[Treatment effects and cost-effectiveness of interdisciplinary multimodal pain treatment of patients with back pain : A controlled observational intervention study based on claims data and survey data of participants]. / Behandlungs- und Kosteneffekte der interdisziplinären multimodalen Schmerztherapie bei Patienten mit Rückenschmerz : Eine kontrollierte, nicht-randomisierte Interventionsstudie mit GKV-Daten und Teilnehmerbefragung.

BACKGROUND: Persons insured by AOK Nordost statutory health insurance (SHI) and on sick leave underwent a 20-day program of interdisciplinary multimodal pain therapy (IMST) following an initial assessment (IA). We evaluated its effectiveness regarding sick leave, utilization/costs of SHI services, and patient-reported characteristics of pain. MATERIALS AND METHODS: Participants with >14 days of IMST in 2013-2015 and with data necessary for comparison (intervention group, IG) were matched 1:1 in 2 steps. From AOK Nordost data, we identified a comparison group (CG) having characteristics matching exactly and by propensity score. Starting on the IA (IG) or a comparable reference day (CG), we analyzed utilization/costs of services related to back pain for 365 days. Participants' characteristics of pain were surveyed on the IA day and within 183-365 days. RESULTS: The 86 IG patients had on average 44.33 (median 12) days of sick leave less than the CG after their initial sick leave starting at the IA (significant, p <0.05). Fewer IG patients had ≥1 hospitalization (OR 0.33; 95%CI 0.12-0.88), ≥1 prescription of physiotherapy (OR 0.35; 95%CI 0.24-0.82), and ≥1 specialist visit (OR 0.39; 95%CI 0.10-0.52) related to back pain. More IG patients had "lasting absence of treatment" (OR 4.06; 95%CI 1.09-15.1). Follow-up interviews were available for 56 IG patients, showing less pain intensity, impairment by pain, and pain severity (significant). Regarding the SHI perspective, cost savings per patient nearly covered the IA and IMST costs. DISCUSSION: For a selected comparable population treated by protocol, IA and IMST was associated with reduction or "lasting absence" of treatment, pain relief, and major savings on sickness benefits. Other than in previous studies we found coverage of IA and IMST costs without consideration of productivity loss.

[Interdisciplinary multimodal assessment and risk-tailored pathways for patients with back pain : Prospective evaluation of an integrated healthcare delivery project]. / Interdisziplinär-multimodales sektorenübergreifendes Assessment und bedarfsorientierte Steuerung für Patienten mit Rückenschmerzen : Prospektive Evaluation eines integrierten Versorgungsprojekts.

BACKGROUND: Back pain is prevalent in the population, sometimes recurrent and may result in everyday and work disabilities. It is often a reason for seeking healthcare support. Analyzing the need of treatment and chronification-risk tailored intervention is a particular demand in healthcare delivery. OBJECTIVES: Reducing downstream consequences of back pain (e. g. pain and disability) by using an interdisciplinary multimodal assessment followed by a risk-tailored intervention. METHODS: Patients with back pain (n = 1638) underwent assessments based on the German Pain Questionnaire (GPQ) and the diagnostic assessment each by a team comprising a physician, a psychologist and a physiotherapist. They were assessed answering a follow-up questionnaire after 6 and/or 12 months (n = 832) for success criteria sensitive to change as pain, everyday and work disability. RESULTS: Patients had on average 62.5 days of work disability and 53.3% had pain up to one year. After assessment, 1447 patients (88.3%) were assigned to receive an intensive interdisciplinary multimodal back pain intervention. Intervention groups were: 120 h of full-time treatment for 4 weeks (n = 1030) or 60 h (n = 224), 48 h part time treatment for 3 months (n = 87), and in-patient hospital treatment for about 17 days (n = 106). The effect sizes of success criteria were large to very large in all treatment groups. CONCLUSIONS: Tailored, interdisciplinary and intensive intervention is effective in reducing downstream consequences of back pain. The treatment assignment was based on patient reports (GPQ score) and multidisciplinary assessments (clinical evidence score). Tailored interventions should include sufficient intensity for highly disabled patients. Care integration such as timely communication between the health insurance system, back pain centers and usual healthcare services as well as patient- and process-related documentation are crucial for this intervention.

Construct and predictive validity of the German Örebro questionnaire short form for psychosocial risk factor screening of patients with low back pain.

PURPOSE: Recognizing patients at risk of developing chronic low back pain is essential for targeted interventions. One of the best researched screening instruments for this purpose is the Örebro Musculoskeletal Pain Questionnaire (ÖMSPQ). This work addresses psychometric properties of the German ÖMSPQ short form and its construct and prognostic validity. METHODS: Analyses are based on a cluster-randomized trial assessing a risk tailored intervention for patients consulting for low back pain in 35 general practices. A total of 360 patients consulting for acute and sub-acute back pain, aged 20-60 years, were included. All patients received a 10-item German short version of the ÖMSPQ, and other generic instruments (Graded Chronic Pain Scale, Patient Health Questionnaire-Depression, Hannover Functional Ability Questionnaire, Fear-Avoidance Beliefs Questionnaire). The construct validity was assessed based on the factorial structure of the items and correlations with generic instruments. The area under the curve (AUC), sensitivity and specificity were calculated as measures of prognostic validity. RESULTS: ÖMSPQ items belonging to the same subscale correlated highest among each other. The internal consistency of the ÖMSPQ items was 0.80 (Cronbach's α). The factorial structure corresponds with theoretic expectations. ÖMSPQ subscales on pain related disability, depression, and fear-avoidance beliefs correlated highest with their counterpart generic scales. The AUC for three ÖMSPQ-based prediction models ranged from 0.77 to 0.81. CONCLUSIONS: Our results support a satisfactory factorial and prognostic validity of the German short ÖMSPQ. The instrument may guide the provision of targeted interventions. Further research should link it to targeted treatments.

[Multidisciplinary outpatient care program vs. usual care : Cost-benefit analysis in patients with chronic low back pain]. / Interdisziplinäre, multimodale Schmerztherapie vs. konventionelle Therapie : Eine Kostenanalyse bei Patienten mit chronischen Rückenschmerzen.

BACKGROUND: Chronic low back pain (CLBP) is a major health problem in industrialized nations and is associated with very high total costs. These costs are split between direct costs brought about by the utilization of health care services and indirect costs due to back pain-related loss of productivity. Despite the existence of some evidence about the effectiveness of a multidisciplinary outpatient care programmes in Germany, the economic benefit of these programmes has not yet been studied in detail. OBJECTIVE: To provide an economic evaluation of the cost benefits of a multidisciplinary outpatient care programme for patients with chronic low back pain (CLBP) compared to those undergoing conventional care. MATERIALS AND METHODS: An economic evaluation was performed in 514 patients who have been diagnosed with LBP. Two interventions will be compared: (1) a multidisciplinary outpatient care programme consisting of education, activity programmes, cognitive behavioural therapy, work hardening and functional restoration and (2) the usual noninvasive care provided by medical specialists and health care professionals. In all, 257 patients were involved in a 4 week multidisciplinary outpatient care programme, while the other 257 were subject to conventional care. RESULTS: The total costs per patient were estimated to be 10,584.14 (± 9,730.87) after 1 year in the group with the multidisciplinary care programme. The results show a significant reduction in the total amount of costs 3,161.63 (range 2,845.30-3,477.96) compared to the usual care group. However, the direct costs are minor (6-12%) compared to the indirect costs (80-93%). CONCLUSION: This study provides important information which is of value for decision-making and making an adequate allocation of medical resources for patients with CLBP. A multidisciplinary outpatient care programme can facilitate rapid return to work.

[Effects of interdisciplinary functional restoration treatment with cognitive behavior therapy in patients with chronic back pain: healthcare research in the context of selective contracts]. / Effekte eines interdisziplinären Functional-restoration-Behandlungsprogramms mit kognitiv-behavioraler Therapie beim chronischen Rückenschmerz : Versorgungsforschung im Kontext von Selektivverträgen.

INTRODUCTION: The efficacy of functional restoration programs for the treatment of chronic back pain is well documented. Nevertheless, there are only a few such centres in Germany and few trials have been conducted in German-speaking regions to demonstrate that implementing such programs in everyday clinical settings with large numbers of patients is just as effective as in a research setting. The present study examined whether the positive effects of such programs can also be observed in the clinically relevant context of a standardized day clinic treatment regimen. MATERIAL AND METHODS: A total of 681 back pain patients in 2 German cities were examined at 4 measurement points (before and immediately after the program, as well as 6 and 12 months after treatment) using a comprehensive questionnaire on perceived pain and symptoms of anxiety and depression, as well as the work situation. RESULTS: In both cities significant and long-term improvements in back pain, pain-related impairment and degree of chronification were observed, as well as a high return-to-work rate after treatment. Hence, the quality of such programs was also confirmed for a large patient population.

["Back pain coach". A project for patients with back pain]. / "Rücken-Coach". Ein Projekt für Patienten mit Rückenschmerzen.

QUESTION: Back pain is a challenge for case management but is a health insurance fund (HIF) that identifies high risk patients and includes them in a back pain assessment and a multimodal program cost-effective? METHODS: Case managers of a HIF contacted selected patients and requested information on pain and current perspectives. Patients in the intervention group were offered a multimodal assessment and, if applicable, a multimodal treatment program. Control group patients received verbal or written (back book) information. Cost data were evaluated with respect to the interview data 1 year prior and 1 year afterwards. FINDINGS: Of the 800 insured persons contacted 621 were nationwide, 88 were regional controls and 91 were intervention patients. Inability to work was still rising in all groups but less in the intervention group versus both control groups. Drugs, hospital as well as cure/adjuvant costs were less for intervention patients than in both control groups. The investment for the program was thus more than refinanced. INTERPRETATION: Case management was well accepted but the intervention was in need of training for case managers and the specific diagnostic and treatment option regionally. FUNDING: The HIF was responsible for the study investment and project partners shared the training of the HIF regional case managers.

[Orthopedic aspects in interdisciplinary multimodal therapy of chronic back pain]. / Orthopädische Aspekte in der multimodalen Therapie chronischer Rückenschmerzen.

The effect of interdisciplinary multimodal therapy of chronic back pain is well documented. With elapsing time changing diagnostic focuses, therapeutic strategies and objectives have to be considered. The chronicity leads to a modification of the relevance of structure-related diagnosis and therapy and changes the significance of the classic orthopedic instruments. The requirement of a rational causal therapy in chronic back pain still remains but the focal points shift to the consideration of somatic, psychological and social disposing and supporting factors.The aim of this paper is to reflect the necessary orthopedic expertise in the context of the pathomechanics of chronic back pain and the interdisciplinary teamwork.

[Measures of success in treatment of chronic back pain: pain intensity, disability and functional capacity: determinants of treatment success in multimodal day clinic setting]. / Vorhersage verschiedener Erfolgsmaße in der Behandlung chronischer Rückenschmerzen: Schmerzintensität, Beeinträchtigung und Funktionskapazität: Determinanten des Behandlungserfolges in einem tagesklinischen multimodalen Setting.

INTRODUCTION: The empirical findings on risk factors for a favorable/unfavorable outcome upraised via pain intensity, disability and functional capacity after empirically well-evaluated multimodal treatment are inconsistent. The objective of this study was to analyze the relevance of psychosocial and pain-related variables for therapeutic outcome in an unselected sample of patients with chronic non-specific back pain (CBP). METHODS: Included were 681 patients with CBP referred to an outpatient-based multidisciplinary pain rehabilitation program and 320 took part in a survey 12 months later. Before, directly after and 12 months after the program the patients received a questionnaire which contained pain-related items on pain intensity, disability, self-reported functional capacity which were defined as outcome variables, psychological items (anxiety, depression) and work-related items which represented probable predictor variables. Multivariable regression analyses were calculated to estimate the contribution of the selected parameters on pain intensity, disability and functional capacity. RESULTS: The calculated regressions showed only a moderate ability to predict or explain the outcomes pain intensity, disability and functional capacity. However, depression and body mass index (BMI) were significantly related to pain-related therapeutic outcome.

[Exercise therapy in the treatment of chronic back pain. An integral part of interdisciplinary therapy]. / Medizinische Trainingstherapie beim chronischen Rückenschmerz. Ein integraler Bestandteil der interdisziplinären Therapie.

Chronic low back pain requires interdisciplinary and biopsychosocial treatment. Apart from the medical, psychological, and physiotherapeutic aspects of therapy, exercise therapy is an important component. Together with"work hardening," it represents the elements for reconditioning. The isolated effect is scientifically difficult to specify with the available data, but in most analytical studies, exercise therapy is an important component in an interdisciplinary setting. A nonspecific, diversified training program is superior to exercise solely of the trunk muscles. The primary tasks are to recover load capacity and diminish pain-avoidance behaviors, with consideration of the principles of"functional restoration." Thorough information and cooperation with the patient, continuous motivation, ratio control, a systematic increase in load, and permanent feedback are necessary. Close communication within the team makes immediate accompanying interventions of other specialized groups possible.

["Work hardening" for chonic back pain. An integral component of multimodal therapy programs]. / "Work hardening" bei chronischen Rückenschmerzen. Ein integraler Bestandteil multimodaler Therapieprogramme.

Work hardening is aimed at a reestablishment of the potentials needed in occupational everyday life. Fundamental motor abilities, such as strength, stability, flexibility and persistence, are restored and merged into the everyday life so that psychological contents, such as fear avoidance behavior will be positively affected. The design of work hardening is interdisciplinary in the sense of a holistic approach to back pain. Handling the pain under load requires sophisticated treatment and the training demands a high degree of individual design. A trusting and mutual agreement between therapist and patient is essential. Work hardening represents an important part of the therapy of chronic back pain and greatly supports regaining confidence in the physical efficiency and the ability to control the body.

[Orthopedic specialists in an interdisciplinary setting. Multimodal therapy for chronic back pain]. / Der Orthopäde im interdisziplinären Setting. Multimodale Therapie beim chronischen Rückenschmerz.

Chronic back pain compels a new therapeutic strategy. A therapeutic team setting and consequent consideration of proven treatments are required. The orthopedic specialist should manage a cooperating team with a psychologist and a physiotherapist, and information should be continuously exchanged according to the criteria for interdisciplinary multimodal pain therapy. The team's therapeutic tasks should be determined and distributed according to the individual patient's problems. Questionably relevant - in particular, somatic-oriented - diagnostic and therapeutic measures should be avoided. The team setting facilitates optimal task sharing and simultaneous professional application of the most effective therapy for chronic back pain: pharmaceutical therapy, including peridural infiltrations by the medical doctor; systematic and controlled increased load by the physiotherapist; and psychosocial assistance from the psychologist.

[Functional diagnostics of mobility control, mobility stabilization and hypermobility. Reliability of clinical tests - results of a multicenter study]. / Funktionelle Diagnostik der Bewegungssteuerung, Bewegungsstabilisation und Hypermobilität. Reliabilität klinischer Tests - Ergebnisse einer Multicenterstudie.

BACKGROUND: Complex forms of musculoskeletal dysfunction are thought to be risk factors for the development of chronic pain syndromes of the locomotor system. Unfortunately there are insufficient data on the reliability and validity of clinical tests for musculoskeletal dysfunctions. METHOD: The intrarater and interrater reliability of clinical tests for hypermobility and for the stabilisation system were examined in a multicentre trial. A total of 68 patients in 6 centres were functionally examined by 2 examiners once (intrarater reliability) and by 1 examiner twice (interrater reliability). RESULTS: The tests for hypermobility showed good to very good reliability. The results for the stabilisation system were more variable whereby 23 tests showed a kappa-coefficient greater than 0.5 and 15 tests good to very good reliability. DISCUSSION: All tests for hypermobility and 23 tests for the stabilisation system are suitable for further evaluation. The broad range in test reliability might be explained by the differences in examiner skills demanded by each test. Therefore, dependent on their validity, some tests will be useful in specialized centres while others might be used in primary care.

[Multimodal integrated assessment and treatment of patients with back pain. Pain related results and ability to work]. / Integrationsversorgung von Patienten mit Rückenschmerzen. Schmerzbezogene Ergebnisse und Arbeitsfähigkeit.

INTRODUCTION: The results of conventional chronic back pain therapy are unsatisfactory. Deconditioning, psychosocial disorders and prolonged disability are common sequelae. MATERIAL AND METHODS: The health insurance fund Deutsche Angestellten Krankenkasse (DAK) offers an interdisciplinary assessment by the Berlin-Brandenburg back pain network (BBR) to its members with ongoing work disability on account of back pain. After medical, physiotherapeutic and psychological exploration one of the following four options is suggested: further diagnostics, outpatient monomodal treatment, day-care pain management program of two intensities or inpatient pain treatment. The data of 394 patients with the leading diagnostic group of back pain (M54, ICD 10, 65.7%) and disability for 92.7 days (mean) are presented. RESULTS: The patients were severely impaired in physical and psychosocial aspects. The chronification was moderate (stage II-III of Mainz Staging System, MPSS). The success of treatment was evaluated 6 months after the initial assessment. All groups showed a significant reduction of pain, anxiety and depression whereas the wellbeing and daily activities improved, but best in the day-care pain management groups. CONCLUSION: Patient selection by a health fund, interdisciplinary assessment and severity adapted treatment resulted in significant reduction in pain and functional improvement in disabled back pain patients.

[Intra-abdominal lymphangioma]. / Das intraabdominelle Lymphangiom.

Mesenteric cystic tumors are very rare. The incidence of the cystic lymphangioma, which belongs to this group, is even lower. Often it is mistakenly classified together with the chylous mesenteric cysts. The term "mesenteric cyst" is of a descriptive topographical nature, whereas the lymphangioma can be classified clearly by the histopathological findings. The lymphangioma typically appears in the first decade and when it is intra-abdominal it shows acute abdominal symptoms. Ultrasonography and computed tomography are very sensitive but not very specific examinations. The differential diagnosis of intra-abdominal lymphangioma includes many benign and malignant tumors. Therefore, a diagnosis is often first made during operation because of the macroscopic aspect and then definitely because of the histological examination. Differentiation between a mesenteric cyst and a cystic lymphangioma is important for the prognosis, because when there is a cystic lymphangioma with an incomplete resection, one has the danger of a recurrence with tendency to invasive growth. The therapy of choice is a complete radical resection. We report the case of an intra-abdominal lymphangioma and have studied the reports published about these tumors. We point out the clinical presentations, diagnosis, differential diagnosis and therapy of the lymphangioma.

[Free intraperitoneal clip as the cause of mechanical ileus of the small intestine]. / Freier intraperitonealer Clip als Ursache eines mechanischen Dünndarmileus.

In the last 10 years the use of mechanical stapling devices in endoscopic surgery have found wide-spread application and acceptance. Even one of the most common surgical operations, the appendectomy, is done regularly laparoscopically. Therefore, utilization of endostaples is commonplace and often results in the spillage of fired staples beyond the margin tissue. We report the case of a 23-year-old patient who developed the clinical signs of bowel obstruction 2 weeks after laparoscopical appendectomy. An exploratory laparotomy was subsequently performed. At the time of exploration, a single band was identified that draped over the ilium central affixed to a staple. The staple was removed and the obstruction relieved without bowel resection. The patient had an uncomplicated recovery. We believe that the cause of this mechanical bowel obstruction was a loose staple.

Protein microheterogeneity and crystal habits: the case of epidermal growth factor receptor isoforms as isolated in a multicompartment electrolyzer with isoelectric membranes.

A purified, soluble form of the epidermal growth factor receptor (sEGFR) was found, by isoelectric focusing in immobilized pH gradients, to consist of three major isoforms (with pI values 6.45, 6.71 and 6.96, respectively) and ca. a dozen minor components. This wild-type sEGFR, while producing crystals, has so far defied any attempt at decoding the structure, due to the very poor diffraction pattern. When the wild-type sEGFR was purified in a multicompartment electrolyzer with isoelectric Immobiline membranes, it yielded the three major isoforms as single-pI components, collected in three separate chambers of the recycling electrolyzer. The pI 6.71 and the pI 6.96 isoforms produced large crystals of apparent good quality. However, while the former produced a high-quality diffraction pattern, which may lead to decoding of three-dimensional structure, the pI 6.96 produced crystals which did not diffract at all. It is concluded that, in the case of "tough" proteins (large size, heterogeneous glycosylation, high water content of crystals), purification to single-charge components might be an essential step for growing proper crystals. The unique advantage of purification via isoelectric membranes is that the protein is collected both isoelectric and isoionic, i.e. uncontaminated by soluble buffers (such as the carrier ampholytes used in conventional focusing).

[The value of blood lactate determination in the postoperative phase]. / Die Bedeutung der Lactatbestimmung im Blut in der postoperativen Phase.

The aim of this study was to investigate whether the measurement of blood lactate in the early postoperative period would be useful for an assessment of the postoperative course. For the determination of a reference curve, the lactate concentration was measured in 10 patients (control group) with uncomplicated courses of the operation which lasted for up to two hours. The investigation group included 111 patients with complicated courses of the operation and/or a duration of the operation of more than 2 hours. The reference value of lactate was 1.3 mmol/l on the average. Lactate values above 2.5 mmol/l were considered as pathological values. In spite of the high physiological range of variations of the blood lactate concentration and many factors which influenced this value, it could be shown that the blood lactate concentration enabled a good prognostic assessment of the course of the early postoperative period in intensive care patients. Intraoperative complications were followed by significantly higher lactate concentrations in the first two postoperative hours (p < 0.001). Increased lactate concentrations during the first two postoperative hours were also a significant parameter for the occurrence of postoperative complications (p < 0.001). Patients with lethal courses already showed intraoperatively increased lactate values in comparison to those patients who could be transferred to a normal ward for further recovery (p < 0.05). From the statistical point of view, patients with lactate concentrations of more than 4.0 mmol/l lasting for more than two hours after an operation had bad prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Crystallization and preliminary X-ray analysis of leukemia inhibitory factor.

Leukemia inhibitory factor (LIF) is a polyfunctional molecule with significant and diverse biological activities. LIF is a glycoprotein secreted by a number of different cell types in vitro. It is induced in fibroblasts, lymphocytes, monocytes and astrocytes by various inducers such as serum, TNF, interleukin-IP and EGF. Due to extensive and variable glycosylation the molecular weight can range from 38 to 67 kDA. The biological functions of LIF are mediated through a receptor and a signal transducer, gp130, which is also used by factors like interleukin-6 (IL-6), cilliary neurotropic factor (CNTF), and oncostatin M (OSM). Here, we report the crystallization of the non-glycosylated human-like LIF expressed in E. coli. The present crystals diffract to 2.0 A using synchrotron radiation. They belong to the monoclinic space group C2, and the cell dimensions are a = 61.5 A, b = 45.3 A, c = 77.7 A and beta = 112.3 degrees.