Thomas Zumbrunn

Return to work coordination programmes for work disability: a meta-analysis of randomised controlled trials.

Background The dramatic rise in chronically ill patients on permanent disability benefits threatens the sustainability of social security in high-income countries. Social insurance organizations have started to invest in promising, but costly return to work (RTW) coordination programmes. The benefit, however, remains uncertain. We conducted a systematic review to determine the long-term effectiveness of RTW coordination compared to usual practice in patients at risk for long-term disability. Methods and Findings Eligible trials enrolled employees on work absence for at least 4 weeks and randomly assigned them to RTW coordination or to usual practice. We searched 5 databases (to April 2, 2012). Two investigators performed standardised eligibility assessment, study appraisal and data extraction independently and in duplicate. The GRADE framework guided our assessment of confidence in the meta-analytic estimates. We identified 9 trials from 7 countries, 8 focusing on musculoskeletal, and 1 on mental complaints. Most trials followed participants for 12 months or less. No trial assessed permanent disability. Moderate quality evidence suggests a benefit of RTW coordination on proportion at work at end of follow-up (risk ratio = 1.08, 95% CI = 1.03 to 1.13; absolute effect = 5 in 100 additional individuals returning to work, 95% CI = 2 to 8), overall function (mean difference [MD] on a 0 to 100 scale = 5.2, 95% CI = 2.4 to 8.0; minimal important difference [MID] = 10), physical function (MD = 5.3, 95% CI = 1.4 to 9.1; MID = 8.4), mental function (MD = 3.1, 95% CI = 0.7 to 5.6; MID = 7.3) and pain (MD = 6.1, 95% CI = 3.1 to 9.2; MID = 10). Conclusions Moderate quality evidence suggests that RTW coordination results in small relative, but likely important absolute benefits in the likelihood of disabled or sick-listed patients returning to work, and associated small improvements in function and pain. Future research should explore whether the limited effects persist, and whether the programmes are cost effective in the long term.

Growth and community responses of alpine dwarf shrubs to in situ CO2 enrichment and soil warming

• Rising CO₂ concentrations and the associated global warming are expected to have large impacts on high-elevation ecosystems, yet long-term multifactor experiments in these environments are rare. • We investigated how growth of dominant dwarf shrub species (Vaccinium myrtillus, Vaccinium gaultherioides and Empetrum hermaphroditum) and community composition in the understorey of larch and pine trees responded to 9 yr of CO₂ enrichment and 3 yr of soil warming at the treeline in the Swiss Alps. • Vaccinium myrtillus was the only species that showed a clear positive effect of CO₂ on growth, with no decline over time in the annual shoot growth response. Soil warming stimulated V. myrtillus growth even more than elevated CO₂ and was accompanied by increased plant-available soil nitrogen (N) and leaf N concentrations. Growth of Vaccinium gaultherioides and E. hermaphroditum was not influenced by warming. Vascular plant species richness declined in elevated CO₂ plots with larch, while the number of moss and lichen species decreased under warming. • Ongoing environmental change could lead to less diverse plant communities and increased dominance of the particularly responsive V. myrtillus in the studied alpine treeline. These changes are the consequence of independent CO₂ and soil warming effects, a result that should facilitate predictive modelling approaches.

Characteristics of Ischemic Brain Lesions After Stenting or Endarterectomy for Symptomatic Carotid Artery Stenosis Results From the International Carotid Stenting Study–Magnetic Resonance Imaging Substudy

Background and Purpose— In a substudy of the International Carotid Stenting Study (ICSS), more patients had new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (MRI) after stenting (CAS) than after endarterectomy (CEA). In the present analysis, we compared characteristics of diffusion-weighted MRI lesions. Methods— Number, individual and total volumes, and location of new diffusion-weighted MRI lesions were compared in patients with symptomatic carotid stenosis randomized to CAS (n=124) or CEA (n=107) in the ICSS-MRI substudy. Results— CAS patients had higher lesion numbers than CEA patients (1 lesion, 15% vs 8%; 2–5 lesions, 19% vs 5%; >5 lesions, 16% vs 4%). The overall risk ratio for the expected lesion count with CAS versus CEA was 8.8 (95% confidence interval, 4.4–17.5; P<0.0001) and significantly increased among patients with lower blood pressure at randomization, diabetes mellitus, stroke as the qualifying event, left-side stenosis, and if patients were treated at centers routinely using filter-type protection devices during CAS. Individual lesions were smaller in the CAS group than in the CEA group (P<0.0001). Total lesion volume per patient did not differ significantly. Lesions in the CAS group were more likely to occur in cortical areas and subjacent white matter supplied by leptomeningeal arteries than lesions in the CEA group (odds ratio, 4.2; 95% confidence interval, 1.7–10.2; P=0.002). Conclusions— Compared with patients undergoing CEA, patients treated with CAS had higher numbers of periprocedural ischemic brain lesions, and lesions were smaller and more likely to occur in cortical areas and subjacent white matter. These findings may reflect differences in underlying mechanisms of cerebral ischemia. Clinical Trial Registration— URL: http://www.isrctn.org. Unique identifier: ISRCTN25337470.

Evaluation of a single leg stance balance test in children

Balance is a major determinate of gait. In high functioning individuals without significant vestibular or vision impairments, a ceiling effect may be present when using a double limb support protocol to assess balance function. For these populations, a single leg stance protocol may be more suitable. 47 typically developing (TD) subjects and 10 patients with CEV performed a single leg stance test on a force plate. The center of pressure (COP) was determined and several COP derived variables were calculated. Included measurements were: standard deviation, maximum excursion, area, average radial displacement, path velocity and frequency of the COP. Directional components of suitable variables were used to analyze anterior/posterior and medial/lateral contributions. Correlations with age of TD subjects indicated that all balance variables except frequency were significantly correlated. Most parameters were highly inter-correlated. Age adjusted COP balance variables also correlated to the Bruininks-Oseretsky balance subtest. Highest correlations were determined by the maximum excursion and velocity of the COP in the anterior/posterior direction. Statistical comparisons between the CEV group and a 4-6 TD group indicated significant differences between groups for most COP balance parameters. These results indicated that a single limb balance assessment may be a useful assessment for determining balance impairments in higher functioning children with orthopedic impairments.

Undertriage in older emergency department patients--tilting against windmills?

Objectives The aim of this study was to investigate the long-term effect of a teaching intervention designed to reduce undertriage rates in older ED patients. Further, to test the hypothesis that non-adherence to the Emergency Severity Index (ESI) triage algorithm is associated with undertriage. Additionally, to detect patient related risk factors for undertriage. Methods Pre-post-test design. The study sample consisted of all patients aged 65 years or older presenting to the ED of an urban tertiary and primary care center in the study periods. A teaching intervention designed to increase adherence to the triage algorithm. To assess, if the intervention resulted in an increase of factual knowledge, nurses took a test before and immediately after the teaching intervention. Undertriage rates were assessed one year after the intervention and compared to the pre-test period. Results In the pre-test group 519 patients were included, and 394 in the post-test-group. Factual knowledge among triage nurses was high already before the teaching intervention. Prevalence of undertriaged patients before (22.5%) and one year after the intervention (24.2%) was not significantly different (χ2 = 0.248, df = 1, p = 0.619). Sex, age, mode of arrival, and type of complaint were not identified as independent risk factors for undertriage. However, undertriage rates increased with advancing age. Adherence to the ESI algorithm is associated with correct triage decisions. Conclusions Undertriage of older ED patients remained unchanged over time. Reasons for undertriage seem to be more complex than anticipated. Therefore, additional contributing factors should be addressed.

Intra- and postoperative intravenous ketamine does not prevent chronic pain: A systematic review and meta-analysis

Abstract Background and aims The development of postoperative chronic pain (POCP) after surgery is a major problem with a considerable socioeconomic impact. It is defined as pain lasting more than the usual healing, often more than 2–6 months. Recent systematic reviews and meta-analyses demonstrate that the N-methyl-D-aspartate-receptor antagonist ketamine given peri- and intraoperatively can reduce immediate postoperative pain, especially if severe postoperative pain is expected and regional anaesthesia techniques are impossible. However, the results concerning the role of ketamine in preventing chronic postoperative pain are conflicting. The aim of this study was to perform a systematic review and a pooled analysis to determine if peri- and intraoperative ketamine can reduce the incidence of chronic postoperative pain. Methods Electronic searches of PubMed, EMBASE and Cochrane including data until September 2013 were conducted. Subsequently, the titles and abstracts were read, and reference lists of reviews and retrieved studies were reviewed for additional studies. Where necessary, authors were contacted to obtain raw data for statistical analysis. Papers reporting on ketamine used in the intra- and postoperative setting with pain measured at least 4 weeks after surgery were identified. For meta-analysis of pain after 1, 3, 6 and 12 months, the results were summarised in a forest plot, indicating the number of patients with and without pain in the ketamine and the control groups. The cut-off value used for the VAS/NRS scales was 3 (range 0–10), which is a generally well-accepted value with clinical impact in view of quality of life. Results Our analysis identified ten papers for the comprehensive meta-analysis, including a total of 784 patients. Three papers, which included a total of 303 patients, reported a positive outcome concerning persistent postsurgical pain. In the analysis, only one of nine pooled estimates of postoperative pain at rest or in motion after 1, 3, 6 or 12 months, defined as a value ≥3 on a visual analogue scale of 0–10, indicated a marginally significant pain reduction. Conclusions Based on the currently available data, there is currently not sufficient evidence to support a reduction in chronic pain due to perioperative administration of ketamine. Only the analysis of postoperative pain at rest after 1 month resulted in a marginally significant reduction of chronic postoperative pain using ketamine in the perioperative setting. Implications It can be hypothesised, that regional anaesthesia in addition to the administration of perioperative ketamine might have a preventive effect on the development of persistent postsurgical pain. An additional high-quality pain relief intra- and postoperatively as well after discharge could be more effective than any particular analgesic method per se. It is an assumption that a low dose infusion ketamine has to be administered for more than 72 h to reduce the risk of chronic postoperative pain.

Predictors of Acute and Persisting Ischemic Brain Lesions in Patients Randomized to Carotid Stenting or Endarterectomy

Background and Purpose— We investigated predictors for acute and persisting periprocedural ischemic brain lesions among patients with symptomatic carotid stenosis randomized to stenting or endarterectomy in the International Carotid Stenting Study. Methods— We assessed acute lesions on diffusion-weighted imaging 1 to 3 days after treatment in 124 stenting and 107 endarterectomy patients and lesions persisting on fluid-attenuated inversion recovery after 1 month in 86 and 75 patients, respectively. Results— Stenting patients had more acute (relative risk, 8.8; 95% confidence interval, 4.4–17.5; P<0.001) and persisting lesions (relative risk, 4.2; 95% confidence interval, 1.6–11.1; P=0.005) than endarterectomy patients. Acute lesion count was associated with age (by trend), male sex, and stroke as the qualifying event in stenting; high systolic blood pressure in endarterectomy; and white matter disease in both groups. The rate of conversion from acute to persisting lesions was lower in the stenting group (relative risk, 0.4; 95% confidence interval, 0.2–0.8; P=0.007), and was only predicted by acute lesion volume. Conclusions— Stenting caused more acute and persisting ischemic brain lesions than endarterectomy. However, the rate of conversion from acute to persisting lesions was lower in the stenting group, most likely attributable to lower acute lesion volumes. Clinical Trial Registration —URL: www.isrctn.org. Unique identifier: ISRCTN25337470.

Personalized Prescription Feedback Using Routinely Collected Data to Reduce Antibiotic Use in Primary Care: A Randomized Clinical Trial

Importance Feedback interventions using routinely collected health data might reduce antibiotic use nationwide without requiring the substantial resources and structural efforts of other antibiotic stewardship programs. Objective To determine if quarterly antibiotic prescription feedback over 2 years reduces antibiotic use when implemented in a complex health care system. Design, Setting, and Participants Pragmatic randomized trial using routinely collected claims data on 2900 primary care physicians with the highest antibiotic prescription rates in Switzerland. Interventions Physicians were randomized to quarterly updated personalized antibiotic prescription feedback over 2 years (n = 1450) or usual care (n = 1450). Feedback was provided both by mail and online from October 2013 to October 2015 and was supported by an initial 1-time provision of evidence-based guidelines. Main Outcomes and Measures The primary outcome was the prescribed defined daily doses (DDD) of any antibiotic to any patient per 100 consultations in the first year analyzed by intention-to-treat. We further analyzed prescriptions of specific antibiotics, age groups, and sex for the first and second year to investigate persistency of effects over time. Results The 2900 physicians had 10 660 124 consultations over 2 years of follow-up, prescribed 1 175 780 packages of antibiotics with 10 290 182 DDD. Physicians receiving feedback prescribed the same amount of antibiotics to all patients in the first year (between-group difference, 0.81%; 95% CI, −2.56% to 4.30%; P = .64) and second year (between-group difference, −1.73%; 95% CI, −5.07% to 1.72%; P = .32) compared with the control group. Prescribing to children aged 6 to 18 years was −8.61% lower in the feedback than in the control group in the first year (95% CI, −14.87% to −1.90%; P = .01). This difference diminished in the second year (between-group difference, −4.10%; 95% CI, −10.78% to 3.07%; P = .25). Physicians receiving feedback prescribed fewer antibiotics to adults aged 19 to 65 years in the second year (between-group difference, −4.59%; 95% CI, −7.91% to −1.16%; P < .01). Prescribing to other patient groups or of specific antibiotic types was not significantly different between groups. Conclusions and Relevance This nationwide antibiotic stewardship program with routine feedback on antibiotic prescribing was not associated with a change of antibiotic use. In older children, adolescents, and younger adults less antibiotics were prescribed, but not consistently over the entire intervention period. Trial Registration clinicaltrials.gov Identifier: NCT01773824

Regaining Native Knee Kinematics Following Joint Arthroplasty: A Novel Biomimetic Design with ACL and PCL Preservation

Lack of ACL and non-anatomic articular surfaces in contemporary total knee implants result in kinematic abnormalities. We hypothesized that such abnormalities may be addressed with a biomimetic bi-cruciate retaining (BCR) design having anatomical articular surfaces. We used dynamic computer simulations to compare kinematics among the biomimetic BCR, a contemporary BCR and cruciate-retaining implant for activities of daily living. During simulated deep knee bend, chair-sit and walking, the biomimetic BCR implant showed activity dependent kinematics similar to healthy knees in vivo. Restoring native knee geometry together with ACL preservation provided these kinematic improvements over contemporary ACL-preserving and ACL-sacrificing implants. Further clinical studies are required to determine if such biomimetic implants can result in more normal feeling knees and improve quality of life for active patients.

Cruciate Retaining Implant With Biomimetic Articular Surface to Reproduce Activity Dependent Kinematics of the Normal Knee

Alterations in normal knee kinematics following total knee arthroplasty (TKA) arise in part from the non-anatomic articular geometry of contemporary implants. In this study, the kinematics of a novel posterior cruciate-retaining (CR) implant with anatomic (biomimetic) articular surface, were compared to that of contemporary CR implants during various simulated activities. Across different simulated activities the biomimetic-CR mimicked normal kinematic patterns more closely than contemporary CR implants. In particular, during deep knee bend and chair-sit, the biomimetic-CR showed medial pivot motion, while other CR implants showed abnormal motion including lateral pivot or no pivot, and paradoxical anterior sliding. Further in vivo and clinical studies are needed to determine whether such biomimetic implants can truly help to achieve a more normal feeling knee and improved patient satisfaction.