Characterization of cognitive symptoms in post COVID-19 patients.

Cognitive symptoms (CS) belong to the most common manifestations of the Post COVID-19 (PC) condition. We sought to objectify CS in PC patients using routine diagnostic assessments: neurocognitive testing (NCT) and brain imaging (BI). Further, we investigated possible associations of CS with patient reported outcomes (PROs), and risk factors for developing CS. Clinical data and PROs of 315 PC patients were assessed at a mean of 6 months after SARS-CoV-2 infection. 231 (73.3%) patients reported any sort of CS. Among them, 78 underwent NCT and 55 received BI. In NCT, the cognitive domains most affected were the working memory, attention, and concentration. Nonetheless, pathological thresholds were exceeded only in few cases. Neurocognitive performance did not differ significantly between patients complaining of severe (n = 26) versus non-severe (n = 52) CS. BI findings were abnormal in 8 (14.5%) cases with CS but were most likely not related to PC. Patients reporting high severity of CS scored worse in the PHQ-9, FSS, WHOQOL-BREF, were more likely to report impaired sleep, and had a higher prevalence of psychiatric diagnoses. Overall, NCT could confirm mild impairment in some but not all PC patients with CS, while BI studies were abnormal in only few cases. CS severity did not affect NCT results, but severe CS were associated with symptoms of depression (PHQ-9), fatigue (FSS), reduced quality of life (WHOQOL-BREF) and higher prevalence of psychiatric illnesses. These findings support the importance of NCT, BI, and neuro-psychological assessment in the work-up of PC patients reporting CS. TRIAL REGISTRATION: Trial registration number and date of registration: DRKS00030974, 22 Dec 2022, retrospectively registered.

Substantial differences in perception of disease severity between post COVID-19 patients, internists, and psychiatrists or psychologists: the Health Perception Gap and its clinical implications.

Patient-reported outcome measures (PROMs) such as the Numeric Pain Rating Scale (NPRS) or Likert scales addressing various domains of health are important tools to assess disease severity in Post COVID-19 (PC) patients. By design, they are subjective in nature and prone to bias. Our findings reveal substantial differences in the perception of disease severity between patients (PAT), their attending internists (INT) and psychiatrists/psychologists (PSY). Patients rated almost all aspects of their health worse than INT or PSY. Most of the differences were statistically highly significant. The presence of fatigue and mood disorders correlated negatively with health perception. The physical health section of the WHO Quality of Life Assessment (WHOQoL-BREF) and Karnofsky index correlated positively with overall and mental health ratings by PAT and INT. Health ratings by neither PAT, PSY nor INT were associated with the number of abnormal findings in diagnostic procedures. This study highlights how strongly perceptions of disease severity diverge between PC patients and attending medical staff. Imprecise communication, different experiences regarding health and disease, and confounding psychological factors may explain these observations. Discrepancies in disease perception threaten patient-physician relationships and pose strong confounders in clinical studies. Established scores (e.g., WHOQoL-BREF, Karnofsky index) may represent an approach to overcome these discrepancies. Physicians and psychologists noting harsh differences between a patient's and their own perception of the patient's health should apply screening tools for mood disorders (i.e., PHQ-9, WHOQoL-BREF), psychosomatic symptom burden (SSD-12, FCV-19) and consider further psychological evaluation. An interdisciplinary approach to PC patients remains imperative. Trial Registration Number & Date of Registration: DRKS00030974, 22 Dec 2022, retrospectively registered.

[Post-COVIDLMU: implementation and evaluation of an interdisciplinary and cross-sectoral healthcare and research network for evidence-based treatment of patients with severe post-COVID syndrome]. / Post-COVIDLMU: Implementierung und Evaluierung eines interdisziplinären und sektorenübergreifenden Versorgungs- und Forschungsnetzwerks für eine evidenzgeleitete Behandlung von Patienten mit schwerem Post-COVID-Syndrom.

Post-COVIDLMU is an interdisciplinary and cross-sectoral healthcare and research network initiated by the Munich University Hospital. The focus is on the treatment and research of adult post-COVID cases with complex and severe symptoms. The treatment of this patient group is carried out with interdisciplinary and comprehensive involvement of numerous specialized clinics of the Munich University Hospital. In addition, the university treatment services cover modern telemedical consultation, interdisciplinary case conferences together with the option for participation of referring physicians as well as the possibility for patients to take part in the respective medical research studies on post-COVID syndrome. The Munich University Hospital acts in close cooperation with physicians in private practice as well as various rehabilitation institutions in Germany.

Long-term trends in the prescription of antidiabetic drugs: real-world evidence from the Diabetes Registry Tyrol 2012-2018.

INTRODUCTION: Prescription patterns of antidiabetic drugs in the period from 2012 to 2018 were investigated based on the Diabetes Registry Tyrol. To validate the findings, we compared the numbers with trends of different national registries conducted in a comparable period of time. RESEARCH DESIGN AND METHODS: Medication data, prescription patterns, age groups, antidiabetic therapies and quality parameters (hemoglobin A1c, body mass index, complications) of 10 875 patients with type 2 diabetes from 2012 to 2018 were retrospectively assessed and descriptively analyzed. The changes were assessed using a time series analysis with linear regression and prescription trends were plotted over time. RESULTS: Sodium/glucose cotransporter 2 inhibitors (SGLT-2i) showed a significant increase in prescription from 2012 to 2018 (p<0.001), as well as metformin (p=0.002), gliptins (p=0.013) and glucagon-like peptide-1 agonists (GLP-1a) (p=0.017). Significant reduction in sulfonylurea prescriptions (p<0.001) was observed. Metformin was the most frequently prescribed antidiabetic drug (51.3%), followed by insulin/analogs (34.6%), gliptins (28.2%), SGLT-2i (11.7%), sulfonylurea (9.1%), glitazones (3.7%), GLP-1a (2.8%) and glucosidase inhibitors (0.4%). CONCLUSIONS: In this long-term, real-world study on prescription changes in the Diabetes Registry Tyrol, we observed significant increase in SGLT-2i, metformin, gliptins and GLP-1a prescriptions. In contrast prescriptions for sulfonylureas declined significantly. Changes were consistent over the years 2012-2018. Changes in prescription patterns occurred even before the publication of international and national guidelines. Thus, physicians change their prescription practice not only based on published guidelines, but even earlier on publication of cardiovascular outcome trials.

Prescription of oral antidiabetic drugs in Tyrol - Data from the Tyrol diabetes registry 2012-2015.

Diabetes mellitus affects 9% of the adult population worldwide and the economic burden of the disease is growing exponentially. In type 2 diabetes mellitus (T2DM), when life style interventions fail to achieve treatment targets, oral antidiabetic drugs are prescribed to improve glycemic control. Several new oral antidiabetics have been launched in the last few years, which enlarged the spectrum of available treatment options in T2DM. The present study aimed to examine T2DM treatment patterns in a cohort of 7769 patients recruited from the Diabetes Registry Tyrol (DRT) with at least one visit from 2012-2015. Secondly, the study aimed to evaluate the use of new oral antidiabetics compared to older oral antidiabetics (OAD). It was found that 43.4% of all patients were treated with OAD alone while 21.2% had oral antidiabetics combined with insulin. 19.9% of the study population were treated with insulin or insulin analogs only. 15.3% had no pharmacological treatment. Metformin was used most frequently (47.9% of the study population), followed by gliptines (27.2%). The most common treatment regimen in this population was the dual therapy of metformin and another OAD (17.2%), followed by metformin monotherapy (16.6%) and triple therapy of metformin and two additional OAD (11.0%).

A standardized treatment regimen for patients with severe haemophilia A undergoing orthopaedic or trauma surgery: a single centre experience.

Recommendations on the administration of clotting factor concentrates in patients with severe haemophilia undergoing surgery are usually determined by monitoring target clotting factor levels. In this retrospective cohort study, we enrolled patients with severe haemophilia A who underwent major orthopaedic or trauma surgery. We wanted to evaluate the feasibility and the safety of a standardized medical treatment procedure. Further on, we wanted to assess whether our standardized treatment regimen enables surgical procedures in certain situations in which measuring clotting factor VIII (FVIII) activity is not available. We created a standardized medical treatment procedure that included a medical protocol and close cooperation with the Haemophilic Treatment Centre. Thirteen surgical procedures in nine patients were examined. The feasibility and safety of this standardized treatment concept were assessed by identifying perioperative complications and by means of a questionnaire. Depending on the surgery, the amount of FVIII administered within the first 10 days ranged between 653 and 1027 units/kg body weight. No allogeneic blood transfusion was required. The measurement of FVIII activity was performed repeatedly in five patients. In all patients activated partial thromboplastin time monitoring was performed during the hospital stays. The surgeons and patients were satisfied with our treatment concept and adhered to the medical regimen protocol. By means of a detailed, standardized medical protocol and by ensuring close cooperation between the patient, the surgeons and the Haemophilic Treatment Centre, we could show that elective and emergency operations can be safely performed even in situations in which FVIII activity could not be monitored.

Observational study of fibrinogen concentrate in massive hemorrhage: evaluation of a multicenter register.

In acute hemorrhage, a critical decrease in fibrinogen often induces acquired coagulopathy. Fibrinogen concentrate has been used to supplement fibrinogen during massive hemorrhage. However, there are limited data on the utilization of fibrinogen concentrate in this setting. This prospective, multicenter observational study analyzed clinical treatment with fibrinogen concentrate in acute bleeding. A prospective multicenter web-based register was developed to document closed cases of massive hemorrhage treated with fibrinogen concentrate perioperatively. Anonymized data including the cause and kinetics of the bleeding, coagulation parameters, coagulation therapy, clinical effects and adverse events were recorded. Two hundred and twenty-three cases entered between September 2008 and August 2009 were eligible for analysis. According to patient needs, additional common blood and coagulation products were administered. Fibrinogen substitution by fibrinogen concentrate and fresh frozen plasma (FFP) was initiated at a median blood loss of 2.0 l and plasma fibrinogen of 1.45 g/l. After a median dose of 12.0 g fibrinogen (4 g in fibrinogen concentrate and 8 g in FFP), plasma fibrinogen rose to 2.19 g/l at the end of surgery; corresponding to a median increment of 0.045 g/l per gram of fibrinogen administered. After substitution, 6% of patients had supra-physiological plasma fibrinogen levels. Three percent of patients sustained thromboembolic complications perioperatively. Logistic regression analysis showed positive correlation of postoperative plasma fibrinogen and survival (P < 0.05). Clinical application of fibrinogen concentrate in bleeding patients is included within a multimodal therapeutic concept. High levels of fibrinogen are necessary in order to reach therapeutic goals. In bleeding patients, higher plasma fibrinogen might be associated with higher rates of survival.

Sevoflurane reduces leukocyte and platelet adhesion after ischemia-reperfusion by protecting the endothelial glycocalyx.

BACKGROUND: Adhesion of polymorphonuclear neutrophils and platelets to the vessel wall contributes to generating ischemia-reperfusion injury. Endothelial adhesion molecules are harbored within the glycocalyx, which covers every healthy vascular endothelium but is deteriorated by ischemia-reperfusion. Pretreating the heart with volatile anesthetics reduces myocardial infarct size and protects against ischemia-reperfusion injury. The authors analyzed a possible protective effect of sevoflurane on the glycocalyx and implications for postischemic cell adhesion. METHODS: Isolated guinea pig hearts were perfused with crystalloid buffer and subjected to 20 min of global warm ischemia and 10 min of reperfusion. An intracoronary bolus of 3 x 10(6) polymorphonuclear neutrophilic leukocytes or 1 x 10(9) platelets of human origin was applied after reperfusion, either with or without pretreating with 0.5 or 1 minimal alveolar concentration sevoflurane. The number of sequestered cells was calculated from the difference between coronary input and output. Coronary effluent was collected throughout reperfusion to measure shedding of the glycocalyx. RESULTS: Ischemia-reperfusion induced a significant increase in median (interquartile range) adhesion versus control nonischemic hearts of both leukocytes (38.9 (36.3-42.9) vs. 14.5 (13.1-16.0)%) and platelets (25.0 (22.5-27.1) vs. 9.4 (8.4-10.7)%). Shedding was evidenced by eightfold increases in washout of syndecan-1 and heparan sulfate versus basal. Sevoflurane reduced cell adhesion to near basal at 1 minimal alveolar concentration (leukocytes: 21.2% (19.2-23.9%), platelets: 11.5% (10.4-12.0%). Shedding measurements and electron microscopy demonstrated that sevoflurane-treated hearts retained much of their 200 nm-thick glycocalyx. CONCLUSIONS: Sevoflurane reduces glycocalyx shedding in the postischemic coronary bed, maintaining the natural cover for endothelial adhesion molecules and, thus, reducing cell adhesion. This may explain beneficial outcomes linked to clinical use of volatile anesthetics after ischemia-reperfusion.

Postoperative changes in procoagulant factors after major surgery.

Surgical patients are primarily at an increased risk of perioperative bleeding; however, after surgery, these patients develop hypercoagulability that favors thrombotic events. Currently, the time course of postoperative coagulation is not well characterized. Thus, the aim of the present study was to provide a detailed description of the changes in procoagulant factors in patients after major surgery and to evaluate coagulation tests based on their ability to detect hypercoagulability. Fifty-one consecutive patients undergoing different types of major surgery were analyzed. Blood samples were taken preoperatively and on postoperative days (PODs) 1, 2, 3, and 6. In addition to prothrombin time (PT) and activated partial thromboplastin time (aPTT), all PT-dependent and aPTT-dependent clotting factors, von Willebrand factor (vWF), and fibrinogen were obtained, and thrombelastometry and multiplate electrode aggregometry (MEA) were performed. On POD 1, the majority of clotting factors, including factors II, VII, X, XI, and XII, showed a significant decrease from baseline. Factors II, X, XI, and XII remained significantly reduced until POD 3. In contrast, starting on POD 2, fibrinogen, factor VIII, and vWF continuously increased. No relevant changes were found for PT or aPTT. Thrombelastometry revealed a continuous increase in clot firmness, and MEA demonstrated an increase in platelet aggregation on POD 6. However, absolute values remained within normal ranges, and only serial measurements showed hypercoagulation. Beginning on POD 2 after major surgery, significant hypercoagulability developed in patients. However, clinically used global coagulation tests and point-of-care devices did not reliably reflect the hypercoagulatory state.

Traumatic dissection of a coronary artery: detection by multislice computed tomography and use of tirofiban as a reversible platelet inhibitor.

We report on a trauma victim without history of or risk factors for cardiac disease, who suffered coronary artery dissection caused by blunt chest injury (BCI). Myocardial ischaemia was detected by multislice computed tomography (MSCT) promptly after trauma centre admission and managed by immediate revascularisation. Thoracic trauma may cause myocardial ischaemia in the absence of a specific risk profile. MSCT, as part of initial work-up in severely injured patients, may support differential diagnosis after BCI. Tirofiban and unfractionated heparin as short-acting anticoagulants warrant stent patency and concurrently offer the possibility of quick recovery of haemostasis in case of haemorrhage.

[Perioperative coagulation monitoring - medical and economic aspects]. / Perioperative Gerinnungsdiagnostik - Medizinische und ökonomische Perspektiven.

For preoperative haemostatic assessment a structured questionnaire for the bleeding history of the patient should be primarily used. Only in case of abnormalities an additional laboratory coagulation testing is recommended. Such a test set must include functional testing of platelets as defects of the primary haemostasis are frequent. In the event of acute acquired perioperative coagulopathy laboratory coagulation testing is a prerequisite for sophisticated and precise diagnosis and therapy. Points of care techniques like thrombelastography are capable to provide fast and extensive information.

Etoricoxib--preemptive and postoperative analgesia (EPPA) in patients with laparotomy or thoracotomy--design and protocols.

BACKGROUND AND OBJECTIVE: Our objective was to report on the design and essentials of the Etoricoxib protocol- Preemptive and Postoperative Analgesia (EPPA) Trial, investigating whether preemptive analgesia with cox-2 inhibitors is more efficacious than placebo in patients who receive either laparotomy or thoracotomy. DESIGN AND METHODS: The study is a 2 x 2 factorial armed, double blinded, bicentric, randomised placebo-controlled trial comparing (a) etoricoxib and (b) placebo in a pre- and postoperative setting. The total observation period is 6 months. According to a power analysis, 120 patients scheduled for abdominal or thoracic surgery will randomly be allocated to either the preemptive or the postoperative treatment group. These two groups are each divided into two arms. Preemptive group patients receive etoricoxib prior to surgery and either etoricoxib again or placebo postoperatively. Postoperative group patients receive placebo prior to surgery and either placebo again or etoricoxib after surgery (2 x 2 factorial study design). The Main Outcome Measure is the cumulative use of morphine within the first 48 hours after surgery (measured by patient controlled analgesia PCA). Secondary outcome parameters include a broad range of tests including sensoric perception and genetic polymorphisms. DISCUSSION: The results of this study will provide information on the analgesic effectiveness of etoricoxib in preemptive analgesia and will give hints on possible preventive effects of persistent pain. TRIAL REGISTRATION: NCT00716833.

Algorithm-based coagulation management of catastrophic amniotic fluid embolism.

Amniotic fluid embolism (AFE) is a rare, but often catastrophic, complication of pregnancy and associated with severe coagulopathy. We present an algorithm-based approach in managing coagulopathy and hemorrhage in a fatal case of histopathologically proven AFE. Thrombelastometry was used for rapid evaluation of the coagulation status. Stop of extensive hyperfibrinolysis with tranexamic acid, stabilization of initial clot formation with high-dose fibrinogen and platelet transfusions, and use of prothrombin complex concentrate together with a 1: 1 transfusion regimen of red packed cells and fresh frozen plasma was successful to control diffuse bleeding and restore clot firmness after hysterectomy. Stable clotting situation was maintained despite further clinical deterioration and development of multiple organ failure in this patient.

Whole blood multiple electrode aggregometry is a reliable point-of-care test of aspirin-induced platelet dysfunction.

BACKGROUND: Aspirin is one of the most commonly ingested over-the-counter drugs. In addition to its analgesic and antiinflammatory actions, it also potently inhibits platelet aggregation. Evaluation of aspirin-induced platelet dysfunction is relevant in various clinical situations, including during complex surgeries with high bleeding risk in individuals who have ingested aspirin. In this study, we examined the suitability of multiple electrode aggregometry (MEA) for time course assessment of the antiplatelet effects of a single oral dose of 500 mg aspirin. We also determined the applicability of this method in the point-of-care (POC) setting by comparing the results of the test after different time intervals after blood sampling. METHOD: Twenty-four adult volunteers were enrolled in the study. After blood drawing at baseline, 500 mg aspirin was administered to all volunteers. Blood samples were taken at 4, 24, 56, 80, and 124 h after aspirin ingestion. At each time point, measurements were performed immediately and 30 and 60 min after drawing blood. Whole blood MEA was performed after stimulation with thrombin receptor activating peptide (TRAPtest, 32 microM) and arachidonic acid (ASPItest, 0.5 mM). Repeated measurement analysis of variance with a Bonferroni correction for multiple comparisons was performed to detect differences between time points. Assay imprecision was determined by calculating the coefficient of variation. The level of statistical significance was set to P < 0.05. RESULTS: Platelet aggregation by ASPItest was markedly decreased 4 h after aspirin intake. From the second day after aspirin intake, ASPItest values recovered with high interindividual variability, and 5 days after aspirin intake, ASPItest values did not differ significantly from baseline. TRAP-induced platelet aggregation (TRAPtest) showed no systematic changes during the study period. The resting time of the sample did not affect TRAPtest or ASPItest values. The coefficients of variation were 10% for the ASPItest and 7% for the TRAPtest. CONCLUSIONS: MEA reliably detected the effects of aspirin. Notably, 500 mg aspirin caused complete inhibition of arachidonic acid-induced platelet aggregation for 2 days in all volunteers. Aggregation returned to baseline values with a wide interindividual variation in time course by day 5. No resting time for the blood sample was required for ASPItest or TRAPtest. These assays can be implemented as real POC tests. The reproducibility of the assays studied here is within the range of modern POC analyzers.

Perioperative haemostatic management of Glanzmann thrombasthenia for abdominal surgery.

Glanzmann thrombasthenia is a rare congenital platelet disorder characterized by spontaneous mucocutaneous bleeding and severe bleeding complications during major surgery. This report centres on the perioperative haemostatic management of a patient with Glanzmann thrombasthenia undergoing elective major abdominal surgery. The treatment regimen was based mainly on recombinant activated factor VII, fibrinogen, and factor XIII, reducing platelet transfusion to a minimum. No red blood cell transfusions were needed perioperatively. For haemostatic monitoring, routine laboratory tests were sufficient.

[Hemostasis management in multiple trauma patients--value of near-patient diagnostic methods]. / Hämostaseologisches Management beim Polytrauma--Stellenwert der patientennahen diagnostischen Methoden.

Massively transfused multiple trauma patients commonly develop a complex coagulopathy which needs immediate treatment. Near-patient diagnostic methods are available for the management of this coagulopathy and for the guidance of the therapeutic options with blood products and haemostatic drugs: conventional laboratory analysis methods adapted to the point-of-care (POC) situation (blood gas analysis, point of care PT, APTT and platelet count), and the complex whole blood methods used for near-patient coagulation monitoring (thromboelastometry and platelet function analysis). Based on the new Guidelines of the German Medical Association for the use of blood and plasma derivates, interventions with blood products and haemostatic drugs in multiple trauma patients are suggested. The diagnostic value of near-patient methods for coagulation monitoring is discussed.

Celiac dissection after blunt abdominal trauma complicated by acute hepatic failure: case report and review of literature.

Injuries of the abdominal visceral vessels are uncommon but devastating entities resulting in extremely high rates of mortality. The most common cause of abdominal vascular injuries is penetrating trauma, accounting for 90% to 95% of these injuries. In contrast, blunt trauma accounts for 5% to 10% of all abdominal vascular lesions. Although traumatic injury to the celiac artery is among the rarest of all vascular injuries, mortality can be as high as 75%. We report a 66-year-old patient who sustained multiple injuries in a motor vehicle crash. The initial whole-body computed tomography (CT) scan revealed a combination of severe brain injury and bilateral thoracic lesions. On day 6 after the accident, the patient's clinical situation deteriorated rapidly. At this time, the abdominal arterial CT scan showed a dissection of the celiac artery. Therapeutic anticoagulation was not feasible because of the intracranial hemorrhage. Also the patient's clinical situation worsened so rapidly that interventional therapy, including surgical and endovascular treatment, could not be performed. Finally, the patient died of fulminant hepatic failure, therefore not surviving a potentially treatable injury. The diagnosis of celiac artery dissection in this patient was significantly delayed because the initial trauma CT protocol did not include an arterial phase of the abdominal vessels.

Fibrinogen concentrate reverses dilutional coagulopathy induced in vitro by saline but not by hydroxyethyl starch 6%.

Severe bleeding often induces coagulopathy via loss, consumption, and dilution of clotting factors and platelets. The aims of our in vitro study were to characterize the influence of progressive hemodilution with either NaCl 0.9% or hydroxyethyl starch (HES) 6% on blood clot formation and to analyze the effect of substitution of fibrinogen and platelets on dilutional coagulopathy. Whole blood samples drawn from 8 volunteers were diluted from 20% to 80% of the sample volume with both diluents separately. Clot formation was measured by thrombelastography. At a 60% dilution, either fibrinogen and/or platelets were added to the samples. Clot firmness became critical after 40% dilution with HES 6% but not until 60% dilution with NaCl 0.9%. When platelet function was blocked, fibrin polymerization was severely impaired after 20% dilution with HES 6%, whereas such an effect was only seen after 80% dilution with NaCl 0.9%. The addition of fibrinogen reconstituted the clot firmness in the presence of NaCl 0.9%, but this had only a minor effect after dilution with HES 6%. Platelets alone or in addition were not able to improve clot firmness to a clinically relevant extent. Dilutional coagulopathy induced by crystalloids can, in vitro, be effectively reversed by supplementation of fibrinogen. In contrast, HES molecules interfere with fibrin polymerization and, thus, administration of fibrinogen after dilution with HES 6% failed to significantly improve clot firmness.

Comparison of a biopsychosocial therapy (BT) with a conventional biomedical therapy (MT) of subacute low back pain in the first episode of sick leave: a randomized controlled trial.

This randomized controlled clinical trial compares the effectiveness of a biopsychosocial treatment with a solely conventional biomedical therapy in patients with subacute low back pain using parameters for pain intensity, functional status, depressive dysfunction and work performance. Sixty-four patients with a first-time sick leave between 3 and 12 weeks due to low back pain were randomly assigned to either a conventional biomedical therapy (MT; n=33) group, or a biopsychosocial therapy (BT; n=31) group including a psychotherapeutic module; both in accordance with a standardized 3 weeks inpatient treatment. Pain intensity, functional back capacity, clinical parameters and depressive dysfunction revealed significant improvement in both treatment groups at end of 3 weeks therapy (T1). However, at 6 months (T2), analysis revealed significant better results for nearly all parameters in the BT group that showed further improvement from T1 to T2, whereas the values in the MT group deteriorated from T1 back to the baseline values. During the 2-year period after therapy, 10% in MT and 59% in BT required no further sick leave due to low back pain. The results of the study indicate that a psychotherapeutic element in the treatment of low back pain appears to positively influence pain, functional status and work performance when conducted at an early stage of chronification and helps in the achievement of a better outcome.

Spatial and temporal parameters of gait disturbances in schizophrenic patients.

This study assessed the locomotor patterns of gait in schizophrenic patients and differentiated intrinsic effects of the illness from those caused by conventional and atypical neuroleptic treatment. Gait parameters of drug-naïve, conventionally and atypically treated patients as well as control subjects were evaluated. Differences in gait velocity and in stride length between the four investigated groups were highly significant (ANOVA: p<0.001). Mean gait velocities of all patient groups were significantly slower than those of controls, with the most striking difference observed between the control group and patients treated with conventional neuroleptics (p <0.001). Amongst the patient groups, significant differences were detected between patients treated with conventional neuroleptics and both patients treated with atypical neuroleptics and drug-naïve patients (p < 0.05), but not between untreated and atypically treated patients. In all patient groups the reduction of gait velocity was due to a smaller mean stride length, while the cadence (steps per minute) was not changed. These results indicate that schizophrenia causes a primary disturbance of stride length regulation. Conventional antipsychotic treatment intensifies this deficit, whereas atypical antipsychotic treatment does not cause any additional gait disturbances. In contrast to the spatial parameters, the temporal structure of schizophrenic gait is not affected either by antipsychotic treatment or schizophrenia itself.