, illustrates that with adequate management oral sustained-release opioid therapy is safe even in infants less than one year old. Case report #2 is the first report on the usage of buccal fentanyl citrate for pediatric break-through pain control. Case report #3 focuses on the adverse effects of opioid pain control in an infant with neurological impairment. Case report #4 reports on the successful tumor pain control using transdermal buprenorphine. We conclude that proven therapeutic strategies for opioid pain control as applied in adults may be adopted for the usage on children in pediatrics. However, it is mandatory to take into account both the pharmacokinetic and pharmacodynamic peculiarities of childhood.

Analgesics, Opioid↗
PubMed2002

[Pain control in German pediatric oncology. An inventory].

As part of a nationwide quality improvement programme, our aim is the assessment of the quality of pain control in German paediatric oncology to tailor the intervention to specific needs. Here we report on the results of a questionnaire-based nationwide survey which addressed the head of the department, one supervising physician, one ward physician, one nurse, and one psychologist/social worker in each of the 76 german paediatric oncology departments. 210/380 health care professionals of 60/76 departments responded to the survey. According to 17% of the physicians (41% of the nurses, p = 0.004) there still exists '(very) often' pain despite pain therapy. Procedures are seen as the main causes of pain. According to 58% of the heads of the department and supervising physician (35% of the nurses and ward physicians, p = 0.005), faces scales are regularly used to score pain intensity. In 80% of the departments a written therapy protocol addressing procedure-related, or postoperative pain is lacking. When larger and smaller departments are compared, in former ones the significantly preferred routes for opioid administration are i. v., or oral for slow release preparations (p = 0.01). The i. m. route is exclusively used in smaller departments. In the treatment of neuropathic pain, only 5% of the physicians regard morphine, but 25% of them regard antidepressants and antiepileptics as ineffective. Only 72% of the physicians (39% of the nurses, p = 0.001) are convinced that during opioid-based pain therapy addiction 'seldom/never' developes. Nurses are less satisfied with pain therapy than are physicians, and they feel more frequently that pain therapy '(very) often' starts too late (p <0.005). The questionnaire revealed obvious deficits in both physicians' and nurses' knowledge regarding pain therapy. Deficits were also addressed by the health care professionals themselves.

Acupuncture Therapy↗
PubMed2001

Long-acting morphine for pain control in paediatric oncology.

BACKGROUND: Guidelines for treatment of paediatric cancer pain recommend the usage of long-acting morphine. However, published paediatric experience with this drug is restricted to 147 children not systematically evaluated, and thus insufficient. We aimed to systematically analyse the age-dependent effects and adverse effects of long-acting morphine in paediatric cancer patients. PROCEDURE: Ninety-five children aged 1 to 19 years were enrolled in a collaborative retrospective study conducted over seven-and-a-half years. Pain was scored according to a numeric rating scale (NRS, range 0 to 5), and the corresponding medication was recorded. RESULTS: In 83 children documentation period started during morphine treatment (71, oral long-acting; 1, rectal; 11, IV). Mean oral/equivalent morphine starting dose was 1.3 mg/kgbw/d (SD 0.9). Mean end dose was 2.8 mg/kgbw/d (SD 2.7). Infants aged < 7 years received the highest average dose (2.6 mg/kgbw/d, SD 2.8), while patients > 12 years received the lowest dose (1.4 mg/kgbw/d, SD 1.1). Median pain intensity decreased from score 1.0 (mean 1.2) NRS at the beginning to 0 (mean 0.6) NRS at the end. The proportion of patients scoring > 2 NRS (severe or most severe pain) under morphine treatment decreased from 26 to 12% (P = 0.08). In children > 12 years pruritus was frequently observed (23% of patients). In all age groups, there were no severe adverse effects during the study period. CONCLUSIONS: In paediatric haematology/oncology, pain control by oral long-acting morphine proved to be safe and effective even in the very young patients. The pharmacological properties of long-acting morphine are ideally suited for paediatric use, combining efficacy and compatibility.

Administration, Oral↗
PubMed2000

[Pain therapy in acute pediatric diseases and vaccination].

PHENOMENON PAIN: While pain is one of the main reasons for an unscheduled visit to the paediatrician, pain due to painful procedures is of major importance in scheduled visits. Actual pain therapy is illustrated in the treatment of burns. Incomplete analgesia may have an unfavourable impact on morbidity and mortality. The pain score does not correlate with the extent of the burned area, and is regularly underestimated. General anaesthesia or analgo-sedation are warranted during the care of the burned patient. INSUFFICIENT ANALGESIA: Consequence of insufficient analgesia during primary care is an increased need of analgesics, and an increased pain treatment failure rate during subsequent procedures. Pain is interfering with anxiety, sleep disturbances and post-traumatic psychologic alterations. All those symptoms must be treated adequately. ACUTE ILLNESS AND INJECTIONS: This article covers pain from otitis media, pharyngitis, Guillain-Barré syndrome, purpura fulminans, Toxic Epidermal Nekrolysis, as well as the usage of local anaesthesia during injections, not to forget the application of non-pharmacologic methods for pain therapy and prophylaxis.

English Abstract↗
PubMed2000

[Musculoskeletal pain].

BACKGROUND: In paediatrics, numerous diseases present with the leading symptom of muscular, articular, or bone-related pain. The pain as such is seldom diagnostic with regard to pain etiology. Regularly, the significance of inflammatory as well as non-inflammatory pain is underestimated. CLASSIFICATION OF MUSCULOSKELETAL DISEASES: We present 4 case reports, illustrating the classification of musculoskeletal diseases into 4 main groups, being the basis for the modelling of disease, and pain treatment. THERAPY: Pain therapy is either symptomatic or based on specific pathophysiology. Pain therapy consists of the moduls analgesics, antiphlogistics, physiotherapy, psychosocial support, and complementary therapies. We give advice on differential therapy. A transparent team-oriented concept comprising physicians, physiotherapists, ergotherapists, psychologists, and social workers is the basis for any successful long-term therapy. Regular outpatient visits in consent with the family doctor are mandatory as are education and treatment periods on ward. We encourage our patients to join formal self-supportive patient groups.

English Abstract↗
PubMed1999

[Practice of pain control in paediatric oncology--recommendations of the quality-monitoring group of the German Society for Paediatric Oncology and Haematology (GPOH)].

In paediatric oncology, optimal pain control is still a challenge.A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented on the WHO analgesic ladder. On no account the paediatric patient should have to climb up the 'analgesic ladder'- strong pain requires the primary use of strong drugs. Opioids should be given by the oral route and by the clock - short acting opioids should be used to treat break-through pain. Alternatives are IV infusion and patient-controlled analgesia. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of paediatric nurses is of utmost importance in paediatric pain control. Nurses' deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our paper we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.

English Abstract↗
PubMed1999

Predicting length-of-stay in preterm neonates.

UNLABELLED: In neonatology, the early prediction of length-of-stay (LOS) may help in decision making. We retrospectively studied the accuracy of two LOS prediction models, namely a multiple linear regression model (MR) and an artificial neural network (ANN). Preterm neonates (n = 2144) were randomly assigned to a training-and-test (75%), or validation patient set (25%). A total of 40 first-day-of-life items (input data) and the date of discharge (output data) were routinely available. Training-and-test set data were used to identify input items with impact on LOS (input variables) using MR analysis to establish a MR prediction model and to train and test an ANN on those selected variables. Fed with validation set data, predicted LOS obtained from MR and ANN was compared individually with actual LOS. Predicted and actual LOS were highly correlated (for MR, r = 0.85 to 0.90; for ANN, r = 0.87 to 0.92). CONCLUSION: Even first-day-of-life data may contain substantial information with which to predict individual length-of-stay.

Humans↗
PubMed1999

[Modular nursing system in pediatric ambulatory care according to nursing insurance legislation XI].

UNLABELLED: In the compulsory nursing insurance according to German legislation, the assessed degree of disablement in children is dependent on their daily quantitative need for nursing care with respect to 19 distinctive items belonging to the four sectors "personal hygiene", "mobility", "nutrition", and "household duties", that exceeds normal age-dependent requirements. In ambulatory nursing, exactly that care is given to the clients. OBJECTIVE: Are there typical combinations of items scoring positively, delivering the basis for a simplified billing schedule? DESIGN AND METHODS: 4500 records from the expert assessment of children < 18 years underwent a hierarchical cluster analysis (SPSS, Ward's method). RESULTS: The resulting dendrogram revealed distinct relationships between items. The items clustered into 4 main groups. Each cluster comprised items with a common thematic relationship (A = household duties, B = mobility, C = personal hygiene, D = nutrition/leaving one's home--scoring positively may indicate extra severe disablement). CONCLUSION: Remarkably enough, the resulting four clusters are very similar to the four sectors as defined by legislation (see above), although each single item is assessed independently. Our results are similar to that found in adults (Michel et al., 1998). Here we deliver the statistical basis for a modularised system of ambulatory paediatric nursing care, or its costing.

Activities of Daily Living↗
PubMed1999

Accidental iatrogenic intoxications by cytotoxic drugs: error analysis and practical preventive strategies.

OBJECTIVES: Drug errors are quite common. Many of them become harmful only if they remain undetected, ultimately resulting in injury to the patient. Errors with cytotoxic drugs are especially dangerous because of the highly toxic potential of the drugs involved. For medico-legal reasons, only 1 case of accidental iatrogenic intoxication by cytotoxic drugs tends to be investigated at a time, because the focus is placed on individual responsibility rather than on system errors. The aim of our study was to investigate whether accidental iatrogenic intoxications by cytotoxic drugs are faults of either the individual or the system. The statistical analysis of distribution and quality of such errors, and the in-depth analysis of contributing factors delivered a rational basis for the development of practical preventive strategies. METHODS: A total of 134 cases of accidental iatrogenic intoxication by a cytotoxic drug (from literature reports since 1966 identified by an electronic literature survey, as well as our own unpublished cases) underwent a systematic error analysis based on a 2-dimensional model of error generation. Incidents were classified by error characteristics and point in time of occurrence, and their distribution was statistically evaluated. The theories of error research, informatics, sensory physiology, cognitive psychology, occupational medicine and management have helped to classify and depict potential sources of error as well as reveal clues for error prevention. RESULTS: Monocausal errors were the exception. In the majority of cases, a confluence of unfavourable circumstances either brought about the error, or prevented its timely interception. Most cases with a fatal outcome involved erroneous drug administration. Object-inherent factors were the predominant causes. A lack of expert as well as general knowledge was a contributing element. In error detection and prevention of error sequelae, supervision and back-checking are essential. Improvement of both the individual training and work environment, enhanced object identification by manufacturers and hospitals, increased redundancy, proper usage of technical aids, and restructuring of systems are the hallmarks for error prevention. CONCLUSIONS: Errors follow general patterns even in oncology. Complex interdependencies of contributing factors are the rule. Thus, system changes of the working environment are most promising with regard to error prevention. Effective error control involves adapting a set of basic principles to the specific work environment. The work environment should allow for rectification of errors without penalty. Regular and ongoing intra-organisational error analysis needs to be an integral part of any error prevention strategy. However, it seems impossible to totally eliminate errors. Instead, if the environment guarantees timely error interception, most sequelae are avoided, and errors transform into a system-wide learning tool.

Antineoplastic Agents↗
PubMed1999

[Is there equality of nursing care insurance coverage for ambulatory and non-ambulatory clients according to German law?].

UNLABELLED: In nursing insurance according to German legislation, the act of classifying the client into degrees of severity of disablement (0 = none, 1 to 3 = considerable, severe, most severe disablement) by expert assessment is based on legally defined distinct criteria (need for help items). Over and above these criteria, information with regard to the activities of daily life (ADL) is also documented routinely. PURPOSE: Is there a fundamental difference between patients suitable for ambulatory or non-ambulatory nursing care, or are their positive pattern scores for needing help fundamentally different? METHODS: Based on 7,000 electronic records of the assessments for ambulatory, and another 7,000 records for non-ambulatory nursing care, we fed artificial neural networks with all, or subsets, of the available items. Thereafter, in a crossover design, we evaluated the nets' classification competencies on independent validation data, using the ambulatory net for non-ambulatory classification, and vice versa. Weighted kappa (kw) was calculated as an index of performance. RESULTS: The nets trained on ambulatory data uniformly performed slightly better on ambulatory than on non-ambulatory data (kw = 0.78 versus 0.65, all items; 0.68 versus 0.67, only ADL items), whereas the non-ambulatory nets showed no consistent difference in respect of the nature of the input data (kw = 0.76/0.77, and 0.71/0.66). Overall, the nets' classification competence was convincing. CONCLUSION: There are inter-group differences regarding the need for care. The more severely disabled clients are mainly in the non-ambulatory group. But the principles governing the need for care are very similar in both groups. Thus, a uniform assessment procedure with regard to individual patient disability is justified. From the viewpoint of quality control, the results are reassuring.

Ambulatory Care↗
PubMed1998

Gosling's Doppler pulsatility index revisited.

In Doppler sonography, the physiological meaning of Gosling's pulsatility index (PI) as a measure of downstream resistance is still under dispute. We deliver the theoretical derivation of its physiological significance. We present a mathematical model based on the linked theories of critical closing pressure (CCP) and cerebrovascular impedance, verified in preterm neonates. Mathematical transformation results in a series of equations interrelating several physiological parameters. Instead of indicating cerebrovascular resistance, PI is linked to the ratio of cerebrovascular impedances at the heart rate and at zero frequency. Next to arterial blood pressure, CCP is the principal determinant of PI. PI is identical to the ratio of the alternate and the direct component of the effective driving force. Thus, PI has no distinctive physiological meaning by itself. At present, our model is confined to physiological conditions where the lowest velocity is the end diastolic, and always more than zero.

Blood Flow Velocity↗
PubMed1998

Artificial neural network for predicting intracranial haemorrhage in preterm neonates.

Intraventricular haemorrhage (IVH) incidence is used to assess peri-/neonatal therapy, and to make intra- and inter-hospital quality assessments. Unbiased assessment is complicated by the amount of confounding factors. Is an artificial neural network (ANN) able to early and accurately forecast the occurrence of severe IVH in an individual patient? Is it superior to classic multiple logistic regression? We conducted an observational study on pre-existing routine data. Admission data were available from 890 preterm neonates (gestational age < 32 weeks, birthweight < 1500 g). Patients were randomly assigned to either a training, or a validation set (50%/50%). Using the training set data an ANN was trained. A second predictive model was developed by stepwise multiple logistic regression analysis. Using the validation set input data both models delivered estimates of the probability for severe IVH to occur in each individual patient. Receiver operating characteristic (ROC) curves were used to compare prognostic performance. The optimal ANN processed 13 input variables, whereas stepwise logistic regression analysis only identified five independent predictor variables. The area under the ROC curve was 0.935 for the ANN and 0.884 for the logistic regression model (p = 0.001). Adjusted for 95%, 90%, 85%, 80% and 75% specificity, the sensitivity of the ANN was significantly superior to that of the logistic regression model. Due to its ability to give an accurate prognosis based solely on admission data, a trained ANN qualifies as a tool for local quality control.

Cerebral Hemorrhage↗
PubMed1998

Artificial neural network for risk assessment in preterm neonates.

AIM: To predict the individual neonatal mortality risk of preterm infants using an artificial neural network "trained" on admission data. METHODS: A total of 890 preterm neonates (< 32 weeks gestational age and/or < 1500 g birthweight) were enrolled in our retrospective study. The neural network trained on infants born between 1990 and 1993. The predictive value was tested on infants born in the successive three years. RESULTS: The artificial neural network performed significantly better than a logistic regression model (area under the receiver operator curve 0.95 vs 0.92). Survival was associated with high morbidity if the predicted mortality risk was greater than 0.50. There were no preterm infants with a predicted mortality risk of greater than 0.80. The mortality risks of two non-survivors with birthweights > 2000 g and severe congenital disease had largely been underestimated. CONCLUSION: An artificial neural network trained on admission data can accurately predict the mortality risk for most preterm infants. However, the significant number of prediction failures renders it unsuitable for individual treatment decisions.

Area Under Curve↗