Felix Angst

Mortality of patients with mood disorders: follow-up over 34–38 years

BACKGROUND All follow-up studies of causes of death in affective disordered patients have found they have markedly elevated suicide rates and a less reproducible increased mortality from other causes. The reported rates by gender, disorder type and treatment are more variable. METHODS Hospitalised affective disordered patients (n=406) were followed prospectively for 22 years or more. Later, mortality was assessed for 99% of them at which time 76% had died. RESULTS Standardised Mortality Rates (observed deaths/expected deaths) for patients were elevated especially for suicide and circulatory disorders in both men and women. Women actually had higher suicide rates but that did not take into account the twofold increase in general population rates for men. Unipolar patients had significantly higher rates of suicide than bipolar Is or IIs. In all groups long term medication treatment with antidepressants alone or with a neuroleptic, or with lithium in combination with antidepressants and/or neuroleptics significantly lowered suicide rates even though the treated were more severely ill. Although at the age of onset the suicide rates were most elevated, from ages 30 to 70 the rates were remarkably constant despite the different courses of illness. LIMITATIONS The patients were identified as inpatients and followed prospectively. The treatments were uncontrolled and are not quantifiable but were documented during the follow-up. CONCLUSIONS Men and women hospitalised for affective disorders have elevated mortality rates from suicide and circulatory disorders. Unipolars have higher suicide rates than bipolar Is or IIs. Long term medication treatment lowers the suicide rates, despite the fact that it was the more severely ill who were treated.

Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with Osteoarthritis of the lower extremities

OBJECTIVE To discuss the concepts of the minimal clinically important difference (MCID) and the smallest detectable difference (SDD) and to examine their relation to required sample sizes for future studies using concrete data of the condition-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the generic Medical Outcomes Study 36-Item Short Form (SF-36) in patients with osteoarthritis of the lower extremities undergoing a comprehensive inpatient rehabilitation intervention. METHODS SDD and MCID were determined in a prospective study of 122 patients before a comprehensive inpatient rehabilitation intervention and at the 3-month followup. MCID was assessed by the transition method. Required SDD and sample sizes were determined by applying normal approximation and taking into account the calculation of power. RESULTS In the WOMAC sections the SDD and MCID ranged from 0.51 to 1.33 points (scale 0 to 10), and in the SF-36 sections the SDD and MCID ranged from 2.0 to 7.8 points (scale 0 to 100). Both questionnaires showed 2 moderately responsive sections that led to required sample sizes of 40 to 325 per treatment arm for a clinical study with unpaired data or total for paired followup data. CONCLUSION In rehabilitation intervention, effects larger than 12% of baseline score (6% of maximal score) can be attained and detected as MCID by the transition method in both the WOMAC and the SF-36. Effects of this size lead to reasonable sample sizes for future studies lying below n = 300. The same holds true for moderately responsive questionnaire sections with effect sizes higher than 0.25. When designing studies, assumed effects below the MCID may be detectable but are clinically meaningless.

Prediction of grip and key pinch strength in 978 healthy subjects.

BackgroundHand strength is an important independent surrogate parameter to assess outcome and risk of morbidity and mortality. This study aimed to determine the predictive power of cofactors and to predict population-based normative grip and pinch strength.MethodsA representative population survey was used as the basis for prediction analyses (n = 978). Bivariate relationships between grip/pinch strengths of the dominate hand were explored by means of all relevant mathematical functions to maximize prediction. The resulting best functions were combined into a multivariate regression.ResultsPolynoms (up to the third degree) were the best predictive functions. On the bivariate level, height was best correlated to grip (46.2% explained variance) and pinch strength (37.7% explained variance) in a linear relationship, followed by sex, age, weight, and occupational demand on the hand. Multivariate regression provided predicted values close to the empirical ones explaining 76.6% of the variance for grip strength and 67.7% for pinch strength.ConclusionThe five easy-to-measure cofactors sex, age, body height, categorized occupational demand on the hand, and body weight provide a highly accurate prediction of normative grip and pinch strength.

What counts: outcome assessment after distal radius fractures in aged patients.

Objectives: Outcome of surgical interventions at the distal radius does not only depend on the type of intervention used, it also depends on the way the outcome is measured. Substantial differences in outcome assessment between different measurement tools and poor correlation among them result in the question about the best instrument for the evaluation of treatment after distal radius fractures. The aim of the review is to discuss pros and cons of the parameters that are available to assess the outcome after distal radius fractures. The review should help to choose the appropriate instruments for a given research question in aged patients with distal radius fractures. Data Sources and Synthesis: Objective and subjective measures were reviewed with respect to their suitability in outcome assessment. Radiological parameters like inclination, palmar slope, and length of the radius are most common and used to determine especially surgical success. Grip strength and range of motion are considered objective and used as study endpoints in many studies. Functional tests like the Jebsen test provide a realistic feedback about disability but require special skills and resources of the testing personnel. Patient self-assessment adds perceived patient benefit. The patient-rated wrist evaluation (PRWE) provides a reliable and valid instrument for subjective outcome assessment. Conclusions: A combination of objective and subjective parameters should be used to assess the outcome of different treatment strategies due to the known discrepancies. Objective parameters like shortening, radial shift, or others should be clearly defined in the study methodology.

ICF CORE SETS FOR DIABETES MELLITUS

OBJECTIVE To report on the results of the consensus process integrating evidence from preliminary studies to develop the first version of a Comprehensive ICF Core Set and a Brief ICF Core Set for diabetes mellitus. METHODS A formal decision-making and consensus process integrating evidence gathered from preliminary studies was followed. Preliminary studies included a Delphi exercise, a systematic review, and an empirical data collection. After training in the ICF and based on these preliminary studies relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS The preliminary studies identified a set of 253 ICF categories at the second, third, and fourth ICF levels with 99 categories on body functions, 40 on body structures, 55 on activities and participation, and 59 on environmental factors. Fifteen experts attended the consensus conference on diabetes mellitus (8 physicians with various sub-specializations; 5 physical therapists, one epidemiologist and one social worker). Altogether 99 categories (85 second-level and 14 third-level categories) were included in the Comprehensive ICF Core Set with 36 categories from the component body functions, 16 from body structures, 18 from activities and participation, and 29 from environmental factors. The Brief ICF Core Set included a total of 33 second-level categories with 12 on body functions, 6 on body structures, 5 on activities and participation, and 10 on environmental factors. CONCLUSION A formal consensus process integrating evidence and expert opinion based on the ICF framework and classification led to the definition of ICF Core Sets for diabetes mellitus. Both the Comprehensive ICF Core Set and the Brief ICF Core Set were defined.

A concept for comprehensively measuring health, function and quality of life following orthopaedic interventions of the upper extremity

The view that subjective complaints rather than “objective” measurements decide on whether to consult the doctor or allow for an intervention to be carried out, should contribute to the decision-making process. This is especially true in diseases with multiple joint impairments. Although a variety of patient self-assessment scores exists, no gold standard is available to measure function and quality of life (QoL) after interventions at the upper extremity. The goal of our concept is to establish a comprehensive score set where patients should rate their generic health resp. quality of life (QoL), function of the upper extremity and specific joint function including activities of daily living, function and pain. A comparison with normative data should be possible in order to estimate how the subjective results of the patient when compared to “healthy” people in the general population. Score sets for measuring intervention effect at the shoulder, elbow and the hand were established after previous methodological testing within an interdisciplinary research project. The provisional sets were defined following a systematic literature search. Each set received a score of measuring the quality of life (SF-36), the whole function of the arm (DASH) and the specific joint function (SPADI/ASES for shoulder, PREE/mASES for the elbow and PRWE/custom for the hand). Individual scores were translated, if necessary according to AAOS-guidelines, and tested for reliability and construct validity. All three score sets were then systematically tested in cross-sectional studies. In addition, characteristic values such as minimal detectable difference and effect size could already be determined in the shoulder set in a long-term study. Definite score sets were defined, which allow quantification of the intervention effect at the upper extremity on function and quality of life after.

Long-term outcome and mortality of treated versus untreated bipolar and depressed patients: A preliminary report

The mortality of patients with mood disorders is elevated as a consequence not only of suicides and accidents but also of cardiovascular and other diseases - for instance, hypothyroidism and hyperthyroidism. Long-term medication can reduce suicides by two-thirds and can probably reduce non-suicidal mortality also. This long-term study of 406 hospital admissions recruited between 1959 and 1963 and followed up until 1991 suggests that not only lithium (as reported in the literature), but also neuroleptics and antidepressants may have such beneficial effects.

Reliability and Validity of the German Version of “The Patient-rated Wrist Evaluation (PRWE)” as an Outcome Measure of Wrist Pain and Disability in Patients with Acute Distal Radius Fractures

The aim was to test the reliability and validity of the German version of the Patient-rated Wrist Evaluation (PRWE) for patients with acute distal radius fractures. To estimate the reliability and construct validity, 44 patients completed a questionnaire booklet containing the German PRWE, the Short Form-36 (SF-36), and the Disability of the Arm, Shoulder, and Hand (DASH) four to six weeks after the fracture, and the PRWE again seven days later. For reliability, the intraclass correlation coefficient (ICC) was 0.94 for the PRWE total score. Its internal consistency was 0.89 (Cronbachs alpha). The PRWE total score showed a moderate correlation with the DASH (0.62) and the SF-36 subscale bodily pain (0.58). Low correlations were found with other scales of the SF-36. Based on our results the German PRWE is a practical, reliable, and valid instrument and can be recommended to measure patient-rated pain and disability in German-speaking patients with acute distal radius fracture.

Lessons learned during the cross-cultural adaptation of the American Shoulder and Elbow Surgeons shoulder form into German

Cross-cultural adaptation and testing of reliability and validity were performed by use of a sample of 118 patients after shoulder arthroplasty. They completed a questionnaire booklet containing the American Shoulder and Elbow Surgeons (ASES) questionnaire, Shoulder Pain and Disability Index (SPADI), Short Form 36, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 1 week later, they completed the ASES questionnaire again. The cross-cultural adaptation procedure revealed no major problems. The intraclass correlation coefficients (ICCs) for the subscales for pain and function and for the total score were very high (>0.84); the ICC for the subscale instability was unacceptably low. Function of the contralateral side was consistently better for all items (P < .01). Reliability for both function scales was similar (ICC >0). The ASES scores showed moderate correlation of 0.57 to 0.67 with the various scales of the SF-36 and higher correlation with the DASH (0.84) and SPADI (0.92). The German ASES showed good reliability and validity and can be used for shoulder-specific patient self-assessment in comparison to the contralateral (unaffected) side and provides additional information to objective parameters. The instability domain does not provide any additional clinical information.

Quality of life assessment in osteoarthritis

Optimal prevention and therapy management depends upon the quality of health assessment in the field of increasingly frequent degenerative health disorders. Quality of life has increased in importance as a result of World Health Organizations’ new concept of health and disease. This review addresses strategies and measurement in the quality of life assessment in osteoarthritis over the past 15 years. The authors produce an overview of valid quality of life instruments and their application on patients with hip or knee osteoarthritis, focused on the responsiveness of the tools and on the effect of different interventions. Continuous improvement of therapy and result quality must remain adjusted to the patient and must involve cost carriers in each individual situation to attain the best quality of life under the given socioeconomic conditions.