Wirksamkeit, Zweckmäßigkeit und Wirtschaftlichkeit des multimodalen Behandlungsansatzes bei chronisch lumbalen Rückenschmerzen

Zusammenfassung: Hintergrund: Der Nachweis der Behandlungskriterien Wirksamkeit, Zweckmäßigkeit und Wirtschaftlichkeit ist bei chronisch lumbalen Rückenschmerzen ["chronic low back pain" (CLBP)] notwendig, da Kostenträger die Übernahme von Behandlungskosten hiervon abhängig machen. Material und Methoden: Eine systematische Literatursuche zu den Behandlungskriterien der interdisziplinären, multimodalen Schmerztherapie ["multidisciplinary treatment" (MDT)] bietet einen Überblick über die aktuelle Literatur zur Behandlung von CLBP. Ergebnisse: Auf die moderate Wirksamkeit von MDT weisen 8Übersichtsarbeiten hin, wenn auch mit einigen Einschränkungen. Die Ergebnisse von 6 bisher in keine Übersichtsarbeit eingeschlossenen Originalarbeiten stützen die Ergebnisse der Übersichtsarbeiten. Die Langzeitergebnisse von MDT und operativen Behandlungen sind, bei höheren Kosten und Risiken für operative Behandlungen, vergleichbar. Die Wirtschaftlichkeit von MDT erreicht in 3Originalarbeiten eine moderate bis hohe Evidenz. Schlussfolgerungen: MDT sind sowohl moderat wirksam als auch wirtschaftlich. Daher sind sie eine kostengünstigere Behandlungsalternative zu operativen Verfahre

Common facultative endosymbionts do not influence sensitivity of cereal aphids to pyrethroids

Cereal aphids, including the bird cherry-oat aphid, Rhopalosiphum padi, and the grain aphid, Sitobion avenae, can transmit viruses that significantly reduce crop yields. To mitigate against yield losses, insecticides are routinely used to manage aphid populations. Aphids can form relationships with endosymbionts that confer fitness benefits or consequences to the aphid. Recent artificial inoculation experiments indicate that endosymbionts could increase aphid susceptibility to insecticides, but this has not been explored using aphid populations naturally infected with endosymbionts. Here, we sampled aphids from an important cereal production region in Lower Saxony, Germany. We characterized the endosymbiont profile of these aphid populations and conducted pyrethroid dose–response assays to test the hypothesis that facultative endosymbionts increase aphid susceptibility to insecticides. We find that the level of insecticide susceptibility is highly variable in S. avenae and we identify populations that are sensitive and tolerant to pyrethroids, including populations collected from the same field. For R. padi, we find evidence for decreased sensitivity to pyrethroids, representing the first report of reduced sensitivity to pyrethroids in R. padi sampled from Central Europe. We detected high endosymbiont infection frequencies in the aphid populations. 84% of aphids carry one facultative endosymbiont and 9% of aphids carry two facultative endosymbionts. We detected associations with Regiella insecticola, Fukatsia symbiotica, and Hamiltonella defensa. However, we do not identify a link between endosymbiont infection and insecticide susceptibility, indicating that other factors may govern the development of insecticide resistance and the need for alternative management strategies

Patient characteristics differently affect early cup and stem loosening in THA: a case-control study on 7,535 patients

We postulated that certain patient characteristics have different effects on early THA component loosening. With two matched case-control studies we assessed 3,028 cups and 5,224 stems. Loosening was defined using signs of mechanical component failure on routine follow-up radiographs or revision for aseptic loosening. Women and men had similar cup-loosening odds, but women had lower odds for stem loosening (p < 0.0001). Odds for cup loosening decreased by 2.1% per additional year of age (p = 0.0004), those for stem loosening by 2.4% (p < 0.0001). Each additional kilogram of weight decreased cup loosening odds by 1.3% (p = 0.0051). Each additional unit of BMI increased stem loosening odds (p = 0.0109). Charnley classes B and C were protective factors against loosening of both components. There were no risk differences for the various main diagnoses. Certain patient characteristics differently affected early cup and stem loosening, although some characteristics had the same protective or harmful effect on component surviva

Development of a documentation instrument for the conservative treatment of spinal disorders in the International Spine Registry, Spine Tango

Spine Tango is the first and only International Spine Registry in operation to date. So far, only surgical spinal interventions have been recorded and no comparable structured and comprehensive documentation instrument for conservative treatments of spinal disorders is available. This study reports on the development of a documentation instrument for the conservative treatment of spinal disorders by using the Delphi consensus method. It was conducted with a group of international experts in the field. We also assessed the usability of this new assessment tool with a prospective feasibility study on 97 outpatients and inpatients with low back or neck pain undergoing conservative treatment. The new ‘Spine Tango conservative' questionnaire proved useful and suitable for the documentation of pathologies, conservative treatments and outcomes of patients with low back or neck problems. A follow-up questionnaire seemed less important in the predominantly outpatient setting. In the feasibility study, between 43 and 63% of patients reached the minimal clinically important difference in pain relief and Core Outcome Measures Index at 3months after therapy; 87% of patients with back pain and 85% with neck pain were satisfied with the received treatment. With ‘Spine Tango conservative' a first step has been taken to develop and implement a complementary system for documentation and evaluation of non-surgical spinal interventions and outcomes within the framework of the International Spine Registry. It proved useful and feasible in a first pilot study, but it will take the experience of many more cases and therapists to develop a version similarly mature as the surgical instruments of Spine Tang

Influence of preoperative leg pain and radiculopathy on outcomes in mono-segmental lumbar total disc replacement: results from a nationwide registry

Purpose: Currently, many pre-conditions are regarded as relative or absolute contraindications for lumbar total disc replacement (TDR). Radiculopathy is one among them. In Switzerland it is left to the surgeon's discretion when to operate if he adheres to a list of pre-defined indications. Contraindications, however, are less clearly specified. We hypothesized that, the extent of pre-operative radiculopathy results in different benefits for patients treated with mono-segmental lumbar TDR. We used patient perceived leg pain and its correlation with physician recorded radiculopathy for creating the patient groups to be compared. Methods: The present study is based on the dataset of SWISSspine, a government mandated health technology assessment registry. Between March 2005 and April 2009, 577 patients underwent either mono- or bi-segmental lumbar TDR, which was documented in a prospective observational multicenter mode. A total of 416 cases with a mono-segmental procedure were included in the study. The data collection consisted of pre-operative and follow-up data (physician based) and clinical outcomes (NASS form, EQ-5D). A receiver operating characteristic (ROC) analysis was conducted with patients' self-indicated leg pain and the surgeon-based diagnosis "radiculopathy”, as marked on the case report forms. As a result, patients were divided into two groups according to the severity of leg pain. The two groups were compared with regard to the pre-operative patient characteristics and pre- and post-operative pain on Visual Analogue Scale (VAS) and quality of life using general linear modeling. Results: The optimal ROC model revealed a leg pain threshold of 40≤VAS>40 for the absence or the presence of "radiculopathy”. Demographics in the resulting two groups were well comparable. Applying this threshold, the mean pre-operative leg pain level was 16.5 points in group 1 and 68.1 points in group 2 (p<0.001). Back pain levels differed less with 63.6 points in group 1 and 72.6 in group 2 (p<0.001). Pre-operative quality of life showed considerable differences with an 0.44 EQ-5D score in group 1 and 0.29 in group 2 (p<0.001, possible score range −0.6 to 1). At a mean follow-up time of 8 months, group 1 showed a mean leg pain improvement of 3.6 points and group 2 of 41.1 points (p<0.001). Back pain relief was 35.6 and 39.1 points, respectively (p=0.27). EQ-5D score improvement was 0.27 in group 1 and 0.41 in group 2 (p=0.11). Conclusions: Patients labeled as having radiculopathy (group 2) do mostly have pre-operative leg pain levels≥40. Applying this threshold, the patients with pre-operative leg pain do also have more severe back pain and a considerably lower quality of life. Their net benefit from the lumbar TDR is higher and they do have similar post-operative back and leg pain levels as well as the quality of life as patients without pre-operative leg pain. Although randomized controlled trials are required to confirm these findings, they put leg pain and radiculopathy into perspective as absolute contraindications for TD

Benchmarking with Spine Tango: potentials and pitfalls

The newly released online statistics function of Spine Tango allows comparison of own data against the aggregated results of the data pool that all other participants generate. This comparison can be considered a very simple way of benchmarking, which means that the quality of what one organization does is compared with other similar organizations. The goal is to make changes towards better practice if benchmarking shows inferior results compared with the pool. There are, however, pitfalls in this simplified way of comparing data that can result in confounding. This means that important influential factors can make results appear better or worse than they are in reality and these factors can only be identified and neutralized in a multiple regression analysis performed by a statistical expert. Comparing input variables, confounding is less of a problem than comparing outcome variables. Therefore, the potentials and limitations of automated online comparisons need to be considered when interpreting the results of the benchmarking procedur