Stephan Mühlig

Pharmaceutical Care Services for Asthma Patients: A Controlled Intervention Study

As asthma is associated with an enormous social, psychological, and economic burden, various patient education programs have been developed to improve outcomes, including quality of life. The authors evaluated the effectiveness of community pharmacy‐based interventions on lung function, health‐related quality of life, and self‐management in asthma patients in a 12‐month controlled intervention study in 26 intervention and 22 control pharmacies. Pharmacies opted whether to take part as intervention or control pharmacies. According to this, patients (ages 18–65) with mild to severe asthma attending the pharmacies were allocated to the intervention (n = 161) or control group (n = 81), respectively. Intervention patients were educated on their disease, pharmacotherapy, and self‐management; inhalation technique was assessed and, if necessary, corrected. Pharmaceutical care led to significantly improved inhalation technique. Asthma‐specific quality of life and the mental health summary score of the SF‐36 improved significantly in the intervention group. At 12 months, the intervention group showed significant improvements with regard to evening peak flow, self‐efficacy, and knowledge.

Community Pharmacy–Based Pharmaceutical Care for Asthma Patients

BACKGROUND Despite significant progress in asthma drug therapy in recent years, there has been no major change in asthma morbidity and mortality. It is still important to determine whether pharmaceutical care (PC) influences health outcomes. OBJECTIVE To evaluate the effectiveness of PC with regard to clinical, humanistic, and economic outcomes in adults with asthma. METHODS An intervention study was conducted over 12 months. At baseline, 39 community/retail pharmacies, 84 primary care physicians (general practitioners, internal specialists, chest physicians), and 183 patients (aged 18–65 y) diagnosed with asthma were included. To evaluate economic outcomes, 2 German statutory health insurance funds provided 2 years of claims data for their insured patients (n = 55). A 1:10 matching was carried out to compare the data of this intervention subgroup with those of a control group (n = 550). RESULTS Significant improvements were found for all humanistic outcomes (eg, asthma-specific quality of life, self-efficacy, knowledge, medication adherence). In addition, asthma severity, self-reported symptoms, peak expiratory flow, and patients’ inhalation technique improved. Increases in forced expiratory volume in 1 second and vital capacity were not significant over time. Evaluation of the insurance claims data revealed a shift toward better adherence to evidence-based therapy. CONCLUSIONS The study shows that PC for people with asthma has a positive impact on humanistic and, to some extent, on clinical outcomes. To determine potential economic benefits, future research should focus on patients with more severe asthma.

Natural course and burden of bipolar disorders

Despite an abundance of older and more recent retrospective and considerably fewer prospective-longitudinal studies in bipolar disorders I and II, there are still remarkable deficits with regard to our knowledge about the natural course and burden. The considerable general and diagnosis-specific challenges posed by the nature of bipolar disorders are specified, highlighting in particular problems in diagnostic and symptom assessment, shifts in diagnostic conventions and the broadening of the diagnostic concept by including bipolar spectrum disorders. As a consequence it still remains difficult to agree on several core features of bipolar disorders, such as when they begin, how many remit spontaneously and how many take a chronic course. On the basis of clinical and epidemiological findings this paper summarizes (i) a significant need to extend the study of the natural course of bipolar disorder in clinical samples beyond the snapshot of acute episodes to the study of the mid-term and long-term symptom course, associated comorbidities and the associated burden of the disease. (ii) In terms of epidemiological studies, that are also of key importance for resolving the critical issues of threshold definitions in the context of the bipolar spectrum concept, there is a clear need for identifying the most relevant risk factors for the first onset and those for the further illness progression in early stages. Since there are some indications that these critical processes might start as early as adolescence, such studies might concentrate on young cohorts and clearly before these prospective patients come to clinical attention. (iii) The value of both types of studies might be enhanced, if beyond the use of standardized diagnostic interview, special attempts are made to use prospective life- and episode-charting methods for bipolar illnesses.

Smoking cessation in patients with COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide. Cigarette smoking is the main cause of COPD. Quitting smoking is thus the most effective treatment strategy and central in COPD prevention. A number of guidelines on prevention, diagnosis, therapy and rehabilitation of COPD have been published. To help implementing and standardizing smoking cessation in COPD a guideline was published 2008 in Germany focusing on this complex issue. The present guideline is an update of the 2008 guideline and has a high grade of evidence (S3 according to the AWMF; Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften). The guideline gives comprehensive and practical information on how to integrate smoking cessation as an central part of COPD therapy.

Smoking Cessation in Chronic Obstructive Pulmonary Disease An Effective Medical Intervention

BACKGROUND As many as 50% of older smokers develop chronic obstructive pulmonary disease (COPD), and more than 80% of COPD-associated morbidity is caused by tobacco smoking. Despite the severe symptoms from which COPD patients suffer, they are often unable to quit smoking on their own. METHODS Experts from 9 medical societies, under the aegis of the German Society of Pulmonology and Respiratory Medicine (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin), have developed an S3 guideline on smoking cessation in COPD. They took previously published guidelines into account, as well as more than 2000 initially surveyed publications, and created the new guideline in two consensus conferences followed by a Delphi process. RESULTS The following strongly evidence-based statements can be made: A smoking cessation strategy based on a combination of medication and psychosocial support has been found to be effective in COPD patients. Smoking cessation improves pulmonary function, alleviates dyspnea and cough, reduces the frequency of COPD exacerbations, and lowers mortality. Mere smoking reduction does not improve pulmonary function or alleviate symptoms. Smoking cessation is the most effective and least expensive single means of lowering the risk of developing COPD and of arresting its progression. Smoking cessation should therefore be strongly promoted at all levels of health care delivery. CONCLUSIONS There is no question that smoking cessation ranks among the most effective medical interventions, yet the German health care system still does not assign it an adequate priority.

Controlled and uncontrolled allergic asthma in routine respiratory specialist care – a clinical–epidemiological study in Germany

Abstract Background: Studies in the last decade showed high rates of poorly treated and poorly controlled asthma in the community. Extending these findings we describe the more recent situation in specialist respiratory care as the most frequent source of treatment provision using comprehensive clinical and patient assessments and exploring predictors for poor control. Methods: This is a German cross-sectional, clinical epidemiological study in a nationally representative stratified treatment prevalence sample of N = 572 outpatients diagnosed with allergic asthma (AA; females 58.2%, aged 47.5 ± 16.3 (16–81 years). Treating physicians completed standardized clinical assessments (lung function, laboratory, clinical findings, severity, illness and treatment history, asthma control [GINA]), supplemented by patients’ self-report measures (EQ5-D, AQLQ, ACT) and mental health module (CIDI-SF). Results: A total of 65.4% of patients were rated (GINA) as controlled, 30.3% partially controlled, and 4.4% uncontrolled; the patient-rated ACT showed lower rates of control (19.9% controlled, 44.2% partial, 35.8% uncontrolled, kappa: 0.2). Consistent with findings of clinical measures, controlled asthma was highest among patients with pre-treatment stage I severity (83.6%) and decreased by pre-treatment severity (stage IV patients: 29.3%). Poorer control was associated with pre-treatment severity, nocturnal attacks, diminished adherence and comorbid anxiety/depression. Patients received complex multiple drug and non-drug interventions, largely consistent with guidelines. Degree of asthma control was associated with improved and even normalized quality of life findings. Conclusion: In this representative sample of longterm treated AA patients in specialist respiratory care we find better control rates and better adherence to guidelines as previous studies. Despite remarkable differences in clinician- vs patient-rated control ratings even the initially most severe stage IV patients (12.9% of patients) showed remarkable control rates and close to normal quality of life. Intensified treatment (e.g. omalizumab) was associated with improved control. Poorer control was associated with higher initial severity, diminished adherence, comorbid anxiety/depression and old age. Limitation: Findings apply to AA patients in respiratory specialist care sector which is likely to treat the more severely affected patients. Thus, findings cannot be generalized to the general population, other treatment settings or asthma types.

Review on psychotherapeutic interventions for cannabis disorders

Ubersicht uber psychotherapeutische Interventionen bei cannabisbezogenen Storungen Ziel: Ubersicht uber die Literatur zur psychotherapeutischen Behandlung von Cannabismissbrauch und Abhangigkeit. Ergebnisse: Beschrankungen von acht identifizierten Studien werden beschrieben. Als wirksame Therapiekomponenten stellten sich die Motivationssteigerungs-Therapie, die kognitive Verhaltenstherapie, das Notfallmanagement und verschiedene Arten der Familientherapie fur jungere gefahrdete Cannabiskonsumenten heraus. Schlussfolgerungen: Insgesamt belegen die Studien, dass es sowohl einen steigenden Bedarf als auch eine potenzielle Wirksamkeit von Behandlungen gibt, die speziell auf cannabisabhangige und gefahrdete Konsumenten zugeschnitten sind. Trotzdem besteht immer noch ein erheblicher Forschungsbedarf zu spezifischen psychologischen Interventionen auf diesem Gebiet. Insbesondere in Europa herrscht ein eklatanter Mangel an Interventionsstudien und der Entwicklung von Behandlung...

Idiopathischer Bauchschmerz im Kindesalter

ZusammenfassungDas idiopathische Bauchschmerzsyndrom (IBS) gehört zu den verbreitetsten Schmerzerkrankungen im Kindesalter. Etwa jedes 5. bis 10. Kind leidet unter wiederkehrenden Bauchschmerzattacken. In fast 50% der Fälle persistieren die Beschwerden über Jahre bis ins Erwachsenenalter. Obwohl das IBS damit zu den häufigsten Anlässen für Arztkonsultationen in der pädiatrischen Praxis zählt, wird die Thematik in der empirischen Forschung bisher stark vernachlässigt. Die Erkenntnisse zur Pathophysiologie der rezidivierenden Abdominalbeschwerden im Kindesalter sind trotz zunehmenden Forschungsinteresses noch rudimentär, die Resultate vielfach noch inkonsistent.Aktuelle Erklärungs- und Therapiemodelle verstehen das IBS als komplexe und multifaktoriell verursachte Störung (biopsychosoziales Paradigma). Das Auftreten der Symptomatik scheint v.a. mit psychopathologischen und psychosozialen Belastungen (Ängste, Depressionen, Alltagsstreß, Lebensereignisse) sowie familiären und Umweltfaktoren (psychopathologische Probleme der Eltern, soziales Modell- bzw. Verstärkerverhalten) in Zusammenhang zu stehen. Die auffällig ausgeprägte Komorbidität des Bauchschmerzsyndroms mit anderen Schmerzbeschwerden deutet auf eine zugrundeliegende (psychopathologische) Somatisierungstendenz bei den betroffenen Kindern hin.Die ungünstige Langzeitprognose unterstreicht die Notwendigkeit frühzeitiger und zielgerichteter Intervention. Voraussetzung für eine effektive psychologische Therapie ist eine z.T. relativ aufwendige organmedizinische Ausschlußdiagnose. Die verhaltensmedizinische Behandlung, die auf der Grundlage einer gründlichen Familienanamnese und Symptomanalyse durchgeführt wird, greift dabei auf die in der psychologischen Schmerztherapie bewährten Verfahren zurück und umfaßt prophylaktische Maßnahmen, Interventionen zum Symptommanagement und Veränderung von krankheitsrelevanten Umweltbedingungen. In den letzten Jahren werden verstärkt komplexere und multidimensionale Schmerzbehandlungsprogramme für Kinder entwickelt, die trotz vielversprechender erster Resultate für den spezifischen Anwendungsbereich des kindlichen Bauchschmerzes aber noch nicht ausreichend evaluiert sind.AbstractRecurrent abdominal pain (RAP) is one of the most common pain syndromes in childhood, with prevalence rates ranging from 10 to 20% in all school-age children. In nearly 50% the complaints persist over many years of their life-span to adolescence or adulthood. Although the empirical findings have increased in the last decade, our knowledge about the etiology, pathogenesis, and pathophysiology is still very limited. Current approaches suggest that we understand recurrent pain syndromes as a complex and multidimensional disturbance (biopsychosocial paradigm). In this respect there is strong evidence for the major importance of psychosocial causes (daily hassles, specific life events), psychopathological factors (anxiety, depression, somatization disorder), and social environmental influences (mother’s psychopathology, social modelling, reinforcement) in the pathogenesis of functional abdominal pain. The noticeable correlation with other pain syndromes and functional disturbances indicates that recurrent pain may possibly be a manifestation of a basic somatization disorder. The unfavourable long-term prognosis supports the need for early and specific interventions. Psychological treatment requires a medical examination to exclude organic origins. Some of these invasive diagnostic procedures can be very difficult, expensive and distressing for the child. Behavioural medicine is based upon having an extensive family history and symptom analysis. The psychological interventions applied in clinical practice include prophylaxis, reduction of pain symptoms and environmental modification. In recent years there has been an increasing trend to create more complex and multidimensional behavioural treatment programs for children. Although preliminary data on the use of these behavioural medicine programs have shown some promise, further investigations are needed to examine the applicability and effectiveness of specific interventions in the treatment of abdominal pain symptoms.

Omalizumab versus ‘Usual Care’: Results from a Naturalistic Longitudinal Study in Routine Care

Background: It is unclear how far the superior efficacy of omalizumab, established in randomized controlled clinical trials of patients with severe allergic asthma (SAA), translates into routine practice and when compared to matched controls. Methods: New-onset omalizumab-treated (OT) patients with SAA (n = 53) were compared to a matched control group of usual-care (UC) patients (n = 53). Treatment and procedures were naturalistic. Subsequent to a baseline assessment, patients were followed up over at least 6 months with at least two follow-up assessments. Primary clinical outcomes were the number of asthma attacks, persistence of asthma symptoms and degree of control [asthma control test (ACT), Global Initiative for Asthma]. Secondary outcome criteria were quality of life (Euro-Qol 5D) and number of medications. For each outcome we compared within-group effects from baseline to 6-month follow-up as well as between-group effects. Results: OT patients showed significant improvements in number [effect size (ES) = 0.03] and frequency (ES = 0.04) of asthma attacks as well as asthma control (ES = 0.09), whereas controls revealed no significant improvements in these measures. Further improvements in the OT group were found for ‘perceived control always’ (ACT, p = 0.006), no impairment (ACT, p = 0.02), reduction of sickness days (p = 0.002) and number of medications needed (p = 0.001). Conclusions: Substantial beneficial effects of omalizumab, similar to those observed in controlled trials and after marketing studies, were confirmed, particularly with regard to the reduction of asthma attacks, persistence of symptoms, asthma control and reduction of concomitant asthma medications. This study provides a tougher test and generalizable evidence for the effectiveness of omalizumab in routine care.

Rauchen und Nikotinabhängigkeit in Deutschland

Zusammenfassung. Theoretischer Hintergrund: Der Konsum von Tabak ist verantwortlich fur zahlreiche korperliche Erkrankungen und kann zu einer psychischen Storung fuhren, der Nikotinabhangigkeit. Ziel: Feststellung der aktuellen Verbreitung, Therapiemoglichkeiten und Versorgungssituation von Rauchern und Nikotinabhangigen in Deutschland. Methode: Ubersicht uber einschlagige (versorgungs-)epidemiologische und klinische Studien. Ergebnisse: Rauchen ist stark verbreitet, Nikotinabhangigkeit eine der haufigsten psychischen Storungen. Die Wirksamkeit von Entwohnungsbehandlungen ist empirisch gut belegt, dennoch sind nur wenige Raucher zu einem Konsumstopp bereit. Die Inanspruchnahmerate insbesondere der wirksamsten multimodalen Behandlungsprogramme ist gering, wobei es allerdings auch an professionellen Anbietern mangelt. Schlussfolgerungen: Die Versorgungssituation von Rauchern in Deutschland ist unzureichend und verbesserungsbedurftig. Als notwendig erscheinen Aufbau einer flachendeckenden Infrastruktur von E...