Elevated TSH Levels: A Database Study of General Practitioners' Course of Action

OBJECTIVE

To investigate general practitioners' course of action after detection of elevated thyroid stimulating hormone (TSH) levels regarding repeat testing, direct levothyroxine replacement, or neither.

METHODS

We conducted a retrospective study of adults without prior evidence of thyroid disease and with a first detection of elevated TSH levels from January 1, 2015, to December 31, 2020, using data from electronic medical records of a Swiss primary care database. We determined the occurrence of either repeat TSH testing or direct levothyroxine initiation in primary care during 12-month follow-up and determined associations with demographic and clinical factors.

RESULTS

Of the 1 591 patients included (median age 65 years, 64.4% female, median TSH 5.7 mIU/L), 34.3% received repeat TSH testing and 12.4% received direct levothyroxine replacement in primary care during follow-up. Repeat TSH testing showed the strongest association with overt hypothyroidism and was more common among patients with high primary care utilization and among patients aged 40-64 years compared to patients aged <40 years. Direct levothyroxine initiation was more likely for TSH levels >7 mIU/L, overt hypothyroidism, female patients, and nonurban practices.

CONCLUSIONS

While the degree of thyroid dysfunction was the main driver of follow-up, we identified important gaps in the primary care-based monitoring of elevated TSH levels in young patients and in patients with infrequent consultations. We also observed potential overtreatment of women and patients in nonurban areas. Our findings highlight the need for standardization and dissemination of guidelines for the management of elevated TSH levels among general practitioners.

Development and internal validation of a prediction model for long-term opioid use-an analysis of insurance claims data

ABSTRACT

In the United States, a public-health crisis of opioid overuse has been observed, and in Europe, prescriptions of opioids are strongly increasing over time. The objective was to develop and validate a multivariable prognostic model to be used at the beginning of an opioid prescription episode, aiming to identify individual patients at high risk for long-term opioid use based on routinely collected data. Predictors including demographics, comorbid diseases, comedication, morphine dose at episode initiation, and prescription practice were collected. The primary outcome was long-term opioid use, defined as opioid use of either >90 days duration and ≥10 claims or >120 days, independent of the number of claims. Traditional generalized linear statistical regression models and machine learning approaches were applied. The area under the curve, calibration plots, and the scaled Brier score assessed model performance. More than four hundred thousand opioid episodes were included. The final risk prediction model had an area under the curve of 0.927 (95% confidence interval 0.924-0.931) in the validation set, and this model had a scaled Brier score of 48.5%. Using a threshold of 10% predicted probability to identify patients at high risk, the overall accuracy of this risk prediction model was 81.6% (95% confidence interval 81.2% to 82.0%). Our study demonstrated that long-term opioid use can be predicted at the initiation of an opioid prescription episode, with satisfactory accuracy using data routinely collected at a large health insurance company. Traditional statistical methods resulted in higher discriminative ability and similarly good calibration as compared with machine learning approaches.

Importance of different electronic medical record components for chronic disease identification in a Swiss primary care database: a cross-sectional study

BACKGROUND

Primary care databases collect electronic medical records with routine data from primary care patients. The identification of chronic diseases in primary care databases often integrates information from various electronic medical record components (EMR-Cs) used by primary care providers. This study aimed to estimate the prevalence of selected chronic conditions using a large Swiss primary care database and to examine the importance of different EMR-Cs for case identification.

METHODS

Cross-sectional study with 120,608 patients of 128 general practitioners in the Swiss FIRE ("Family Medicine Research using Electronic Medical Records") primary care database in 2019. Sufficient criteria on three individual EMR-Cs, namely medication, clinical or laboratory parameters and reasons for encounters, were combined by logical disjunction into definitions of 49 chronic conditions; then prevalence estimates and measures of importance of the individual EMR-Cs for case identification were calculated.

RESULTS

A total of 185,535 cases (i.e. patients with a specific chronic condition) were identified. Prevalence estimates were 27.5% (95% CI: 27.3-27.8%) for hypertension, 13.5% (13.3-13.7%) for dyslipidaemia and 6.6% (6.4-6.7%) for diabetes mellitus. Of all cases, 87.1% (87.0-87.3%) were identified via medication, 22.1% (21.9-22.3%) via clinical or laboratory parameters and 19.3% (19.1-19.5%) via reasons for encounters. The majority (65.4%) of cases were identifiable solely through medication. Of the two other EMR-Cs, clinical or laboratory parameters was most important for identifying cases of chronic kidney disease, anorexia/bulimia nervosa and obesity whereas reasons for encounters was crucial for identifying many low-prevalence diseases as well as cancer, heart disease and osteoarthritis.

CONCLUSIONS

The EMR-C medication was most important for chronic disease identification overall, but identification varied strongly by disease. The analysis of the importance of different EMR-Cs for estimating prevalence revealed strengths and weaknesses of the disease definitions used within the FIRE primary care database. Although prioritising specificity over sensitivity in the EMR-C criteria may have led to underestimation of most prevalences, their sex- and age-specific patterns were consistent with published figures for Swiss general practice.

The Effect of Paraspinal Fatty Muscle Infiltration and Cumulative Lumbar Spine Degeneration on the Outcome of Patients With Lumbar Spinal Canal Stenosis: Analysis of the Lumbar Stenosis Outcome Study (LSOS) Data

STUDY DESIGN

Prospective.

OBJECTIVE

To investigate the influence of paraspinal fatty muscle infiltration (FMI) and cumulative lumbar spine degeneration as assessed by magnetic resonance imaging on long-term clinical outcome measures in patients with lumbar spinal canal stenosis (LSCS) of the Lumbar Stenosis Outcome Study (LSOS) cohort.

SUMMARY OF BACKGROUND DATA

Past studies have tried to establish correlations of morphologic imaging findings in LSCS with clinical endpoints. However, the impact of FMI and overall lumbar spinal degeneration load has not been examined yet.

MATERIALS AND METHODS

Patients from the LSOS cohort with moderate to severe LSCS were included. Two radiologists assessed the degree of LSCS as well as cumulative degeneration of the lumbar spine. FMI was graded using the Goutallier scoring system. Spinal Stenosis Measure (SSM) was used to measure the severity level of symptoms and disability. European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) was used to measure health-related quality of life.

RESULTS

The nonsurgically treated group consisted of 116 patients (age 74.8±8.5 yr), whereas the surgically treated group included 300 patients (age 72.3±8.2 yr). Paraspinal FMI was significantly different between the groups (54.3% vs. 32.0% for Goutallier grade ≥2; P <0.001). Total degeneration score was comparable in both groups (9.5±2.0 vs. 9.3±2.0; P =0.418). FMI was associated with lower SSM function and lower EQ-5D-3L (all P <0.05), but not with SSM symptoms. Total degeneration of the lumbar spine was associated neither with SSM symptoms, nor with SSM function, nor with EQ-5D-3L (all P >0.05).

CONCLUSIONS

FMI is associated with higher disability and worse health-related quality of life of LSCS patients in the LSOS cohort. There was no significant association between total cumulative lumbar spine degeneration and the outcome of either surgically or nonsurgically treated patients.

LEVEL OF EVIDENCE

3.

Incidence of Revision Surgery After Decompression With vs Without Fusion Among Patients With Degenerative Lumbar Spinal Stenosis

IMPORTANCE

Only limited data derived from large prospective cohort studies exist on the incidence of revision surgery among patients who undergo operations for degenerative lumbar spinal stenosis (DLSS).

OBJECTIVE

To assess the cumulative incidence of revision surgery after 2 types of index operations-decompression alone or decompression with fusion-among patients with DLSS.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from a multicenter, prospective cohort study, the Lumbar Stenosis Outcome Study, which included patients aged 50 years or older with DLSS at 8 spine surgery and rheumatology units in Switzerland between December 2010 and December 2015. The follow-up period was 3 years. Data for this study were analyzed between October and November 2021.

EXPOSURES

All patients underwent either decompression surgery alone or decompression with fusion surgery for DLSS.

MAIN OUTCOMES AND MEASURES

The primary outcome was the cumulative incidence of revision operations. Secondary outcomes included changes in the following patient-reported outcome measures: Spinal Stenosis Measure (SSM) symptom severity (higher scores indicate more pain) and physical function (higher scores indicate more disability) subscale scores and the EuroQol Health-Related Quality of Life 5-Dimension 3-Level questionnaire (EQ-5D-3L) summary index score (lower scores indicate worse quality of life).

RESULTS

A total of 328 patients (165 [50.3%] men; median age, 73.0 years [IQR, 66.0-78.0 years]) were included in the analysis. Of these, 256 (78.0%) underwent decompression alone and 72 (22.0%) underwent decompression with fusion. The cumulative incidence of revisions after 3 years of follow-up was 11.3% (95% CI, 7.4%-15.1%) for the decompression alone group and 13.9% (95% CI, 5.5%-21.5%) for the fusion group (log-rank P = .60). There was no significant difference in the need for revision between the 2 groups over time (unadjusted absolute risk difference, 2.6% [95% CI, -6.3% to 11.4%]; adjusted absolute risk difference, 3.9% [95% CI, -5.2% to 17.0%]; adjusted hazard ratio, 1.40 [95% CI, 0.63-3.13]). The number of revisions was significantly associated with higher SSM symptom severity scores (β, 0.171; 95% CI, 0.047-0.295; P = .007) and lower EQ-5D-3L summary index scores (β, -0.061; 95% CI, -0.105 to -0.017; P = .007) but not with higher SSM physical function scores (β, 0.068; 95% CI, -0.036 to 0.172; P = .20). The type of index operation was not significantly associated with the corresponding outcomes.

CONCLUSIONS AND RELEVANCE

This cohort study showed no significant association between the type of index operation for DLSS-decompression alone or fusion-and the need for revision surgery or the outcomes of pain, disability, and quality of life among patients after 3 years. Number of revision operations was associated with more pain and worse quality of life.

Prescription Rates, Polypharmacy and Prescriber Variability in Swiss General Practice—A Cross-Sectional Database Study

Purpose: The frequency of medication prescribing and polypharmacy has increased in recent years in different settings, including Swiss general practice. We aimed to describe patient age- and sex-specific rates of polypharmacy and of prescriptions of the most frequent medication classes, and to explore practitioner variability in prescribing.

Methods: Retrospective cross-sectional study based on anonymized electronic medical records data of 111 811 adult patients presenting to 116 Swiss general practitioners in 2019. We used mixed-effects regression analyses to assess the association of patient age and sex with polypharmacy (≥5 medications) and with the prescription of specific medication classes (second level of the Anatomical Therapeutic Chemical Classification System). Practitioner variability was quantified in terms of the random effects distributions.

Results: The prevalence of polypharmacy increased with age from 6.4% among patients aged 18–40 years to 19.7% (41–64 years), 45.3% (65–80 years), and 64.6% (81–92 years), and was higher in women than in men, particularly at younger ages. The most frequently prescribed medication classes were antiinflammatory and antirheumatic products (21.6% of patients), agents acting on the renin-angiotensin system (19.9%), analgesics (18.7%), and drugs for acid related disorders (18.3%). Men were more often prescribed agents targeting the cardiovascular system, whereas most other medications were more often prescribed to women. The highest practitioner variabilities were observed for vitamins, for antiinflammatory and antirheumatic products, and for mineral supplements.

Conclusion: Based on practitioner variability, prevalence, and risk potential, antiinflammatory drugs and polypharmacy in older patients appear to be the most pressing issues in current drug prescribing routines.

[Increase in New Approvals of Strong Opioid Medications in Switzerland]

Increase in New Approvals of Strong Opioid Medications in Switzerland Abstract. Consumption of pain medication, especially opioids, has risen sharply since 2000, both worldwide and in Switzerland. However, it is unknown whether this increased use is associated with an increase in new approvals of pain medications. An analysis of new approvals of painkillers in Switzerland showed a significant increase from the year 2000 onwards. The majority of new registrations were strong opioid preparations, while the trend in new registrations of non-opioid painkillers was decreasing. Furthermore, the treatment duration of newly approved strong opioids increased significantly from the year 2000 onwards, which may lead to a higher risk of overdoses or dependence.

Increased risk of adverse events in non-cancer patients with chronic and high-dose opioid use-A health insurance claims analysis

Background

Chronic and high dose opioid use may result in adverse events. We analyzed the risk associated with chronic and high dose opioid prescription in a Swiss population.

Methods

Using insurance claims data covering one-sixth of the Swiss population, we analyzed recurrent opioid prescriptions (≥2 opioid claims with at least 1 strong opioid claim) between 2006 and 2014. We calculated the cumulative dose in milligrams morphine equivalents (MED) and treatment duration. Excluded were single opioid claims, opioid use that was cancer treatment related, and opioid use in substitution programs. We assessed the association between the duration of opioid use, prescribed opioid dose, and benzodiazepine use with emergency department (ED) visits, urogenital and pulmonary infections, acute care hospitalization, and death at the end of the episode.

Results

In 63,642 recurrent opioid prescription episodes (acute 38%, subacute 7%, chronic 25.8%, very chronic (>360 days) episodes 29%) 18,336 ED visits, 30,209 infections, 19,375 hospitalizations, and 9,662 deaths occurred. The maximum daily MED dose was <20 mg in 15.8%, 20−<50 mg in 16.6%, 50−<100 mg in 21.6%, and ≥100 mg in 46%. Compared to acute episodes (<90 days), episode duration was an independent predictor of ED visits (chronic OR 1.09 (95% CI 1.03–1.15), very chronic (>360 days) OR 1.76 (1.67–1.86)) for adverse effects; infections (chronic OR 1.74 (1.66–1.82), very chronic 4.16 (3.95–4.37)), and hospitalization (chronic: OR 1.22 (1.16–1.29), very chronic OR 1.82 (1.73–1.93)). The risk of death decreased over time (very chronic OR 0.46 (0.43–0.50)). A dose dependent increased risk was observed for ED visits, hospitalization, and death (≥100mg daily MED OR 1.21 (1.13–1.29), OR 1.29 (1.21–1.38), and OR 1.67, 1.50–1.85, respectively). A concomitant use of benzodiazepines increased the odds for ED visits by 46% (OR 1.46, 1.41–1.52), infections by 44% (OR 1.44, 1.41–1.52), hospitalization by 12% (OR 1.12, 1.07–1.1), and death by 45% (OR 1.45, 1.37–1.53).

Conclusion

The length of opioid use and higher prescribed morphine equivalent dose were independently associated with an increased risk for ED visits and hospitalizations. The risk for infections, ED visits, hospitalizations, and death also increased with concomitant benzodiazepine use.

Impact of the Introduction of High-Sensitive Troponin Assay in the Emergency Department: A Retrospective Study

BACKGROUND

Compared with troponin T/I test, the introduction of a high-sensitive (hs) troponin test may result in a higher proportion of positive test results in patients with chest pain and over-testing in patients without acute coronary syndrome. We assessed the impact of the introduction of the hs-troponin assay on the discharge diagnoses and the number of diagnostic tests in patients presenting with chest pain in a real-life setting in an emergency department.

METHODS

Retrospective chart review of patients presenting with chest pain to one of the largest hospitals in Switzerland. We compared the standard troponin period (December 2009 to November 2010) with the hs-troponin period (December 2010 to December 2011).

RESULTS

Data from 1274 patients (standard 597 [46.9%], hs-troponin 677 [53.1%]) were analyzed. The proportion of patients with non-ST-segment elevation myocardial infarction increased (hs-troponin 14.9%, compared with 9.7%); the proportion in unstable angina (1.5% to 4.0%) and other cardiac illnesses (8.1% to 11.7%) decreased. Although the proportion of noncardiac chest pain illnesses (67%) remained unchanged, the proportion of positive hs-troponin was higher (6.1% vs 2.0%). The average number of additional tests/person decreased in troponin-positive patients (2.0 to 1.7 test per patient; P = .02) and troponin-negative patients (3.1 to 2.8 tests; P < .0001).

CONCLUSION

Although the introduction of the hs-troponin test resulted in a higher proportion of positive hs-troponin tests in patients with noncardiac chest pain, the average number of diagnostic tests decreased in patients with chest pain presenting to an emergency department, indicating an increased confidence of clinicians in their diagnosis.

Datasets describing the introduction of the high-sensitive troponin in the emergency department

Chest pain is a common clinical condition in the emergency department. A high sensitive (hs) troponin test assay may help to identify patients with acute coronary syndrome earlier compared to conventional tests but also entails the risk of a high proportion of positive test results in patients without cardiac disease. We assessed the impact of the introduction of the hs-troponin test in clinical practice in an emergency department. We compared December 1, 2009 until November 30, 2010 (standard test period) to December 1, 2010 - the date of the introduction of the hs-troponin assay - until December 31, 2011 (hs troponin test period) of patients presenting with chest pain to one of the ten largest hospitals in Switzerland. We identified electronic health records using the following ICD-10 codes: R06.4 (hyperventilation), R07.1 (chest pain when breathing), R07.2 (precordial pain), R07.3 (other chest pain), and R07.4 (chest pain not specified), I20 (angina pectoris), I21 (acute MI), I22 (recurrent MI), I23 (complications after acute MI), and I24 (other acute ischemic heart disease). Included were all medical records of adult patients (≥18 years) presenting to the ED with chest pain and with ≥1 troponin test. Excluded were records without troponin test, pregnancy, trauma patients/life-threatening conditions, malignant disease, current fracture, renal replacement therapy/severe kidney failure (creatinine clearance <30ml/min/1.73m2), patients with disability, or patients disagreeing that their data will be used for scientific purposes. Two researchers screened all records for in-/exclusion. The first presentation for chest pain to the ED and all presentations within the following three months extracted. Presentations after >3 months due to chest pain were defined as a new index visit of a second episode. The extraction form with predefined variables was pilot-tested in 20 records. Additional diagnostic tests were ECG, treadmill test, coronary angiography, MIBI scintigraphy, echocardiography, chest X-ray, computer tomography (CT) of the chest or abdomen, sonography of the abdomen or pleura, gastroscopy, and lung function tests. We compared the number of non-invasive / invasive cardiac diagnostic tests in troponin positive and negative patients and the number of diagnostic tests after the exclusion of patients with STEMI diagnosis. Non-invasive / invasive cardiac tests included treadmill test, coronary angiography, MIBI scintigraphy, and echocardiography. We calculated average monthly tests per patient and compared mean tests per patient between groups. We used a t-test to quantify the evidence for differential number of diagnostic tests per patient in each period. Between-group differences were estimated with 95% confidence intervals. All analyses were performed with the statistical software R for windows [1]. Interpretation of this data can be found in a research article titled Impact of the introduction of high-sensitive troponin assay on the evaluation of chest pain patients in the emergency department: a retrospective study [2]).

The influence of endplate (Modic) changes on clinical outcomes in lumbar spinal stenosis surgery: a Swiss prospective multicenter cohort study

PURPOSE

To investigate if the presence or absence of preoperative endplate Modic changes (MC) is predictive for clinical outcomes in degenerative lumbar spinal stenosis (DLSS) patients undergoing decompression-alone or decompression with instrumented fusion surgery.

METHODS

Two hundred five patients were included and categorized into four groups; 102 patients into the decompression-alone group with MCs, 41 patients into the fusion group with MCs, 46 patients into the decompression-alone group without MCs, and 16 patients into the fusion group without MCs. Clinical outcome was quantified with changes in spinal stenosis measure (SSM) symptoms, SSM function, NRS pain, and EQ-5D-3L sum score over time (measured at baseline, 12-, 24-, and 36-month follow-up) and minimal clinically important difference (MCID) in SSM symptoms, SSM function, and NRS pain from baseline to 36-month follow-up. To investigate if possible effects of MCs had been modified or hidden by confounding variables, we used the group LASSO method to search for good prognostic models.

RESULTS

There were no obvious differences in any of the clinical outcome measures between groups at baseline. At 12 months, most patients have improved in all outcomes and maintained improved conditions over time (no significant group differences). Between 70 and 90 percent of the patients maintained a clinically important improvement up to 36 months.

CONCLUSIONS

Endplate MCs have no significant influence on clinical outcome parameters in patients with lumbar spinal stenosis compared to patients without MCs, independent of the chosen surgical strategy. All patients benefitted from surgical therapy up to 36-month follow-up. These slides can be retrieved under Electronic Supplementary Material.

Opioid Prescription in Switzerland: Appropriate Comedication use in Cancer and Noncancer Pain

BACKGROUND

In Europe, limited information on the use of opioids is available.

OBJECTIVES

To assess how guideline recommendations to manage opioid-related adverse events were followed in cancer- and noncancer-related opioid use.

STUDY DESIGN

Analysis of health insurance data of one of the major health insurers in Switzerland.

SETTING

All opioid claims between 2006 and 2014.

METHODS

Opioid episodes were cancer-related when cancer treatments were used within ± 3 months of the first opioid claim. Recurrent strong episodes were defined as >/= 2 opioid claims with at least one strong opioid claim. Episode duration were acute (< 90 days), subacute, or chronic (>/= 120 days >/= 90 days +>/= 10 claims).

RESULTS

Out of 591,633 opioid episodes 76,968 (13%) were recurrent episodes: 94% were noncancer related (83% in recurrent episodes) and 6% cancer related (17% recurrent). Chronic opioid use was observed in 55% (noncancer) and 58% (cancer) recurrent episodes. Recommended laxatives were used in 50% noncancer and in 67% cancer episodes. Antiemetic drugs were used in 54% noncancer and in 83% cancer episodes. Not recommended coprescription of benzodiazepines was observed in 34% recurrent noncancer and 46% cancer episodes.

LIMITATIONS

No clinical information was available to assess the indication for opioid use.

CONCLUSIONS

In this study, opioids were primarily used outside the context of cancer-related treatment. In noncancer-related opioid use, we found a substantial higher proportion without recommended laxative and antiemetic medications. Coprescription of benzodiazepines may increase the risk for opioid overdose and was present in one-third of the noncancer episodes and in almost every second cancer episode.

KEY WORDS

Pain medications, opioids, nonopioids, benzodiazepines, health insurance claims data, cancer pain, noncancer pain, chronic opioid use, adverse events prevention, guideline recommendations.

Appetite-Suppressing and Satiety-Increasing Bioactive Phytochemicals: A Systematic Review

The prevalence of obesity is increasing worldwide. Bioactive phytochemicals in food supplements are a trending approach to facilitate dieting and to improve patients' adherence to reducing food and caloric intake. The aim of this systematic review was to assess efficacy and safety of the most commonly used bioactive phytochemicals with appetite/hunger-suppressing and/or satiety/fullness-increasing properties. To be eligible, studies needed to have included at least 10 patients per group aged 18 years or older with no serious health problems except for overweight or obesity. Of those studies, 32 met the inclusion criteria, in which 27 different plants were tested alone or as a combination, regarding their efficacy in suppressing appetite/hunger and/or increasing satiety/fullness. The plant extracts most tested were derived from Camellia sinensis (green tea), Capsicum annuum, and Coffea species. None of the plant extracts tested in several trials showed a consistent positive treatment effect. Furthermore, only a few adverse events were reported, but none serious. The findings revealed mostly inconclusive evidence that the tested bioactive phytochemicals are effective in suppressing appetite/hunger and/or increasing satiety/fullness. More systematic and high quality clinical studies are necessary to determine the benefits and safety of phytochemical complementary remedies for dampening the feeling of hunger during dieting.

Outcome of unilateral versus standard open midline approach for bilateral decompression in lumbar spinal stenosis: is "over the top" really better? A Swiss prospective multicenter cohort study

OBJECTIVE

In this retrospective analysis of a prospective multicenter cohort study, the authors assessed which surgical approach, 1) the unilateral laminotomy with bilateral spinal canal decompression (ULBD; also called "over the top") or 2) the standard open bilateral decompression (SOBD), achieves better clinical outcomes in the long-term follow-up. The optimal surgical approach (ULBD vs SOBD) to treat lumbar spinal stenosis remains controversial.

METHODS

The main outcomes of this study were changes in a spinal stenosis measure (SSM) symptoms score, SSM function score, and quality of life (sum score of the 3-level version of the EQ-5D tool [EQ-5D-3L]) over time. These outcome parameters were measured at baseline and at 12-, 24-, and 36-month follow-ups. To obtain an unbiased result on the effect of ULBD compared to SOBD the authors used matching techniques relying on propensity scores. The latter were calculated based on a logistic regression model including relevant confounders. Additional outcomes of interest were raw changes in main outcomes and in the Roland and Morris Disability Questionnaire from baseline to 12, 24, and 36 months.

RESULTS

For this study, 277 patients met the inclusion criteria. One hundred forty-nine patients were treated by ULBD, and 128 were treated by SOBD. After propensity score matching, 128 patients were left in each group. In the matched cohort, the mean (95% CI) estimated differences between ULBD and SOBD for change in SSM symptoms score from baseline to 12 months were -0.04 (-0.25 to 0.17), to 24 months -0.07 (-0.29 to 0.15), and to 36 months -0.04 (-0.28 to 0.21). For change in SSM function score, the estimated differences from baseline to 12 months were 0.06 (-0.08 to 0.21), to 24 months 0.08 (-0.07 to 0.22), and to 36 months 0.01 (-0.16 to 0.17). Differences in changes between groups in EQ-5D-3L sum scores were estimated to be -0.32 (-4.04 to 3.40), -0.89 (-4.76 to 2.98), and -2.71 (-7.16 to 1.74) from baseline to 12, 24, and 36 months, respectively. None of the group differences between ULBD and SOBD were statistically significant.

CONCLUSIONS

Both surgical techniques, ULBD and SOBD, may provide effective treatment options for DLSS patients. The authors further determined that the patient outcome results for the technically more challenging ULBD seem not to be superior to those for the SOBD even after 3 years of follow-up.

What is the treatment effect of surgery compared with nonoperative treatment in patients with lumbar spinal stenosis at 1-year follow-up?

OBJECTIVE

The aim of this study was to obtain an unbiased causal treatment estimate of the between-group difference of surgery versus nonoperative treatment with respect to outcomes on quality of life, pain, and disability in patients with degenerative lumbar spinal stenosis (DLSS) 12 months after baseline.

METHODS

The authors included DLSS patients from a large prospective multicenter observational cohort study. Propensity score matching was used, including 15 demographic, clinical, and MRI variables. Linear and logistic mixed-effects regression models were applied to quantify the between-group treatment effect. Unmeasured confounding was addressed in a sensitivity analysis, assessing the robustness of the results.

RESULTS

A total of 408 patients were included in this study, 222 patients after matching, with 111 in each treatment group. Patients with nonoperative treatment had lower quality of life at the 12-month follow-up (-6.21 points, 95% CI -9.93 to -2.49) as well as lower chances of reaching a minimal clinically important difference in Spinal Stenosis Measure (SSM) symptoms (OR 0.26, 95% CI 0.13 to 0.53) and SSM function (OR 0.26, 95% CI 0.14 to 0.49), than patients undergoing surgery. These results were very robust in case of unmeasured confounding. The surgical complication rate was low; 5 (4.5%) patients experienced a durotomy during intervention, and 5 (4.5%) patients underwent re-decompression.

CONCLUSIONS

The authors used propensity score matching to assess the difference in treatment efficacy of surgery compared with nonoperative treatment in elderly patients with DLSS. This study delivers strong evidence that surgical treatment is superior to nonoperative treatment. It helps in clinical decision-making, especially when patients suffer for a long time, sometimes over many years, hoping for a spontaneous improvement of their symptoms. In light of these new results, the number of years with disability can hopefully be reduced by providing adequate treatment at the right time for this ever-growing elderly and frail population.

Qualitative versus quantitative lumbar spinal stenosis grading by machine learning supported texture analysis-Experience from the LSOS study cohort

PURPOSE

To investigate and compare the reproducibility and accuracy of qualitative ratings and quantitative texture analysis (TA) in detection and grading of lumbar spinal stenosis (LSS) in magnetic resonance imaging (MR) scans of the lumbar spine.

MATERIALS AND METHODS

From a nationwide multicenter and multidisciplinary lumbar stenosis outcome study (LSOS) register 82 patients, undergoing MR scans of the lumbar spine due to clinical indication of spinal claudication, with a single level central or lateral severe LSS were included. In total 343 transaxial T2-weighted images of the lumbar spine were included from one to five levels (L1 to S1) per patient. One expert radiologist serving as reference standard rated LSS grade according to a standard four-point (normal to severe) as well as to an eight-point Schizas grading scale. DICOM data were then rescaled to a defined pixel size. Two independent readers performed qualitative ratings analogous to expert reader in addition to TA of spinal canals by manually placing two regions of interest (ROI) per image reflecting qualitative scales: (1) dural sac only (2) inner contour of the spinal canal including epidural fat and bilateral recesses. Interreader agreements of qualitative and quantitative parameters were assessed by Cohen's Kappa (κ) and intraclass correlation (ICC), respectively. TA feature reduction was performed by ICC threshold > 0.75. Remaining features were analyzed with machine learning algorithms (Weka 3 tool) for correlation with LSS grades using 10-fold cross validation.

RESULTS

Qualitative ratings showed only moderate reproducibility for both LSS classification systems but high correlation with cut-off cross-sectional area (CSA) <130mm² for severe spinal stenosis. In quantitative TA of both ROIs, machine learning analysis with a decision tree classifier revealed higher performances for LSS grading compared to qualitative assessments using the reference CSA cut-off, respectively.

CONCLUSION

Qualitative LSS grading independent of classification system shows moderate reproducibility. TA with machine learning offers highly reproducible quantitative parameters that increase accuracy for severe LSS detection with minor impact of grading score and CSA border definition.

Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study

BACKGROUND

Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out.

OBJECTIVE

To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED).

METHODS

Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing.

RESULTS

In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation.

CONCLUSION

In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.

Prognostic function to estimate the probability of meaningful clinical improvement after surgery - Results of a prospective multicenter observational cohort study on patients with lumbar spinal stenosis

BACKGROUND

Approximately two thirds of patients with lumbar spinal stenosis (LSS) who undergo surgical treatment benefit from the surgery. The objective of this study was to derive a prognostic probability function (PPF) to identify patients with a high probability of post-surgical improvement because there is currently no method available.

METHODS

In this multicenter, prospective, observational study, we collected data from eight medical centers in Switzerland in which patients underwent surgery for LSS. The endpoints were meaningful clinically important differences (MCID) in pain and disability one year after baseline. We developed a PPF named PROCESS (PostopeRative OutComE Spinal Stenosis), based on a large set of prognostic indicators extracted from the literature. The PPF was derived using data from a random subset of two thirds of the patients and validated in the remaining third. We addressed overfitting by shrinking the regression coefficients. The area under the ROC curve (AUC) and calibration determined the accuracy of the PPF.

RESULTS

In this study, 452 LSS patients received surgery. 73% of the 300 patients in the derivation subset reached an MCID in pain and 68% reached an MCID in disability. The corresponding values were 70% and 63% in the validation subset, respectively. In the derivation subsample, the AUC was 0.64 (95% CI 0.57 to 0.71) for of the PPF predicting MCID in pain and 0.71 (0.64 to 0.77) for MCID in disability, after shrinkage. The corresponding numbers were 0.62 (0.52 to 0.72) and 0.70 (0.60 to 0.79) in the validation subsample, and the PPF showed good calibration.

CONCLUSIONS

Surgical treatment for patients with lumbar spinal stenosis is being performed with increasing frequency. PROCESS is conditional on the individual pattern of preoperatively available prognostic indicators, and may be helpful for clinicians in counselling patients and in guiding the discussion on individual treatment decision in the era of personalized medicine.

Benefits of Mobile Apps in Pain Management: Systematic Review

Background

Pain is a common condition with a significant physical, psychosocial, and economic impact. Due to enormous progress in mobile device technology as well as the increase in smartphone ownership in the general population, mobile apps can be used to monitor patients with pain and support them in pain management.

Objective

The aim of this review was to assess the efficacy of smartphone or computer tablet apps in the management of patients with pain.

Methods

In December 2017, a literature search was performed in the following databases: MEDLINE, EMBASE, CINAHL, Cochrane, and PsycINFO. In addition, a bibliography search was conducted. We included studies with at least 20 participants per arm that evaluated the effects of apps on smartphones or computer tablets on improvement in pain.

Results

A total of 15 studies with 1962 patients met the inclusion criteria. Of these, 4 studies examined the effect of mobile apps on pain management in an in-clinic setting and 11 in an out-clinic setting. The majority of the original studies reported beneficial effects of the use of a pain app. Severity of pain decreased in most studies where patients were using an app compared with patients not using an app. Other outcomes, such as worst pain or quality of life showed improvements in patients using an app. Due to heterogeneity between the original studies—patient characteristics, app content, and study setting—a synthesis of the results by statistical methods was not performed.

Conclusions

Apps for pain management may be beneficial for patients, particularly in an out-clinic setting. Studies have shown that pain apps are workable and well liked by patients and health care professionals. There is no doubt that in the near future, mobile technologies will develop further. Medicine could profit from this development as indicated by our results, but there is a need for more scientific inputs. It is desirable to know which elements of apps or additional devices and tools may improve usability and help patients in pain management.

Correlation of listhesis on upright radiographs and central lumbar spinal canal stenosis on supine MRI: is it possible to predict lumbar spinal canal stenosis?

OBJECTIVE

To investigate whether upright radiographs can predict lumbar spinal canal stenosis using supine lumbar magnetic resonance imaging (MRI) and to investigate the detection performance for spondylolisthesis on upright radiographs compared with supine MRI in patients with suspected lumbar spinal canal stenosis (LSS).

MATERIALS AND METHODS

In this retrospective study, conventional radiographs and MR images of 143 consecutive patients with suspected LSS (75 female, mean age 72 years) were evaluated. The presence and extent of listhesis (median ± interquartile range) were assessed on upright radiographs and supine MRI of L4/5. In addition, the grade of central spinal stenosis of the same level was evaluated on MRI according to the classification of Schizas and correlated with the severity/grading of anterolisthesis on radiographs.

RESULTS

Anterolisthesis was detected in significantly more patients on radiographs (n = 54; 38%) compared with MRI (n = 28; 20%), p < 0.001. Pairwise comparison demonstrated a significantly larger extent of anterolisthesis on radiographs (9 ± 5 mm) compared with MRI (5 ± 3 mm), p < 0.001. A positive correlation was found regarding the extent of anterolisthesis measured on radiographs and the grade of stenosis on MRI (r = 0.563, p < 0.001). Applying a cutoff value of ≥5 mm anterolisthesis on radiographs results in a specificity of 90% and a positive predictive value of 78% for the detection of patients with LSS, as defined by the Schizas classification.

CONCLUSION

Upright radiographs demonstrated more and larger extents of anterolisthesis compared with supine MRI. In addition, in patients with suspected LSS, the extent of anterolisthesis on radiographs (particularly ≥5 mm) is indicative of LSS and warrants lumbar spine MRI.

Texture analysis of paraspinal musculature in MRI of the lumbar spine: analysis of the lumbar stenosis outcome study (LSOS) data

OBJECTIVE

To evaluate association of fatty infiltration in paraspinal musculature with clinical outcomes in patients suffering from lumbar spinal stenosis (LSS) using qualitative and quantitative grading in magnetic resonance imaging (MRI).

MATERIALS AND METHODS

In this retrospective study, texture analysis (TA) was performed on postprocessed axial T2 weighted (w) MR images at level L3/4 using dedicated software (MaZda) in 62 patients with LSS. Associations in fatty infiltration between qualitative Goutallier and quantitative TA findings with two clinical outcome measures, Spinal stenosis measure (SSM) score and walking distance, at baseline and regarding change over time were assessed using machine learning algorithms and multiple logistic regression models.

RESULTS

Quantitative assessment of fatty infiltration using the histogram TA feature "mean" showed higher interreader reliability (ICC 0.83-0.97) compared to the Goutallier staging (κ = 0.69-0.93). No correlation between Goutallier staging and clinical outcome measures was observed. Among 151 TA features, only TA feature "mean" of the spinotransverse group showed a significant but weak correlation with worsened SSM (p = 0.046). TA feature "S(3,3) entropy" showed a significant but weak association with worsened WD over 12 months (p = 0.046).

CONCLUSION

MR TA is a reproducible tool to quantitatively assess paraspinal fatty infiltration, but there is no clear association with the clinical outcome in asymptomatic LSS patients.

Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims

BACKGROUND

In Europe, scant information is available about prescription practices for pain medications. The aim of this research was to assess changes in prescription rates of non-opioid, weak opioid, and strong opioid medications between 2006 and 2013 in the Swiss population.

METHODS

Using insurance claims data covering one-sixth of the Swiss population, we analyzed the numbers of reimbursed pain medications, the number of reimbursements per persons, and the cumulative dose in milligrams. For opioids, the morphine equivalent dose and treatment days were calculated. Data were extrapolated to the dose per day per 100'000 population stratified by age, gender, and canton.

RESULTS

In total, 4'746'942 paracetamol, 2'156'620 NSAIDs or Coxibs, 931'129 metamizole, 1'322'272 weak opioid, and 807'835 strong opioid claims were analyzed. Between 2006 and 2013, the increase in claims per 100'000 persons was 32% for paracetamol, 242% for metamizole, 107% for NSAIDS, 86% for Coxibs, 13% for weak opioids, and 121% for strong opioids. For strong opioids the total MED in mg /100'000 increased by 117%, the treatment days /100'000 by 101%. For strong opioids, fentanyl was most frequently used (increase between 2006 and 2013 by 91% for MED/100'000 persons and 94% treatment days / 100'000) followed by buprenorphine and oxycodone. The highest proportional increase in MED / 100'000 was observed for methadone (+1414%) and oxycodone (+313%). Marked geographical variation was detected in the use of metamizole, paracetamole, and strong opioids in different cantons.

CONCLUSION

The analysis of insurance claims data provides evidence that the prescription rates for pain medications increased in Switzerland within the last ten years, in particular for metamizole and strong opioids. Furthermore, the prescription rates for metamizole, paracetamol, and strong opioids varied substantially between different cantons in Switzerland.

Pain levels and typical symptoms of acute endodontic infections: a prospective, observational study

BACKGROUND

This study aimed to identify key symptoms that could be associated with the diagnosis of acute forms of symptomatic apical periodontitis (SAP) and symptomatic irreversible pulpitis (SIP), and to identify a diagnostic algorithm based on these symptoms.

METHODS

In this prospective, observational study 173 emergency patients diagnosed with acute pain of endodontic origin and no swelling or fistula were included. Patients were asked 11 specific questions from a checklist with a possible discerning value between acute SAP and acute SIP. Pain levels were recorded using the numeric rating scale (NRS-11). Subsequently, the painful tooth was diagnosed. Logistic regression was used to evaluate the checklist regarding its differentiation between SAP (N = 103) and SIP (N = 70). Moreover, a decision tree was constructed based on recursive partitioning to identify a hierarchy in differentiating symptoms.

RESULTS

With identical median NRS-11 scores of 8, the teeth diagnosed with acute SAP and SIP were severely painful. The decision tree analysis resulted in a tree with splits according to pain on cold, perceived tooth extrusion, and pain duration. The overall sensitivity of the tree to detect SAP based on key symptoms was 95 %, its specificity was 31 %.

CONCLUSIONS

The best indicator for SAP was a reported absence of pain to cold stimuli. In teeth that did have a history of pain triggered by cold stimuli, the decision tree correctly identified SAP in 72 % of the teeth that felt too high and had hurt for less than one week.

The impact of incidental durotomy on the outcome of decompression surgery in degenerative lumbar spinal canal stenosis: analysis of the Lumbar Spinal Outcome Study (LSOS) data--a Swiss prospective multi-center cohort study

Background

Incidental durotomy is a well-known complication during surgery for degenerative lumbar spinal stenosis (DLSS). In this prospective multicenter cohort study including eight medical centers our aim was to assess whether incidental durotomy during first-time lumbar spinal stenosis decompression surgery without fusion has an impact on long-term outcome.

Methods

Patients of the multi-center Lumbar Stenosis Outcome Study (LSOS) with confirmed DLSS undergoing first-time decompression without fusion were enrolled in this study. Baseline patient characteristics and outcomes were analyzed at 6, 12, and 24 months follow-up respectively with the Spinal Stenosis Measure (SSM), the Numeric Rating Scale (NRS), Feeling Thermometer (FT), the EQ-5D-EL, and the Roland and Morris Disability Questionnaire (RMDQ).

Results

A total of 167 patients met the inclusion criteria. Fifteen (9 %) of those patients had an incidental durotomy. Baseline characteristics were similar between the durotomy and no-durotomy group. All patients improved over time. In the group of durotomy patients, the median improvement in SSM symptoms scale was 1.1 points at 6 months, 1.1 points at 12 months, and 1.6 points at 24 months after baseline. For the no-durotomy group, these improvements were 0.8, 0.9, and 0.9. For SSM function the improvements were 1.0, 0.8, and 0.9 in the durotomy group, and 0.6, 0.8, and 0.8 in the no-durotomy group. None of the between-group differences were statistically significant.

Conclusions

Incidental durotomy in patients with DLSS undergoing first-time decompression surgery without fusion did not have negative effect on long-term outcome and quality of life. However, only 15 patients were included in the durotomy group but these findings remained even after adjusting for observed differences in baseline characteristics.

Arguments for the choice of surgical treatments in patients with lumbar spinal stenosis - a systematic appraisal of randomized controlled trials

BACKGROUND

Lumbar spinal stenosis is the most common reason for spinal surgery in elderly patients. However, the surgical management of spinal stenosis is controversial. The aim of this review was to list aspects a surgeon considers when choosing a specific type of treatment.

METHODS

Appraisal of arguments reported in randomized controlled trials (RCTs) included in systematic reviews published or indexed in the Cochrane library studying surgical treatments in patients with spinal stenosis.

RESULTS

Eight out of nine RCTs listed arguments for the choice of their treatments under investigation. The argument for decompression alone was the high success rate, the argument against was a potential increase in vertebral instability. The argument for decompression and fusion without instrumentation was that it is a well-established technique with a high fusion success rate, the argument against it was that the indication for fusion in spinal stenosis has remained unclear. The argument for decompression and fusion with instrumentation was an increased fusion rate compared to decompression and fusion without instrumentation, the argument against this was that the invasive procedure is associated with more complications.

CONCLUSIONS

The main argument identified in this appraisal for and against decompression alone in patient with lumbar spinal stenosis was whether or not instability should be treated with (instrumented) fusion procedures. However, there is disagreement on how instability should be defined. In a first step it is important that researchers and clinicians agree on definitions for important key concepts such as instability and reoperations.

Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment.

OBJECTIVES

To summarize treatment efficacy for patients presenting with NCCP.

METHODS

Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group).

RESULTS

Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions.

LIMITATIONS

Only a small number of studies were available.

CONCLUSIONS

Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.