Predicting low back pain outcome following rehabilitation for low back pain.

BACKGROUND: Psychosocial factors are known to play a key role in determining the progress of back pain patients. However, it is not known whether these factors are applicable to military personnel, who tend to be fitter than the general population. OBJECTIVE: The aim was to identify physical and psychological predictors in a prospective study of the outcome of back pain rehabilitation over 6 months and a longer follow-up time of between 15 and 32 months. METHODS: Two hundred and fifty military personnel reporting for a residential rehabilitation programme completed a battery of physical and psychological tests. The physical tests included 800 m run time and the Biering-Sorensen test. The psychological/psychosocial measures included items on fear avoidance, self efficacy, anxiety and depression and occupational psychosocial factors such as job satisfaction. RESULTS: Self efficacy and 800 m run time predicted self-reported functional ability at 6 months and medical discharge/return to full fitness at 15­32 months. Patients with 800 m run times of more than 3 minutes 31 seconds had a four times greater chance of medical discharge from the Armed forces. CONCLUSIONS: Eight hundred metre run time and self-efficacy were independent predictors of both self-reported functional ability at 6 months and return to full fitness/medical discharge at 15­32 months. Self-efficacy also predicted 40% of the variance in the intensity of back pain and 10% of other non-back pain. Rehabilitation should include greater emphasis on physical fitness and on improving self-efficacy.

Predicting erectile function outcome in men after radical prostatectomy for prostate cancer.

OBJECTIVE: • To identify the reported rates of potency after prostatectomy in the recent literature for men without preoperative erectile dysfunction (ED) and to develop a statistical model for predicting the expected potency after prostatectomy. MATERIALS AND METHODS: • A Medline search was conducted with the keywords 'potency' and 'prostatectomy' from 2003 to 2009. • In total, 33 studies in the English language reporting pre- and postoperative erectile function were identified. • Data from studies reporting outcome after open, laparoscopic and robot-assisted prostatectomy were analyzed separately. • Only data obtained from potent men before surgery were included in the analysis. RESULTS: • In potent men before surgery, the main predictors of post-treatment erectile function are age and time after treatment. • The cumulative range of potency rates at 48 months for all ages (45-75 years) was 49-74% for open, 58-74% for laparoscopic and 60-100% for robotic prostatectomy. • The predicted outcome differs by type of operation and patient age. CONCLUSIONS: • Men aged <60 years have a significant likelihood of regaining erectile function after radical prostatectomy. • The reported statistical model provides a reliable estimation of erectile function outcome after prostatectomy for men with localized prostate cancer and intact erectile function.

Job strain related to cognitive failure in naval personnel.

The Naval Service Stress Study (2007-2012) is investigating job strain, its characteristics, causes and distribution in the Service. Data from phases I, II and III of the study (January 2007, June 2007 and January 2008) were analysed to determine the relationship between General Health questionnaire scores and a score on the Cognitive Failures Questionnaire (CFQ) completed at phase III. Of 791 personnel who completed questionnaires at all phases, 43.6% had no job strain at any phase, whereas 9.9% had strain on all three occasions ('chronic strain'). 27% had strain at one of the three phases and 19% had strain at two of the three phases. The particular phase at which job strain was experienced was not related to CFQ score at phase III, whereas the total strain experienced over the period was related. High strain over the year was the strongest predictor of high CFQ score. A 'strain dose' variable, which combined both the amount of strain exposure and the timing of the exposure, explained little additional variance in CFQ score. The findings might be interpreted to indicate that a high CFQ score is a vulnerability factor for adverse reactions to work stress. The hypothesis that recent job strain elevates CFQ score was not supported. STATEMENT OF RELEVANCE: Current models of occupational stress focus on psychosocial factors and much of the advice about stress management in organisations is centred on the identification and control of psychosocial risk factors. The present paper provides evidence that cognitive factors are also important and suggests that support for those with poor executive function should be part of stress management in complex environments.

Occupational stress in submariners: the impact of isolated and confined work on psychological well-being.

This study aimed to identify work-related and personal factors associated with occupational stress in submariners. Work and well-being questionnaires were distributed to 219 male submariners (mean age 34 years), as part of a larger cohort study involving a stratified sample of 4951 Royal Navy (RN) personnel. The stress rate in submariners was 40%; significantly higher than the stress rate in the general RN, although once demographic factors were controlled for in a matched control sample, this difference was no longer significant. A summary model accounted for 49% of the variance in submariner stress, with key differences emerging between the occupational factors associated with stress in submariners and in the general RN. The longitudinal nature of this study permits stress in submariners to be monitored over 5 years, which will provide valuable insights into the chronicity of stress in this specialised occupational group. STATEMENT OF RELEVANCE: This paper contributes to the current literature on the negative impact of working in isolated conditions. It is demonstrated that occupational stress in submarines can be partially explained using current theories of stress in the workplace. However, the constraints of a restricted environment introduce additional factors which can also be associated with occupational stress.

Resuscitation decisions among hospital physicians and intensivists.

The decision to perform cardiopulmonary resuscitation (CPR) remains one of the most important and difficult decisions a physician must make. This study examined differences in CPR decision making among senior hospital clinicians. A questionnaire was sent out to consultants and specialist registrars in general medicine, elderly care and intensive care in a large UK district general hospital, with anonymous returns. Short clinical scenarios were presented, and participants stated their CPR decision and their confidence level. In total, 86 questionnaires were sent out and 54 replies (63%) were received. There were significant differences between specialties in making the decision to perform CPR and the confidence in doing so, with three cases producing polarised results within the specialties, despite equal confidence in the decision. There is lack of consensus with the CPR decisions made between specialties and within them. Formal training in recognition of futility should be encouraged for all clinicians.

Clinical profile of botulinum toxin A in patients with chronic headaches and cervical dystonia: a prospective, open-label, longitudinal study conducted in a naturalistic clinical practice setting.

BACKGROUND AND OBJECTIVES: Some evidence for the efficacy of botulinum toxin A as a preventive treatment for chronic primary headaches has been reported in randomized, controlled clinical studies. This study investigated the clinical profile of botulinum toxin A in a naturalistic clinical practice setting in a population of patients with cervical dystonia associated with chronic headache and a history of migraine. METHODS: This was a prospective, open-label, longitudinal study. Following a prospective run-in period, eligible patients were given three sets of botulinum toxin A injections at 8- to 12-week intervals over a 16- to 24-week period and were monitored for 3 months after the final injections. Efficacy was assessed in terms of headache-related disability (using the Migraine Disability Assessment [MIDAS] questionnaire), pain and emotional function (using the Short Pain Inventory [SPI]), quality of life (QOL, using the Short-Form-36 [SF-36] questionnaire) and patient-assessed headache frequency and severity, and medication use and its effectiveness. Safety was assessed as adverse events. The primary endpoint was the change in MIDAS score from baseline following treatment with botulinum toxin A. RESULTS: Twenty-four patients took part in the study and 17 (71%) completed the study. There were significant improvements in headache-related disability (MIDAS score), pain and emotional function (SPI), QOL (SF-36), headache frequency and medication use following treatment with botulinum toxin A (p < 0.05 for all endpoints). An efficacy response occurred within 8 weeks of treatment initiation and was maintained throughout the study duration. Botulinum toxin A was generally well tolerated. CONCLUSIONS: This study demonstrated that botulinum toxin A is an effective and well tolerated preventive treatment for chronic headache in patients with cervical dystonia and a history of migraine. These results warrant further investigation in a large, randomized, controlled study.

Patient preference for triptan formulations: a prospective study with zolmitriptan.

OBJECTIVES: To investigate patterns of patient preference for 3 formulations of zolmitriptan, in a primary care study utilizing a naturalistic longitudinal design. BACKGROUND: Although differences in efficacy between individual triptans tend to be small, migraine patients show clear preferences for individual triptans and formulations. The groups of patients suitable for the different triptan formulations, and the reasons underlying individual preferences, are not clearly understood. METHODS: Migraine patients entered a prospective, randomized, open, crossover, longitudinal design study, with patients receiving zolmitriptan formulations according to UK prescribing recommendations. Patients naïve to zolmitriptan received zolmitriptan 2.5-mg film-coated tablets or 2.5-mg Orally Disintegrating Tablets (ODT) for 1 month, before being crossed over to receive the alternative formulation for Month 2. All patients then received zolmitriptan nasal spray 5 mg for Month 3. Patients could then choose the formulation(s) of their choice for a further 7 months. Patients recorded their preferences for individual formulations, the reasons for their preferences, and also the headache-related disability (measured by the Migraine Disability Assessment [MIDAS] score) at clinic visits. Primary endpoints were the individual preferences and changes in MIDAS scores. Adverse events were also recorded. RESULTS: Forty-eight patients took part in the study. At baseline, most patients expressed a preference for conventional tablets. After 4 months, 46.9% of patients preferred zolmitriptan ODT, 43.8% zolmitriptan nasal spray, and 6.3% the conventional tablet. The most common reasons given for preferring conventional tablets were personal reasons: for zolmitriptan ODT, convenience and, to a lesser extent, speed of onset: for zolmitriptan nasal spray, speed of onset, and overall efficacy. MIDAS scores decreased significantly following treatment with zolmitriptan. Zolmitriptan was well tolerated. CONCLUSIONS: Patient experience of newer zolmitriptan formulations influenced a change in preference away from conventional tablets. Speed and efficacy were the key drivers of preference for zolmitriptan nasal spray, while convenience mostly drove preference for the ODT formulation. Open, longitudinal, naturalistic studies may, allowing for biases, sometimes be an appropriate way of conducting migraine studies in primary care.

Reliability, validity, and clinical utility of the Migraine-ACT questionnaire.

BACKGROUND: The 4-item Migraine-ACT questionnaire is an assessment tool for use by primary care physicians to identify patients who require a change in their current acute migraine treatment. It has been shown to be easy to use, and to be reliable and accurate in its assessments. OBJECTIVES: To further analyze the Migraine-ACT study database, providing additional information on the reliability, validity, and potential clinical utility of the questionnaire. METHODS: Reliability was assessed by recording the distribution of Migraine-ACT scores recorded at baseline and 1 week later (test-retest reliability). Analyses of consistency of Migraine-ACT scores were conducted on the total sample of patients and for the separate centers, using Pearson and Spearman correlations. Validity was assessed by comparing the t-discrimination values for clinically relevant questions within domains of the original 27-item questionnaire. Reliability and validity were also assessed by constructing an "alternative" (Form B) Migraine-ACT questionnaire, derived from an analysis of the second-best items in each domain in the original study data. Clinical utility was assessed using Pearson pairwise correlations to compare Migraine-ACT scores with clinically defined criteria as analyzed by the SF-36 Quality of Life questionnaire, the Migraine Disability Assessment (MIDAS) questionnaire, and the Migraine Therapy Assessment (MTAQ) questionnaire. RESULTS: The distribution of Migraine-ACT scores between the 2 completions of the questionnaire was consistent for the total sample (test-retest reliability, r= .81) and between the individual countries (r= .61 to .92). In this study, the validity (assessed as t-discrimination) of the Migraine-ACT "impact" and "global assessment of relief" questions were markedly higher than those of other endpoints used in migraine clinical studies. The Form B Migraine-ACT questionnaire was almost as reliable and accurate as the original Form A questionnaire. The distribution of Migraine-ACT scores was: 0 = 12.6%, 1 = 13.7%, 2 = 14.7%, 3 = 20.5%, and 4 = 38.4%. The change in Migraine-ACT score correlated with, and had a linear relationship with changes in SF-36, MIDAS, and MTAQ scores, and indicated that a Migraine-ACT score of

Disability associated with headaches occurring inside and outside the menstrual period in those with migraine: a general practice study.

OBJECTIVES: This study investigated the disability of females who have migraine and other headache attacks occurring during and outside the menstrual period. METHODS: One thousand four hundred and thirty-four of 3470 female patients (41.3%) aged 14 to 50 years registered at a UK general practice completed two questionnaires. The first questionnaire assessed the prevalence of headache, depression, and bodily pain in the total population. The second questionnaire assessed the disability of all headaches over a 2-month period (to capture a complete menstrual cycle) for patients reporting migraine who were still menstruating. Disability was assessed as the time lost and time spent at less than 50% productivity in normal activities due to headache, and analyzed as rank sums using the Mann-Whitney U-test. RESULTS: The first part of the study showed that the prevalence of headache (66.1%), depression (55.4%), and bodily pain (40.6%) were high in this population of women. Thirty migraine patients who were still menstruating reported 89 migraine and 114 nonmigraine headache episodes in the second part of the study. For migraine, the rank order of time at less than 50% productivity was greater for attacks taking place inside the menstrual period than for those occurring outside the menstrual period. The comparison was significant for time at less than 50% productivity (P=.01). For nonmigraine headaches, the rank order of time lost was greater for attacks taking place outside the menstrual period than for those occurring inside the menstrual period. The comparison was not significant for time lost (P= .06). CONCLUSIONS: For those with migraine, migraine attacks that took place during the menstrual period tended to be slightly more disabling than those taking place outside the menstrual period, but the opposite was true for nonmigraine headache.