Correction to: Mild Depression in Low Back Pain: the Interaction of Thought Suppression and Stress Plays a Role, Especially in Female Patients.

This article was updated to correct the author names. Family and given names are in the correct order.

Mild Depression in Low Back Pain: the Interaction of Thought Suppression and Stress Plays a Role, Especially in Female Patients.

PURPOSE: Mild depression has been shown as a precursor and as a consequence of low back pain, even in early phases of acute or subacute pain. Chronic daily life stress as well as dysfunctional pain-related cognitions such as thought suppression (TS) seem to play a role in the pain-depression cycle; however, the mechanisms of these associations are less understood. Experimentally induced TS, conceived as the attempt to directly suppress sensations such as pain, has been shown to paradoxically cause a delayed and non-volitional return of the suppressed thoughts and sensations and to increase affective distress. These dysfunctional processes are supposed to increase under high cognitive load, such as high stress. METHOD: In the present cross-sectional study, we for the first time sought to examine a possible interaction between habitual TS and stress on depression in N = 177 patients with subacute low back pain (SLBP), using the following questionnaires: Subscale Thought Suppression from Avoidance-Endurance Questionnaire, Beck Depression Inventory, and Kiel Interview of Subjective Situation. A three-way ANOVA was conducted with two groups of TS (high/low), stress (high/low) and sex as independent factors and depression as dependent. RESULTS: Results indicated a significant three-way interaction with highest depression scores in female patients showing high TS and high stress. Overall main effects for sex and stress indicated higher depression in women and in highly stressed patients. CONCLUSION: Our findings support the hypothesis that TS heightens depressive mood under conditions of high cognitive load especially in female patients with SLBP indicating a special vulnerability for depressive mood in women with SLBP.

Self-Assessment of competence during post-graduate training in general medicine: A preliminary study to develop a portfolio for further education.

Awareness of one's own strengths and weaknesses is a key qualification for the specialist physician. We examined how physicians undergoing specialist training in general medicine rate themselves in different areas. For this purpose, 139 participants receiving post-graduate training in general practice offered by the Medical Association of Westfalen-Lippe assessed themselves regarding their subjective confidence in 20 core competencies and 47 situations involving patient counseling in general practice. Their self-assessments were recorded on a five-point Likert scale. The study questions addressed acceptance and practicability of self-assessment, mean values, reliability, stratification and plausibility of the results in group comparison. On average participants rated their subjective confidence with 3.4 out of 5 points. The results are self-consistent (Cronbach's alpha >0.8), although there are considerable differences among competencies and among participants. The latter can be explained partly by biographical data, which supports the plausibility of the data. Participants stated that regularly gathering data on subjective learning needs and the discussion of these needs with mentors and trainers contributes to improving their specialist training. Elements for self-assessment are suitable for integration into a postgraduate training portfolio. These should be supplemented by formative assessment procedures.

[Medical care and costs in the last year of life - propensity score matching of AAPV and SAPV insurants]. / Medizinische Versorgung und Kosten im letzten Lebensjahr.

INTRODUCTION: Patients with life limiting diseases need special medical treatments at the end of life. In Germany, since 2007 there is specialized outpatient palliative care (SAPV) available for patients in need of special treatments additional to regular outpatient palliative care (AAPV). Distribution of specialized palliative care is not homogenous in german regions and there is no evidence about medical gain and total costs yet. METHODS: Deceased patients from both groups are compared by propensity score matching with regard to their medical biographies of their last year of life. This retrospective study uses data of the health insurance company DAK. The data set contains information about items of medical care including their particular costs. RESULTS: Results show significant higher costs for patients in specialized care settings with exception of nursing costs. The most striking difference was found for drug expenditures which were twice as much for patients in specialized care than for patients treated with regular outpatient palliative care. CONCLUSION: The specialty of care is represented by the average costs of specialized outpatient palliative care in patients last year of life. A proportion of 75% of the costs for specialized outpatient palliative care follow from temporary inpatient care and drug expenditures. Further investigations should measure to what extend higher costs are resulting from additional benefits of care and how they could be interpreted in terms of cost efficiency.

Recommendations for undergraduate training in the primary care sector--position paper of the GMA-Primary Care Committee.

During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system. Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care--including home-care. This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM). It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience ("Hospitation"), 4-week clinical traineeships of a casual nature ("Famulatur") and 2-week courses of structured and assessed clinical training ("Blockpraktikum") as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, "PJ"). The recommendations encompass structural and process criteria for internships in different general practices. In addition, for the first time recommendations for teaching on campus--in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training--are set down here. In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training.

Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up.

Recent research has found individual differences in back pain patients due to behavioral avoidance vs persistence. However, there is a lack of prospective studies of nonspecific low back pain patients. The avoidance-endurance model (AEM) suggests at least 3 pathways leading to chronic pain: fear-avoidance response, distress-endurance response, and eustress-endurance response. We sought to compare these 3 maladaptive subgroups with an adaptive group using a classification tool that included the following scales: the thought suppression and behavioral endurance subscale of the Avoidance-Endurance Questionnaire and the Beck Depression Inventory. The psychological characteristics, and pain and disability of the AEM subgroups were investigated. We report results from 177 patients with subacute nonspecific low back pain at the start of outpatient treatment and at follow-up after 6 months. At baseline, a multivariate analysis of variance found that the fear-avoidance patients scored higher in pain catastrophizing than the other groups. The distress-endurance patients displayed elevated anxiety/depression and helplessness/hopelessness accompanied with the highest scores in the classification variables thought suppression and persistence behavior. The eustress-endurance patients had the highest humor/distraction scores, pain persistence, and positive mood despite pain. All 3 maladaptive groups revealed a higher pain intensity than the adaptive patients at follow-up after 6 months; however, disability at follow-up was elevated only in the fear-avoidance and distress-endurance patients. The study provides preliminary evidence for the construct and prospective validity of AEM-based subgroups of subacute, nonspecific back pain patients. The results suggest the need for individually targeted cognitive behavioral treatments in the maladaptive groups.