Which Back Pain Patients Benefit From Multidisciplinary Pain Management? A Comparative Cost Analysis Using Claims Data of Statutory Health Insurance.

Aim: Multidisciplinary pain therapy (MPT) is considered as best practice for treating patients with chronical back pain. Several studies showed the cost effectiveness of interdisciplinary treatment. The aim of the present study is to identify patient characteristics that, under condition of MMT, can be associated with favourable cost trajectories after intervention. We assume that an improved health status leads to less health care utilisation. Furthermore, we aim at identifying those patients with back pain without MPT for whom we can expect favourable cost trajectories. Methods: On the basis of pseudonymised claims data of a nationwide health insurance, we identified MMT back pain patients as well as a control group of back pain patients without MMT. Using comparative cost analysis (costs insensitive to indication), we determined those MMT patients for whom the cumulated total costs per patient for the two postinterventional years were lower than the mean cumulated total costs of the control group. By means of a CART analysis, we identified statistically significant characteristics (profiles) associated with these favourable cost trajectories. Additionally, we quantified control group patients with the same profiles. Results: The study population comprised 1 252 patients with specific back pain and 767 patients with pain due to spinal disc conditions who received MPT. Compared to the control group, total post-therapy costs (insensitive to indication) of MPT patients were higher. For roughly half of MPT patients per pain type, we could identify favourable cost trajectories as per definition. These patients mainly displayed lower levels of pain intensity, no pain-related hospitalisation, and less (mental) co-morbidity in the year preceding the intervention. These profiles concerned to 58-65% of back pain patients without MPT. Conclusion: The developed methodology enables identification of back pain patients likely to benefit from MPT. The study points out the need for patient individual pain management and underlines the importance of early-stage integration of patients into multidisciplinary pain management programmes.

Associations between lifetime PTSD symptoms and current substance use disorders using a five-factor model of PTSD.

This paper aimed to extend the existing knowledge on the association between PTSD symptoms, alcohol use disorders (AUD) and nicotine dependence (ND) by distinguishing between anxious and dysphoric arousal PTSD symptoms and by considering the putative contribution of additional comorbidity. Data stem from a cross-sectional study in a stratified, representative sample of 1483 recently deployed soldiers using standardized diagnostic interviews. All lifetime PTSD symptom clusters (occurrence of any symptom and number of symptoms) were associated with current AUD and ND in crude models except that anxious arousal was not related to AUD. Associations were reduced in magnitude when controlling for comorbidity. Current ND was related to the occurrence of any emotional numbing and to the number of re-experiencing symptoms above the contribution of other symptom clusters and comorbidity. In conclusion, associations between PTSD symptoms, AUD and ND may be partially attributable to additional comorbidity. Findings also yield further evidence for a role of emotional numbing and re-experiencing symptoms in the comorbidity between PTSD and ND and for a distinction between dysphoric and anxious arousal PTSD symptoms.

Predictors of changes in daily alcohol consumption in the aftermath of military deployment.

BACKGROUND: Several studies have documented factors related to increase in alcohol consumption in the context of stressful experiences. However, little is known about predictors of different courses of alcohol use in this context. This study aims to investigate diverse predictors and correlates of increase and decrease of average daily alcohol consumption (aDAC) in the aftermath of military deployment taking into account a variety of potentially relevant factors. METHODS: N=358 soldiers were examined before (T1) and 12 months after return from deployment (T2) using standardized interviews. Change in aDAC was categorized into decreased (n=72), stable (n=215) and increased (n=71) aDAC. RESULTS: Overall, aDAC did not change significantly between T1 and T2 (median change=0.0 g, inter quartile range=11.3g). Compared to stable aDAC, increase was characterized by a lower proportion of high-educated individuals (OR: 0.3 (0.1-0.7), p=0.008), lower rank (marginally significant: OR: 2.0 (1.0-4.1), p=0.050), and less acceptance (trend: MR: 0.97 (0.93-1.00), p=0.053). Correlates of increased aDAC were less social support (MR: 0.84 (0.71-0.99), p=0.043), more sleeping problems (MR: 1.15 (1.00-1.31), p=0.045) and more negative post-event cognitions following deployment (MR: 2.32 (1.28-4.21), p=0.006). Decrease in aDAC was predicted by lower PTSD symptom severity before deployment (MR: 0.34 (0.16-0.72), p=0.005) and less childhood emotional neglect (marginally significant: MR: 0.78 (0.60-1.00), p=0.050). CONCLUSIONS: Increase and decrease in alcohol use after stressful experiences might have differential risk factors and correlates. Findings might stimulate future research that could result in improved measures to prevent increases as well as in interventions that could foster decreases in alcohol consumption in the context of stressful experiences.

Substance use and substance use disorders in recently deployed and never deployed soldiers.

BACKGROUND: Military studies investigating the prevalence of substance use (SU) and substance use disorders (SUD) and the relation between SU and mental disorders often lack a comprehensive assessment of SU, SUD and mental disorders and comparable groups of deployed and non-deployed personnel. There is also limited data regarding SU and SUD in the German military to date. METHODS: Cross-sectional examination of n=1483 soldiers recently deployed in Afghanistan and 889 never deployed soldiers using a fully-standardized diagnostic interview (MI-CIDI) including a comprehensive substance section. RESULTS: Across both groups, 12-months prevalence of DSM-IV alcohol use disorders was 3.1%, 36.9% reported binge drinking, 13.9% heavy drinking, 1.3% illegal drug use. 55.1% were regular smokers, 10.9% nicotine dependent. Although recently deployed soldiers revealed slightly higher rates in some measures, there were no significant differences to the never deployed regarding SU und SUD except that recently deployed soldiers smoked more cigarettes per day. The association of SU with mental mental disorders was substantially different though, revealing significant associations between SU and mental disorders only among recently deployed soldiers. CONCLUSIONS: We do not find remarkable differences in the prevalence of SU and SUD between recently deployed and never deployed soldiers. Especially binge drinking and regular smoking were prevalent across both samples indicating needs for improved interventions. The finding that SU and mental disorders are only associated in recently deployed soldiers might have implications for improved screening and prevention and suggests that deployment might promote different pathways and mechanisms involved in the evolution of SU and mental disorders.

Characteristics of developmentally early alcohol use disorder symptom reports: a prospective-longitudinal community study.

BACKGROUND: There is little prospective-epidemiological information on symptoms of DSM-IV-alcohol use disorder (alcohol abuse and dependence; AUD) that may be typical for early AUD stages or the developmental periods of adolescence and early adulthood. AIMS: To investigate AUD symptoms (AUDS) cross-sectionally at three subsequent assessment waves regarding prevalence rates, symptom counts, associated drinking patterns, positive predictive values (PPV) for DSM-IV-alcohol dependence (AD), and AUDS stability over time. METHODS: N=2039 community subjects (baseline age 14-24 years) participated in a baseline and two follow-up assessment(s) over up to ten years. DSM-IV-AUDS, DSM-IV-AUD and craving were assessed with the DSM-IV/M-CIDI. RESULTS: Over the assessment waves, tolerance and much time were most and role obligations and withdrawal least frequent. Most subjects with DSM-IV-AUDS reported only one symptom (47.2-55.1%). PPV for DSM-IV-AD only exceeded 70% for activities, problem, withdrawal, and desired control; PPV were lowest for tolerance and hazardous use. For most AUDS, AUDS report compared to non-report was associated with elevated drinking frequency and amounts. Stability of baseline AUDS at four-year and ten-year follow-up did not exceed 36.4% for any symptom. CONCLUSIONS: The overall pattern of most/least frequent AUDS reported in adolescence and early adulthood resembles findings in older adults and does not suggest a developmentally specific symptom pattern. Moderate AUDS-stability and considerable remission rates indicate that AUDS in this age group are transient for a considerable proportion of subjects. However, the associations with elevated consumption indicate that AUDS reports early in life need to be taken seriously in prevention and intervention.

Efficacy of a targeted cognitive-behavioral treatment program for cannabis use disorders (CANDIS).

AIMS: To examine the efficacy, 3- and 6-month follow-up effects of a psychological treatment for older adolescents and adults with DSM-IV cannabis use disorders. The program was tailored to the needs of this patient population. EXPERIMENTAL PROCEDURES: A randomized controlled clinical trial of 122 patients aged 16 to 44 years with DSM-IV cannabis dependence as the main substance use diagnosis was conducted. Patients were randomly assigned to either Active Treatment (AT, n = 90) or a Delayed Treatment Control group (DTC, n = 32). Treatment consisted of 10 sessions of therapy, detailed in a strictly enforced manual. Assessments were conducted at baseline, during each therapy session, at post treatment and at follow-up assessments at 3 and 6 months. RESULTS: The treatment retention rate was 88%. Abstinence was achieved in 49% of AT patients and in 13% of those in DTC (p < 0.001; intend-to-treat (ITT) analysis). Further, AT patients improved significantly (p < = 0.001) in the frequency of cannabis use per week, addiction severity, number of disability days, and overall level of psychopathology. Program effects were maintained over a 3-month- (abstinence rate: 51%) and 6-month follow-up (45%) period. CONCLUSION: The treatment program is effective in obtaining abstinence as well as reducing cannabis use and improves the associated social and mental health burden.

The role of mental disorders in the risk and speed of transition to alcohol use disorders among community youth.

BACKGROUND: Among adolescents and young adults with DSM-IV alcohol use disorders (AUDs), there are inter-individual differences in the speed of transition from initial alcohol use (AU) to AUD. AUDs are highly co-morbid with other mental disorders. The factors associated with rapid transition from first AU to AUD remain unknown and the role of mental disorders in rapid transitions is unclear. Given this background we examined (1) whether prior anxiety, mood, externalizing and non-alcohol substance use disorders are related to the risk and speed of transition from first AU to DSM-IV alcohol abuse (AA) and alcohol dependence (AD) and (2) whether early age of onset of prior mental disorders (PMDs) is a promoter of rapid transition. METHOD: A total of 3021 community subjects (97.7% lifetime AU) aged 14-24 years at baseline were followed up prospectively for up to 10 years. AU and mental disorders were assessed with the DSM-IV/M-CIDI. RESULTS: Among subjects with lifetime AU, several PMDs, such as specific phobia, bipolar disorder and nicotine dependence, were associated with an increased risk of AUD independent of externalizing disorders. Associations of PMDs with the speed of transition to AUDs were mostly weak and inconsistent. Only social phobia and externalizing disorders were associated with faster transitions to AD even after adjustment for other PMDs. Earlier age of onset of PMD was not associated with rapid transition. CONCLUSIONS: Mental disorders are associated with the risk of AUD. With the possible exception of social phobia and externalizing disorders, they do not promote rapid transition, even if they occur particularly early. Future research needs to identify factors relevant to rapid transition to AUD.

Transitions from first substance use to substance use disorders in adolescence: is early onset associated with a rapid escalation?

BACKGROUND: Early substance use (SU) in adolescence is known to be associated with an elevated risk of developing substance use disorders (SUD); it remains unclear though whether early SU is associated with more rapid transitions to SUD. OBJECTIVE: To examine the risk and speed of transition from first SU (alcohol, nicotine, cannabis) to SUD as a function of age of first use. METHODS: N=3021 community subjects aged 14-24 years at baseline were followed-up prospectively over 10-years. SU and SUD were assessed using the DSM-IV/M-CIDI. RESULTS: (1) The conditional probability of substance-specific SU-SUD transition was the greatest for nicotine (36.0%) and the least for cannabis (18.3% for abuse, 6.2% for dependence) with alcohol in between (25.3% for abuse; 11.2% for dependence). (2) In addition to confirming early SU as a risk factor for SUD we find: (3) higher age of onset of any SU to be associated with faster transitions to SUD, except for cannabis dependence. (4) Transitions from first cannabis use (CU) to cannabis use disorders (CUD) occurred faster than for alcohol and nicotine. (5) Use of other substances co-occurred with risk and speed of transitions to specific SUDs. CONCLUSION: Type of substance and concurrent use of other drugs are of importance for the association between age of first use and the speed of transitions to substance use disorders. Given that further research will identify moderators and mediators affecting these differential associations, these findings may have important implications for designing early and targeted interventions to prevent disorder progression.

What are the high risk periods for incident substance use and transitions to abuse and dependence? Implications for early intervention and prevention.

BACKGROUND: For a better understanding of the evolution of addictive disorders and the timely initiation of early intervention and prevention, we have to learn when and how quickly the critical transitions from first substance use (SU) to regular use and from first SU and regular SU to abuse and dependence occur. Little data are currently available on the transitions to substance use disorders (SUDs) across the spectrum of legal and illegal drugs taking into account gender differences. It is the aim of this paper to describe the high density incidence and transition periods of SU and SUD for alcohol, nicotine, cannabis and other illicit drugs for young males and females. METHODS: A sample of (N = 3021) community subjects aged 14-24 at baseline were followed-up prospectively over 10-years. SU and SUD were assessed using the DSM-IV/M-CIDI. RESULTS: Ages 10-16 are the high risk period for first alcohol and nicotine use (up to 38% of subjects start before age 14). Onset of illegal SU occurs later. Substantial proportions of transitions to regular SU and SUD occur in the first three years after SU onset. Only few gender differences were found for time patterns of SU/SUD incidence and transition. CONCLUSION: Except for alcohol the time windows for targeted intervention to prevent progression to malignant patterns in adolescence are critically small, leaving little time for targeted intervention to prevent transition. The fast transitions to abuse and dependence in adolescence may be indicative for the increased vulnerability to substance effects in this time period. Basic research on the determinants of transitions should thus target this period in adolescence.

[Psychotherapeutic care of dysphonic patients]. / Psychotherapeutische Weiterbetreuung stimmgestörter Patienten.

The diagnosis of vocal dysfunction is a prerequisite for referring a patient for specialized medical therapy. This mostly requires a holistic approach, and should also consider related symptoms and the social environment of the patient. Regulations on psychotherapy, promulgated in 1999, have provided clarity in relation to the indications for treatment in an inpatient and outpatient basis. Within the German health care system, every individual can now directly contact an officially certified psychotherapist (so called psychological psychotherapist) for probationary sessions, aimed at determining a basis and indication for further psychotherapy. In case of psychotherapy provided from others than physicians, an additional medical report from a physician is obligatory. Patients with functional and psychogenic voice problems often believe that organic disorders are the reason for their dysphonia. Thus, when caring for voice disordered patients and sending them to a psychotherapist, it is of great importance that physicians facilitate their referral by reacting in an empathic, fear reducing, and professional way.

[Differential diagnosis of sinugenic enophthalmos]. / Differenzialdiagnose des sinugenen Enophthalmus.

BACKGROUND: Spontaneous enophthalmos without recent trauma is a rare condition. Its origin is difficult to evaluate. METHOD: Specific properties of this symptom complex are presented based on a literature review and on case reports. Possible connections between enophthalmos and paranasal sinus diseases as well as differential diagnoses are analysed. PATIENTS: 1. 31 year old female patient with right spontaneous enophthalmos and no history of trauma. CT-imaging disclosed tissue formation in the maxillary sinus, partially destroyed medial orbital wall and floor, descended orbital contents following Caldwell-Luc procedure several years previously. After endonasal surgery of ethmoidal and maxillary sinus with removal of a large cyst good functional and cosmetical result. 2. 25 year old male patient complaining of pain in the periorbital region, presenting with left enophthalmos and superonasal deviation of the eyeball. MRI and CT revealed a tumor in the orbital floor region with total destruction of the roof of the maxillary sinus. Removal of the tumor by a combined lateral rhinotomy and subciliary approach. DIAGNOSIS: Leiomyoma. Orbital reconstruction with PDS-sheet. Postoperatively, improved globe position and motility. No recurrence during three year follow-up. CONCLUSION: When evaluating the causes of enophthalmos, chronic diseases of the paranasal sinuses or their walls must be considered. Surgical therapy is promising.

Interaction of Bartonella henselae with endothelial cells results in rapid bacterial rRNA synthesis and replication.

Bartonella henselae is a slow-growing microorganism and the causative pathogen of bacillary angiomatosis in man. Here, we analysed how interaction of B. henselae with endothelial cells might affect bacterial growth. For this purpose, bacterial rRNA production and ribosome content was determined by fluorescence in situ hybridization (FISH) using rRNA-targeted fluorescence-labelled oligonucleotide probes. B. henselae grown on agar plates showed no detectable rRNA content by means of FISH, whereas B. henselae co-cultured with endothelial cells showed a rapid increase of rRNA production within the first 18 h after inoculation. The increased rRNA synthesis was paralleled by a approximately 1000-fold intracellular bacterial replication, whereas bacteria grown on agar base showed only a approximately 10-fold replication within the first 48 h of culture. Pretreatment of host cells with paraformaldehyde prevented adhesion, invasion, intracellular replication and bacterial rRNA synthesis of B. henselae. In contrast, inhibition of host cell protein synthesis by cycloheximide did not affect bacterial adhesion and invasion, but prevented intracellular replication although bacterial rRNA content was increased. Inhibition of actin polymerization by cytochalasin D did not affect adhesion, invasion, increased rRNA content or intracellular replication of B. henselae. These results demonstrate that rRNA synthesis and replication of B. henselae is promoted by viable host cells with intact de novo protein synthesis.

Effect of folding on the multifocal silicone intraocular lens: scanning electron microscopic study.

PURPOSE: To evaluate whether the surface of the refractive zonal multifocal silicone intraocular lens (IOL) is altered by different folding and implantation instruments and is more sensitive to manipulation during folding than the surface of a monofocal IOL. SETTING: Department of Ophthalmology, University Hospital, Kiel, Germany. METHODS: Evaluated were the refractive multifocal silicone IOL (SA-40N, Array) and an otherwise identical monofocal IOL (SI-40NB) from the same manufacturer (Allergan Inc.). Different folding devices (folding blocks, folding and implantation forceps, and an injector system) were used. The IOLs were kept folded for 60 seconds; 24 hours later, scanning electron microscopy (SEM) was performed. In addition, the cartridges of the injector system were examined by SEM. RESULTS: Overall, regardless of the folding and implantation instruments used, both the multifocal and monofocal IOLs had discrete surface alterations. The cartridges of the injector system had a rough surface at the tip, while the proximal portion appeared smooth. CONCLUSION: There were no signs of lesions particularly affecting the surface of multifocal IOLs.

[Severe intra- and postoperative supra-choroid hemorrhage. Risk factors, therapy, results]. / Schwere intra- und postoperative suprachorioidale Blutungen. Risikofaktoren, Therapie, Ergebnisse.

BACKGROUND: The aim of this study was to analyze risk factors, therapeutic strategies, and functional and anatomic results of eyes with severe suprachoroidal hemorrhage. PATIENTS: Eight of 11 bleeding episodes occurred intraoperatively and 3/11 postoperatively. Bleeding was associated with the following surgical procedures: perforating keratoplasty (5x), extracapsular cataract extraction (3x), pars plana vitrectomy (2x), intracapsular cataract extraction (1x). RESULTS: Nine operations were performed with general anesthesia, two after retrobulbar injection. Ocular risk factors (e.g., prior operations, ocular diseases) and general risk factors (e.g., cardiovascular diseases, diabetes) were analyzed. At the end of the follow-up time visual acuity had improved in three eyes, and it was unchanged in one eye and worse in seven eyes. Four eyes were amaurotic; two of them had to be enucleated. CONCLUSIONS: In spite of using state-of-the-art surgical techniques the prognosis of suprachoroidal bleeding remains serious. Patients who have a combination of several ocular and general risk factors almost exclusively are the ones who afflicted by this complication.

[Bilateral simultaneous acute amaurosis in neuritis nervi optici. Initial manifestation of encephalomyelitis disseminata]. / Bilaterale simultane akute Amaurose bei Neuritis nervi optici. Erstmanifestation einer Encephalomyelitis disseminata.

BACKGROUND: Bilateral simultaneous acute amaurosis as a primary manifestation of demyelinating disease is extremely rare. PATIENT: The clinical course of a 24-year-old patient who initially presented with a bilateral complete loss of vision is demonstrated. Morphologically both optic discs appeared slightly blurred and prominent. Otherwise there were no anterior and posterior segment abnormalities. Examination of the cerebrospinal fluid revealed an increased number of cells and protein without oligoclonal bands. On MRI multiple white matter lesions were visible. Laboratory tests showed no specific abnormalities, especially with respect to infectious or vasculitic diseases. Under intensive steroid therapy (initially 1000 mg prednisolone/day), visual acuity recovered almost completely. Nine months after onset of the disease visual acuity was 1.0 in both eyes. CONCLUSIONS: Even in patients with a fulminant onset of the disease almost complete visual recovery is possible. Differential diagnosis should rule out vasculitic autoimmune optic neuritis, infections, tumors, processes of the paranasal sinuses, toxic, and hereditary causes.

MRI features of craniofacial fibrous dysplasia.

A 13-year-old female with a 4-year history of monostotic fibrous dysplasia had noticed a progressive proptosis of the right eye and diplopia on upward gaze for 4 weeks. A few years previously an incisional biopsy of the skull had verified the presumed diagnosis of fibrous dysplasia with recurrent bleeding into pathologic cystic bony structures of the skull. The patient was known to have craniofacial fibrous dysplasia with involvement of the frontal and intermediate cranial base, the posterior ethmoidal labyrinth, and the sphenoidal and maxillary sinuses. Eye examination showed a reduced visual acuity in the right eye without defects of the visual field. MR imaging showed a fluid-filled cystic cavity in the orbital frontal bone pushing the globe downwards. Four months later she developed similar symptoms on the other side while proptosis of the right eye was regressive. T2-weighted MRI revealed a large fluid-filled cystic cavity with a fluid-fluid level in the upper part of the left orbit. It is concluded that follow-up studies can be easily performed by MRI without additional exposure to radiation. The total extent of osseous involvement can be determined. Thus, MRI may be helpful in deciding between operative or conservative therapy.