Targeting self-efficacy more important than dysfunctional behavioral cognitions in patients with longstanding chronic low back pain; a longitudinal study.

BACKGROUND: Multidisciplinary pain management programs based on cognitive behavioral training (CBT) principles have been shown moderately effective in improving daily functioning in patients with chronic low back pain (CLBP). To optimize health-related outcomes as daily functioning, a clear understanding of the working mechanisms of these programs is warranted. Being confident to achieve a desired outcome, i.e. self-efficacy, is suggested to be a more potent determinant for beneficial treatment outcomes than restructuring the patient's dysfunctional behavioral cognitions (pain catastrophizing and fear of movement [FoM]), but the evidence is scarce. The objective of this study was twofold: 1) to determine whether a two-week pain management program resulted in post-treatment improvements in self-efficacy and decreased dysfunctional behavioral cognitions in patients with CLBP, and 2) to examine the unique contribution of self-efficacy to improvement in post-treatment disability. METHODS: A secondary analysis of an historical cohort study was performed, including 524 patients (59% females). PRIMARY OUTCOME: functional status (Oswestry Disability Index v2.1a). SECONDARY OUTCOMES: catastrophizing (Pain Catastrophizing Scale), FoM (Tampa Scale for Kinesiophobia), and self-efficacy (Pain Self-Efficacy Questionnaire). ASSESSMENTS: pre-, post-treatment, 1, and 12-months follow-up. Paired Student's t-tests were applied and clinical relevancy of improvements was described using minimal clinical important changes. Adjusted multivariate linear regression analyses were performed to explore the unique contribution of self-efficacy. RESULTS: The mean age of patients was 46 (SD = 9.5) years and they had longstanding CLBP (mean 12.5 [SD = 10.8] years). Mean functional status, self-efficacy, and dysfunctional behavioral cognitions improved significantly at post-treatment, with improvements maintained at 12 months follow-up. Post-treatment relevant improvements in self-efficacy and dysfunctional behavioral cognitions ranged from 62.4% (FoM) to 68.7% (self-efficacy). Post-treatment self-efficacy improved the model explaining post-treatment functional disability (basic model R2 = 0.49, F(6,517) = 83.67, p < 0.001; final model R2 = 0.57, F(8,515) = 85.20, p < 0.001). This was further substantiated by the relative contribution (standardized betas) of self-efficacy: 5.67 times more than catastrophizing and 9.75 times more than FoM. CONCLUSIONS: Targeting self-efficacy contributes to fast improvement in functional status for selected and motivated patients with persistent CLBP. In pain management programs and (online) self-management programs for CLBP, targeting patients' self-efficacy should have a prominent place.

Construct Validity of the Trunk Impairment Classification System in Relation to Objective Measures of Trunk Impairment.

OBJECTIVE: To determine the validity of the Trunk Impairment Classification system (TIC) with 4 possible scores (0, most impaired; 0.5; 1.0; 1.5, least impaired) in relation to objective, instrumented measures of impairment. DESIGN: Cross-sectional design. SETTING: National wheelchair rugby and basketball competitions of The Netherlands and Belgium. PARTICIPANTS: Volunteer sample of athletes (N=34) with a minimum of 1-year experience in their sport. INTERVENTIONS: Static sitting balance tasks on a stable and unstable surface; dynamic sitting balance tasks in anterior-posterior, left-right, and oblique directions; and trunk muscle strength tasks in forward, left, right, and backward directions. MAIN OUTCOME MEASURES: Sway area of the center of pressure in static sitting balance, maximum excursion of center of pressure displacement in dynamic sitting balance, and maximum isometric force in trunk muscle strength. RESULTS: Athletes with TIC score 0 were not able to sit unsupported. The Kruskal-Wallis test showed a significant difference in trunk muscle strength (P<.001) and dynamic balance in the oblique direction forward to the left and backward to the right between the TIC scores (P=.012). Post hoc analysis showed a significant difference between TIC score 0 and the other TIC scores for trunk muscle strength in all directions. There was a significant difference between TIC score 1.5 on one hand and TIC scores 0.5 and 1.0 on the other hand for dynamic balance in the right oblique direction. CONCLUSIONS: The TIC is a valid scale for trunk impairment, which measures neuromusculoskeletal trunk impairment, independent of the health condition causing the impairment. Additional research is needed for coordination impairment and to assess whether TIC scores 0.5 and 1.0 should continue as separate scores.

Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain.

PURPOSE: The aim of this longitudinal study is to determine the factors which predict a successful 1-year outcome from an intensive combined physical and psychological (CPP) programme in chronic low back pain (CLBP) patients. METHODS: A prospective cohort of 524 selected consecutive CLBP patients was followed. Potential predictive factors included demographic characteristics, disability, pain and cognitive behavioural factors as measured at pre-treatment assessment. The primary outcome measure was the oswestry disability index (ODI). A successful 1-year follow-up outcome was defined as a functional status equivalent to 'normal' and healthy populations (ODI ≤22). The 2-week residential programme fulfills the recommendations in international guidelines. For statistical analysis we divided the database into two equal samples. A random sample was used to develop a prediction model with multivariate logistic regression. The remaining cases were used to validate this model. RESULTS: The final predictive model suggested being 'in employment' at pre-treatment [OR 3.61 (95 % CI 1.80-7.26)] and an initial 'disability score' [OR 0.94 (95 % CI 0.92-0.97)] as significant predictive factors for a successful 1-year outcome (R (2) = 22 %; 67 % correctly classified). There was no predictive value from measures of psychological distress. CONCLUSION: CLBP patients who are in work and mild to moderately disabled at the start of a CPP programme are most likely to benefit from it and to have a successful treatment outcome. In these patients, the disability score falls to values seen in healthy populations. This small set of factors is easily identified, allowing selection for programme entry and triage to alternative treatment regimes.

Improvement of the classification system for wheelchair rugby: athlete priorities.

A representative sample (N=302) of the wheelchair rugby population responded to a survey about the classification system based on prioritized items by International Wheelchair Rugby Federation members. Respondents stated, "The classification system is accurate but needs adjustments" (56%), "Any athlete with tetraequivalent impairment should be allowed to compete" (72%), "Athletes with cerebral palsy and other coordination impairments should be classified with a system different than the current one" (75%), and "The maximal value for trunk should be increased from 1.0 to 1.5" (67%). A minority stated, "Wheelchair rugby should only be open to spinal cord injury and other neurological conditions" (36%) and "There should be a 4.0 class" (33%). Results strongly indicated that athletes and stakeholders want adjustments to the classification system in two areas: a focus on evaluation of athletes with impairments other than loss of muscle power caused by spinal cord injury and changes in classification of trunk impairment.

CNS effects of indomethacin: should patients be cautioned about decreased mental alertness and motor coordination?

AIMS: In many European countries as well as in the USA, the leaflet, or even the packaging of indomethacin, contains a specific warning to refrain from activities requiring mental alertness and motor coordination, such as driving a car. In this placebo-controlled randomized study with a crossover design we attempted to find evidence for that warning. METHODS: Indomethacin 75 mg slow release or a visually identical placebo with similar flavour was taken orally twice daily for 2.5 days. It was suggested that indomethacin affects the motor coordination required to avoid obstacles successfully during walking and that this effect will be even stronger when simultaneously performing a cognitive task that puts mental alertness to the test. Nineteen healthy middle-aged individuals (60 ± 4.7 years, eight female) performed an obstacle avoidance task on a treadmill), combined with a cognitive secondary task. Biceps femoris (BF) muscle response times, obstacle avoidance failure rates and composite scores ((100 × accuracy)/verbal response time) were used to evaluate the data. RESULTS: No differences between indomethacin and placebo were found on the outcome measures regarding motor coordination, avoidance failure rates (P = 0.81) and BF response times (P = 0.47), nor on the performance on the secondary cognitive task (P = 0.12). CONCLUSIONS: Even though surrogate methods were used, the current study provides evidence to suggest that there might be no need to caution patients who experience CNS side effects after indomethacin use to avoid activities requiring quick and adequate reactions, such as walking under challenging circumstances and maybe also driving a car.

Pharmacokinetics of 450 mg ropivacaine with and without epinephrine for combined femoral and sciatic nerve block in lower extremity surgery. A pilot study.

AIMS: No pharmacokinetic data exist on doses of ropivacaine larger than 300 mg for peripheral nerve block in man, although in clinical practice higher doses are frequently used. The purpose of the present study was to describe the pharmacokinetic profile in serum of 450 mg ropivacaine with and without epinephrine in patients undergoing anterior cruciate ligament reconstruction. METHODS: Twelve patients were randomly allocated to receive a single shot combined sciatic/femoral nerve block with 60 ml of either ropivacaine 0.75% alone (group R, n = 6) or ropivacaine 0.75% plus epinephrine 5 µg ml(-1) (group RE, n = 6). Venous blood samples for total and free ropivacaine serum concentrations were obtained during 48 h following block placement. Pharmacokinetic parameters were calculated using a non-compartmental approach. RESULTS: Results are given as mean (SD) for group R vs. group RE (95% CI of the difference). Total Cmax was 2.81 (0.94) µg ml(-1) vs. 2.16 (0.21) µg ml(-1) (95% CI -0.23, 1.53). tmax was 1.17 (0.30) h vs. 1.67 (0.94) h (95% CI -1.40, 0.40). The highest free ropivacaine concentration per patient was 0.16 (0.08) µg ml(-1) vs. 0.12 (0.04) µg ml(-1) (95% CI -0.04, 0.12). t(1/2) was 6.82 (2.26) h vs. 5.48 (1.69) h (95% CI -1.23, 3.91). AUC was 28.35 (5.92) µg ml(-1) h vs. 29.12 (7.34) µg ml(-1) h (95% CI -9.35, 7.81). CONCLUSIONS: Free serum concentrations of ropivacaine with and without epinephrine remained well below the assumed threshold of 0.56 µg ml(-1) for systemic toxicity. Changes in pharmacokinetics with epinephrine co-administration did not reach statistical significance.

Outcomes After Lumbar Disk Herniation Surgery in the Dutch Population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: There is only limited data on the outcome of primary surgery of lumbar disk herniation (LDH) in Dutch patients. The objective of this study is to describe undesirable outcomes after primary LDH. METHODS: The National Claims Database (Vektis) was searched for primary LDH operations performed from July 2015 until June 2016, for reoperations within 18 months, prescription of opioids between 6 to 12 months and nerve root block within 1 year. A combined outcome measure was also made. Group comparisons were analyzed with the Student's t-test. RESULTS: Primary LDH surgery was performed in 6895 patients in 70 hospitals. Weighted mean of reoperations was 7.3%, nerve root block 6.7% and opioid use 15.6%. In total, 23.0% of patients had one or more undesirable outcomes after surgery. The 95% CI interval exceeded the 50% incidence line for 14 out of 26 hospitals with less than 50 surgical interventions per year. Although the data suggested a volume effect on undesired outcomes, the t-tests between hospitals with volume thresholds of 100, 150 and 200 interventions per year did not support this (P values 0.078, 0.129, 0.114). CONCLUSION: This unique nationwide claims-based study provides insight into patient-relevant undesirable outcomes such as reoperation, nerve root block and opioid use after LDH surgery. About a quarter of the patients had a serious complication in the first follow up year that prompted further medical treatment. There is a wide variation in complication rates between hospitals with a trend that supports concentration of LDH care.

Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence?

Background: On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards. Objective: To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI). Design setting and participants: Patients who underwent RP during 2016-2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d. Outcome measurements and statistical analysis: The relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection. Results and limitations: RP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19-85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (>120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (>120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (>120 RPs/yr for 5 yr). Conclusions: A focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended. Patient summary: In the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.

A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain: two-year follow-up results of a prospective cohort.

PURPOSE: Cognitive behavioral interventions are recommended as non-invasive treatment options for patients with chronic low back pain (CLBP). However, most treatment effects are small and short-lived. Although a 2-week intensive pain management program for patients with CLBP seems to be effective, the long-term results are not known. The purpose of this study is to evaluate the stability of the 2-year follow-up results and whether this is reflected in the use of health-care services. METHODS: A prospective cohort study was performed. Pre-treatment characteristics of patients and data of outcomes obtained at 1-year follow-up were used. At 2-year follow-up a structured interview was conducted following the principles of a post-marketing survey. Outcomes included daily functioning, quality of life, current intensity of pain, disturbance of pain during daily activities, and indicators of the use of pain medication and health-care services. RESULTS: Of the 90 eligible patients 85 (94%) participated in the post-marketing survey. The 1-year clinical relevant effects are maintained at 2-year follow-up. Effect sizes for functioning and quality of life were large. More than 65% reached preset minimal clinically important differences. At pre-treatment all patients consulted their general practitioner (GP) and medical specialist (MS). At 2-year follow-up 73% reported having consulted neither a GP nor an MS during the previous year. Most of the patients indicated not to use any pain medication (57%) and the percentage patients using opioids have decreased (14%). Moreover, 81% reported to be at work. CONCLUSIONS: The gained results from selected and motivated patients with longstanding CLBP at 1-year follow-up are stable at 2-year follow-up. Above all, most of the participants are at work and results indicate that the use of both pain medication and health care have decreased substantially.

Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease.

BACKGROUND: The number of surgical techniques for decompression and solid interbody fusion as treatment for cervical spondylosis has increased rapidly, but the rationale for the choice between different techniques remains unclear. OBJECTIVES: To determine which technique of anterior interbody fusion gives the best clinical and radiological outcomes in patients with single- or double-level degenerative disc disease of the cervical spine. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2009, issue 1), MEDLINE (1966 to May 2009), EMBASE (1980 to May 2009), BIOSIS (2004 to May 2009), and references of selected articles. SELECTION CRITERIA: Randomised comparative studies that compared anterior cervical decompression and interbody fusion techniques for participants with chronic degenerative disc disease. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias using the Cochrane Back Review Group criteria. Data on demographics, intervention details and outcome measures were extracted onto a pre-tested data extraction form. MAIN RESULTS: Thirty-three small studies ( 2267 patients) compared different fusion techniques. The major treatments were discectomy alone, addition of an interbody fusion procedure (autograft, allograft, cement, or cage), and addition of anterior plates. Eight studies had a low risk of bias. Few studies reported on pain, therefore, at best, there was very low quality evidence of little or no difference in pain relief between the different techniques. We found moderate quality evidence for these secondary outcomes: no statistically significant difference in Odom's criteria between iliac crest autograft and a metal cage (6 studies, RR 1.11 (95% CI 0.99 to1.24)); bone graft produced more effective fusion than discectomy alone (5 studies, RR 0.22 (95% CI 0.17 to 0.48)); no statistically significant difference in complication rates between discectomy alone and iliac crest autograft (7 studies, RR 1.56 (95% CI 0.71 to 3.43)); and low quality evidence that iliac crest autograft results in better fusion than a cage (5 studies, RR 1.87 (95% CI 1.10 to 3.17)); but more complications (7 studies, RR 0.33 (95% CI 0.12 to 0.92)). AUTHORS' CONCLUSIONS: When the working mechanism for pain relief and functional improvement is fusion of the motion segment, there is low quality evidence that iliac crest autograft appears to be the better technique. When ignoring fusion rates and looking at complication rates, a cage has a weak evidence base over iliac crest autograft, but not over discectomy alone. Future research should compare additional instrumentation such as screws, plates, and cages against discectomy with or without autograft.

A clinical classification system for rheumatoid forefoot deformity.

BACKGROUND AND PURPOSE: In the present study a classification system for the rheumatoid forefoot is reported with its intra- and interobserver reliability and clinical relevance. The classification is based on the sequence of anatomical changes resulting from the loss of integrity of the MTP joints, loss of motion and changes regarding the quality and position of the plantar soft tissues. It is hypothesized that with progression of the amount of deformity of the MTP joint(s), patients have more pain and functional loss. PATIENTS AND METHODS: In total 94 patients were included in the study following precise inclusion criteria. The forefeet of the patients were classified according to the introduced classification system by two observers in order to determine the intra- and interobserver reliability. The relation of the suggested classification between pain, function scores, and plantar foot pressure measurements was examined. RESULTS AND CONCLUSION: According to the Cohen's kappa and the ICC, the intra- and inter-observer reliability were high. Despite the large variation between subjects in a certain grade, a clear trend was found between increase in classification and VAS for pain, FFI difficulty with activities, and plantar peak pressure under the metatarsals. The suggested classification is of clinical relevance and can be used to develop therapeutical algorithms and to test interventions.

Thickened saliva after effective management of drooling with botulinum toxin A.

AIM: The aim of this study was to evaluate the rheological properties of saliva after submandibular botulinum toxin type A (BoNT-A) injections. METHOD: We enrolled 15 children (11 males and six females; age range 3-17 y, mean age 9 y 10 mo) diagnosed with spastic (n=9) or dyskinetic (n=6) quadriplegic cerebral palsy (CP); Gross Motor Function Classification System level IV or V; and two children with intellectual disability (IQ<70) who experienced moderate to severe drooling. Salivary flow rate and drooling quotient were measured at baseline and at different times after BoNT-A injections up to 24 weeks. The mucin concentration of saliva was analysed before and after BoNT-A treatment. RESULTS: Both submandibular salivary flow rate (baseline 0.38 mL/min; 24 wks after injection 0.26 mL/min) and drooling quotient (baseline 42.5%; 24 wks 28.80%) were substantially reduced, with a concomitant increase in mucin concentration within 8 weeks after BoNT-A injection (from 0.612 to 1.830 U/mL). The parents of nine children observed thickened saliva. Swallowing and chewing were problematic in seven children. Two of these children needed treatment with mucolytics because of pooling of thickened saliva in the throat. INTERPRETATION: When making decisions about the use of BoNT-A, the risk of problems with masticatory and swallowing functions as a result of thickening of saliva after BoNT-A treatment should be taken into account.

Botulinum toxin versus submandibular duct relocation for severe drooling.

AIM: Botulinum neurotoxin type A (BoNT-A) has been described as an effective intervention for drooling and is being increasingly adopted. However, its effectiveness compared with established treatments is still unknown. We undertook a within-participants observational study to examine this. METHOD: An historic cohort was formed of 19 children and young adults (10 males, nine females) with severe drooling who underwent BoNT-A injections followed by surgical re-routing of the submandibular duct at least 6 months later. Mean age at time of admission was 11 years 5 months (range 5-17 y) and mean age at the time of surgery was 14 years (range 6-23 y). Fifteen children were diagnosed with bilateral cerebral palsy (CP), three with unilateral CP, and one with non-progressive developmental delay. Gross Motor Function Classification System levels were the following: level I, n=1; level II, n=2; level III, n=7; level IV, n=6; and level V, n=3). The primary outcome was the drooling quotient, which was assessed before each intervention and 8 and 32 weeks thereafter. A multivariate analysis of variance of repeated measures was performed, with the measurement points as the within-participant variables. RESULTS: The drooling quotient was reduced to a greater extent after surgery than after BoNT-A administration (p=0.001). Compared with a baseline value of 28, the mean drooling quotient 8 weeks after surgery was 10, and 32 weeks after surgery was 4 (p<0.001). Among the group treated with BoNT-A, the drooling quotient showed a significant reduction from a baseline value of 30 to 18 after 8 weeks (p=0.02), and a continued but diminished effect after 32 weeks (drooling quotient 22; p=0.05). INTERPRETATION: Both interventions are effective, but surgery provides a larger and longer-lasting effect.

Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management.

Chronic low back pain (CLBP) is associated with persistent or recurrent disability which results in high costs for society. Cognitive behavioral treatments produce clinically relevant benefits for patients with CLBP. Nevertheless, no clear evidence for the most appropriate intervention is yet available. The purpose of this study is to evaluate the mid-term effects of treatment in a cohort of patients with CLBP participating in an intensive pain management programme. The programme provided by RealHealth-Netherlands is based on cognitive behavioral principles and executed in collaboration with orthopedic surgeons. Main outcome parameters were daily functioning (Roland and Morris Disability Questionnaire and Oswestry Disability Questionnaire), self-efficacy (Pain Self-Efficacy Questionnaire) and quality of life (Short Form 36 Physical Component Score). All parameters were measured at baseline, last day of residential programme and at 1 and 12 months follow-up. Repeated measures analysis was applied to examine changes over time. Clinical relevance was examined using minimal clinical important differences (MCID) estimates for main outcomes. To compare results with literature effect sizes (Cohen's d) and Standardized Morbidity Ratios (SMR) were determined. 107 patients with CLBP participated in this programme. Mean scores on outcome measures showed a similar pattern: improvement after residential programme and maintenance of results over time. Effect sizes were 0.9 for functioning, 0.8 for self-efficacy and 1.3 for physical functioning related quality of life. Clinical relevancy: 79% reached MCID on functioning, 53% on self-efficacy and 80% on quality of life. Study results on functioning were found to be 36% better and 2% worse when related to previous research on, respectively, rehabilitation programmes and spinal surgery for similar conditions (SMR 136 and 98%, respectively). The participants of this evidence-based programme learned to manage CLBP, improved in daily functioning and quality of life. The study results are meaningful and comparable with results of spinal surgery and even better than results from less intensive rehabilitation programmes.

NSAIDs and the risk of accidental falls in the elderly: a systematic review.

Accidental falls, especially those occurring in the elderly, are a major health and research topic nowadays. Besides environmental hazards and the physiological changes associated with aging, medication use (e.g. benzodiazepines, vasodilators and antidepressants) and polypharmacy are significant risk factors for falling as well. Exposure to NSAIDs has been associated with accidental falls too, although information on this area is less consistent. Therefore, the main goal of this review is to provide an updated overview of all the evidence published on the risk of falling due to NSAID use thus far. A systematic literature search for material published between 1966 and March 2008 in PubMed, EMBASE, the Cochrane Database of Systematic Reviews, Exerpta Medica, Current Contents and Science Citation Index was combined with a check of the reference lists of all the retrieved articles. Validity and data extraction of the eligible articles was assessed by adapted criteria, based on checklists that were originally developed to assess case-control or cohort studies. From the 16 selected articles, two studies were rejected because of clustering of data and one article was excluded because it contained the same data as that in one of the included articles. None of the articles retrieved included a randomized controlled trial. The remaining 13 studies all showed some lack in completeness of their statistical methods, and much variation in reporting of effects. The overall mean age was high in the study populations, leaving the results to be poorly generalizable to a larger population and other age categories. Despite these imperfections, all studies showed an increased risk of falling due to NSAID use (four significant, nine non-significant), and a tendency towards an increased fall risk with NSAID exposure could be noted. The results shown in the present review suggest that an increased risk for accidental falls is probable when elderly individuals are exposed to NSAIDs. The studies with the highest quality show that the community-dwelling elderly in particular appear to be at higher risk. This review can serve as a comprehensive overview of the published evidence on fall risk of elderly individuals attributable to the use of NSAIDs, and as an inducement for future research.

[Increase in opioid prescribing in extramural care in the Netherlands: assessment of use and prescription behaviour, based on claims data]. / Toename in extramuraal opioïdgebruik in Nederland.

OBJECTIVE: Describe the trends in extramural prescription of opioids in the Netherlands. DESIGN: Descriptive, retrospective research based on claims data of Dutch health insurers. METHOD: For each healthcare-insured Dutch resident we selected claims data for all opioids, except codeine and buprenorphine, for the period 2010-2017. We calculated the total numbers of opioid and oxycodone users, and stratified these numbers by age and sex. The average number of prescribed Defined Daily Doses (DDD), the chronicity of use, the type of prescriber, and regional patterns in opioid use were investigated. RESULTS: A total of 3,655,265 different insured persons used opioids during the research period. The yearly number of opioid users increased from 650,864 in 2010 to 1,010,474 in 2017. This increase was mainly driven by an increase in oxycodone prescriptions. Elderly and female patients were more frequent users of opioids. The ratio of short- versus long-term opioid users remained steady during the research period, with opioids being used for four months or longer in 21% of cases. General practitioners prescribed 82% of the DDDs of all opioids in 2017. The percentage of DDDs of oxycodone prescribed by medical specialists increased from 2.8% in 2010 to 14.2% in 2017. CONCLUSION: Opioid use is increasing in the Netherlands, but the long-term vs short-term use ratio has not changed in recent years. General practitioners prescribe the largest share of opioids, but a growing number of prescriptions originates from medical specialists.

Comparison of biomechanical properties of cervical artificial disc prosthesis: a review.

Cervical artificial discs are frequently implanted. Clinical data are frequently presented. However, biomechanical data are scarce. The literature is extensively reviewed following general rules for systemic review. The manufacturers of cervical artificial discs are requested for information. Only 10 articles were suitable for review. Together with some information of the manufacturer, data of 5 out of 8 discs can be provided. Comparison is not possible since testing methods differ. Before introduction of a new device biomechanical data should be provided. This should be done after standardized testing and presentation of the results. Only then comparison is possible as is a responsible choice for our patients.

From satisfaction to expectation: the patient's perspective in lower limb prosthetic care.

PURPOSE: To obtain information about the wishes and experiences of patients with a lower limb amputation with regard to prosthetic prescription and their exchange of information with the healthcare providers. DESIGN: Cross-sectional questionnaire. SETTING: Outpatient clinic of a Rehabilitation Centre. STUDY PARTICIPANTS: A random sample of patients with a lower limb amputation (n = 81). MAIN OUTCOME MEASURES: In analogy with the QUOTE questionnaire a focus group technique was used. Prosthetic users formulated 24 specific items, which were of importance according to them. The items were divided into 4 categories: (i) service demand, (ii) prosthetic prescription, (iii) information, (iv) insurance aspects. The questionnaire consisted of two sets (A and B) of 24 items rating importance of items and experience in everyday practice. To identify different dimensions within the 24 items, a factor analysis in SPSS was performed for lists A and B followed by a varimax rotation. Impact factors were calculated by multiplying the mean score of importance on an item with the percentage of patients that experienced this item as negative. RESULTS: A total of 113 questionnaires were sent by e-mail with a response of 73%. The outcomes of the questionnaires resulted in 2 sets of information: One concerning the importance of several items in the process of prosthetic prescription, the other the experience of the prosthetic user about those items. By multiplying the scores on importance by the percentage of negative experience per item (impact score) points of improvement for clinical practice were formulated. CONCLUSIONS: A discrepancy between the needs of patients and what they experience in their contacts with clinical professionals as the most important dimension was noticed. A questionnaire with specific items for a homogeneous target group is a good method to formulate points of improvement for clinical practice in healthcare.

Development of the Stroke-unit Discharge Guideline: choice of assessment instruments for prediction in the subacute phase post-stroke.

The purpose of this paper is to present the design of an evidence-based dataset of assessment instruments for the prognostic factors of the Stroke-unit Discharge Guideline (SDG), a consensus based guideline for the decision of the discharge destination from the hospital stroke unit. In our systematic literature reviews and in known standard works we have looked for assessment instruments which are being used most frequently in stroke care, and subsequently we have searched for information regarding their validity and reliability. For 17 out of the 26 prognostic factors we found known applicable assessment instruments. Clinical feasibility and psychometric properties of most of these instruments are sufficient to good. For two factors we had to construct a new instrument. A simple definition was sufficient for the remaining seven factors. The SDG contains an evidence-based dataset of prognostic factors and assessment instruments, and should be applied at the hospital stroke-unit, which is the first location to start with a uniform use of stroke assessment instruments. The SDG assessment instruments are part of the stroke service chain information system, which contains recently developed specifications for application in web-based electronic patient records nationwide in The Netherlands.

Drooling in children with cerebral palsy: a qualitative method to evaluate parental perceptions of its impact on daily life, social interaction, and self-esteem.

Research on the treatment of drooling applies measures such as salivary flow rate, qualitative observations of drooling severity in standardized situations, and anecdotal or one-dimensional parental and teacher reports. To assess drooling severity in a range of everyday conditions, and its impact on the daily life of children and their families, two parent questionnaires were constructed. Results of baseline measurements of 43 children with cerebral palsy showed that the questionnaires measured the variation in drooling severity across daily life conditions, and enabled evaluation of the impact of drooling on the ability to eat, drink and speak, on daily care, economic consequences, and social interactions. The section on the impact of drooling on self-esteem appeared not to be fully applicable for non-speaking children with a low developmental status. The questionnaires offer a qualitative method to evaluate parental perceptions of the impact of drooling and evaluate the effectiveness of interventions to reduce drooling.