[Sensitivity, specificity, positive and negative predictive value]

What does it mean that a screening test has a sensitivity of 80 % and a specificity of 80 %? What conclusion can be drawn as to the probability of a patient tested positive having the target disorder? Is this probability dependent on the prevalence of the target disorder? These are the questions addressed in the present paper. The classical concepts of sensitivity and specificity are presented as well as the more modern and clinically relevant concepts of the predictive values of a positive and a negative test. The author employs different didactic methods such as 2 x 2 tables, graphical illustrations and natural frequencies for elaborating on these often intermixed concepts in a clear and easily understandable way.

Kardiologische Rehabilitation - Erwartungen und Einschätzungen von Patienten

Patients' expectancies are widely hypothesized to influence the course of rehabilitation. Therefore, an exploratory cross-sectional survey was performed in cardiological rehabilitation patients to analyse the relationships of patients' expectations and rehabilitation outcomes. Patients were recruited from ambulatory heart groups (phase III rehabilitation). All participants judged both their expectations and experiences regarding their inpatient rehabilitation (phase II) in retrospect. Of 300 eligible heart group members, 238 (79 %) consented to participate (81 % male; mean age 65.5 years). Discussions with their physician, in-depth clinical examination, and information regarding treatment and healthy life-style were rated as most important by the patients. Nutritional counselling, gymnastics, massage, walking and the pleasant surroundings of the clinic were also frequently mentioned. One third stated that they had changed their attitudes regarding life-style, stress management, and nutrition as a result of rehabilitation. However, according to their self-reports, changes in body weight were not substantial whereas the proportion of smokers declined. 70 % reported to be interested in attending a future rehabilitation treatment. Patients with high expectations regarding physical training, health counselling, behaviour modification and physician care had better rehabilitation outcomes. When interpreting the results, both the selective nature of the sample and possible recall bias due to the retrospective assessments have to be considered. Our findings may thus be seen as hints as to patients overall judging their rehabilitation in a positive way. However, critical aspects were also mentioned. While these did not touch the general concepts of the interventions, they highlighted specific aspects of its performance and implementation, issues that should be taken into account by the individual rehabilitation clinic.

Änderungssensitivität

In rehabilitation research patient questionnaires are widely used for evaluative purposes, i. e. to measure improvements or deteriorations over time. This is only possible if the questionnaires applied appropriately reflect "true" change over time, i. e. they have to be sensitive to change. The aim of this paper is to point out the importance of the "sensitivity to change" concept for evaluative assessment tools and evaluative studies, respectively, considering quality of life research as an example. Various qualitative aspects, e. g. scaling of response options of assessment tools, are covered as well as quantitative methods, i. e. study designs and indices. Furthermore, recommendations for interpretation are given.

[Significance, effect size, and confidence interval]

The term "statistical significance" is often misunderstood. The result of a study may be labelled to be "highly significant" as if implying "highly important". Statistically significant, however, does only mean that a study result might have been found with a predefined probability (conventionally set at 5 %) even when the null hypothesis is true in the population, i. e. the effect found in the study sample does not exist in reality. Whether a result proves to be significant or not largely depends on sample size. Thus, in a large sample minimal effects of no practical relevance may turn out significant whereas in a small sample even large, important effects may fail to reach the significance level. As a consequence, when presenting the results of a study the effect size should be reported together with a confidence interval indicating the probable range that contains the population effect.

Reliabilitäts-, Validitäts- und Änderungssensitivitätsprüfung des Funktionsfragebogens Bewegungsapparat (SMFA-D) in der stationären Rehabilitation von Patienten mit konservativ behandelter Coxarthrose

BACKGROUND

Modern patient based outcome measures like the SMFA-D (German Short Musculoskeletal Function Assessment Questionnaire) are able to detect the impairment and functional capacity of patients with musculoskeletal extremity disorders. The SMFA-D was successfully evaluated in several cohorts treated operatively for osteoarthritis of the knee and hip, rotator cuff tears and rheumatoid arthritis. The aim of the present study was the evaluation of the SMFA-D in patients with conservative treatment for hip osteoarthritis.

PATIENTS AND METHODS

69 patients with osteoarthritis of the hip were enrolled in a prospective controlled clinical trial. All patients completed the SMFA-D, SF-36, WOMAC, FFbH-OA. A standardized test of walking speed and the functional status of the patient as judged by the physician were recorded. Statistical analysis were done for the following: re-test reliability (ICC), internal consistency (Cronbach's alpha), validity and responsiveness.

RESULTS

Internal consistency (Cronbach's alpha) was alpha = 0.89 and alpha = 0.97 for the SMFA-D scales. The retest reliability (ICC, unjust, mixed effect) was 0.91 (p < 0.001) for the function index and 0.73 (p < 0.001) for the bother index. Both indices correlated significantly with the FFbH-OA (r = 0.66 to r = 0.84), the WOMAC (r = 0.55 to r = 0.86) and the scales of the SF-36 (r = - 0.34 to r = - 0.85) on all three time points, which supports construct validity. There was mainly a significant correlation between the SMFA-D scales and the functional status of the patient (r = 0.21 to r = 0.44), pain reported by the patient (r = 0.43 to = 0.54) and the self selected walking speed (r = 0.28 to r = 0.51), which supports external validity. We were able to differentiate operatively and conservatively treated patients (discriminant construct validity). At the end of the rehabilitation program we were able to demonstrate small to medium treatment effects in SMFA-D and SF-36. The WOMAC and FFbH-OA were not able to demonstrate these treatment effects.

CONCLUSION

Even in patients with conservative treatment of hip osteoarthritis the SMFA-D represents a reliable, valid and responsive measure. The use of the SMFA-D can be recommended as a patient based outcome measure.

[Intention-to-treat]

What is meant by intention-to-treat? Why should data be analyzed in controlled trials in a way that all participants are included in the group to which they were randomly assigned, regardless of whether they completed the intervention given to the group? In this Tutorial, the logic of the intention-to-treat principle is outlined. It is shown that study results may be biased by excluding patients post hoc thus producing spurious effects that do not exist in the population under study. The intention-to-treat strategy avoids this bias.

[Design and evaluation of the Extra Short Musculoskeletal Function Assessment Questionnaire XSMFA-D]

AIM

The XSMFA-D (German Extra Short Musculoskeletal Function Assessment Questionnaire) was developed on the basis of the SMFA-D to provide a short questionnaire for assessment of the functional status from patient's perspective in routine use.

METHODS

Based on psychometric and medical aspects 16 items were extracted from the SMFA-D during an iterative process. 633 SMFA-D questionnaires of 199 patients were used as basic data. The XSMFA-D was evaluated on 67/51 patients with primary osteoarthritis of the knee/hip undergoing total joint replacement.

RESULTS

The tests for reliability and internal consistency produced favorable results. The Knee Score, Harris Hip Score, WOMAC and SMFA-D showed significant correlations to the XSMFA-D indicating construct validity. The criterion validity could be demonstrated successfully by relations with external parameters like walking distance, patients reported pain, mobility judgements by physicians and degree of osteoarthritis. The discriminant validity could also be demonstrated by significant differences between several different patient groups. Almost all effect sizes were generally large.

CONCLUSIONS

The XSMFA-D could be demonstrated to be an appropriate short questionnaire for the evaluation of therapy results from patient's perspective. The use of the XSMFA-D can be recommended for routine use. Further investigations of the instrument will be undertaken.

The German Short Musculoskeletal Function Assessment questionnaire: reliability, validity, responsiveness, and comparison with the Short Form 36 and Constant score—a prospective evaluation of patients undergoing repair for rotator cuff tear

In a prospective clinical trial, first the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D) was tested for reliability, validity, and responsiveness in 23 patients with rotator cuff tears, and secondly the Short Form (SF)-36, and the Constant score were evaluated comparatively in 45 patients with rotator cuff tear undergoing open repair. Retest reliability was excellent for the functional index of the SMFA-D and satisfactory for the bother index. The SMFA-D showed good validity and responsiveness. All three instruments demonstrated significantly the positive effect of rotator cuff repair at 12-month follow-up. Using comparable scales, effect sizes were bigger with the SMFA-D than with the SF-36 and as big as the Constant score. Significant correlations of the SMFA-D indices with the SF-36 scales and the Constant score could be shown preoperatively. At 12-month follow-up, all correlations between SMFA-D indices, SF-36 scales, and Constant score function scales were still significant. We recommend use of the SMFA-D to assess changes in functional status concerning patients with rotator cuff tear undergoing open repair.

Reliabilit�ts-, Validit�tsund Responsivit�tspr�fung des Funktionsfragebogen Bewegungsapparat (SMFA-D) bei Patienten mit Coxarthrose und totalendoprothetischem Gelenkersatz des H�ftgelenkes

BACKGROUND

The aim of the present study was to check for reliability, validity and responsiveness of the Musculoskeletal Function Assessment questionnaire (SMFA-D) in patients with coxarthrosis undergoing total hip replacement.

PATIENTS AND METHOD

In a prospective clinical trial the SMFA-D, the SF-36, the Harris Hip score, test of walking speed and the functional impairment according to the physician assessment were recorded.

RESULTS

The reliability of the instrument could be demonstrated by a correlation coefficient of r = 0.78 for the function index and r = 0.84 for the bother index. Patients could be distinguished by the physician's assessment to show discriminative validity. Both indices correlated significantly with the Harris Hip score, scales of the SF-36 and the walking speed supporting the construct validity. The responsiveness could be shown with large effect sizes (1.04 for the function index and 1.02 for the bother index) at the three-month follow-up.

CONCLUSIONS

The SMFA-D was found to be a reliable, valid and responsive instrument in patients with coxarthrosis undergoing hip replacement and the use of this instrument can be recommended.

[Shared decision making: an approach to strengthening patient participation in rehabilitation]

In this paper, the concept of Shared Decision Making, i. e. the participation of the patient regarding the selection of therapeutic goals and treatment options, is presented. The degree of patient participation in medical decisions varies widely across different models of the physician-patient relationship. According to the paternalistic model, the physician knows best what is in the patient's interest; patient participation is limited. This model clearly does not take into account patients' autonomy and desire for information appropriately. In contrast, the informative model claims that values are well-known to the patient while the physician's role is restricted to providing him with the necessary information. However, the assumption of fixed values may be challenged. Patients expect their doctors to be not only technical experts but also caring persons. In the interpretive model, the physician's task is to help the patient to identify and express his values. In the deliberative model, both physician and patient engage in an open discussion about the values the patient could and should pursue. The physician is allowed to present his own preferences, and conflicting values are discussed explicitly. Thus, the patient is empowered to choose between alternative preferences. This model forms the basis of shared decision making, which involves at least two participants who engage in a process of both mutual information and interactive discussion. Patient participation should result in a greater sense of personal control, more satisfaction with treatment, better compliance and transfer into the daily routine of disease management and, consequently, better outcomes. Although it is largely unknown whether these outcomes are achieved, indirect evidence may be gained from systematic reviews showing that a favourable physician-patient communication (i. e. allowing patients to express their information needs and concerns and to receive both information and emotional support) produced better outcomes regarding both mental and physical health. There are several barriers to shared decision making. No information exists regarding the degree to which physicians are interested in shared decision making. While there is ample evidence that patients' needs for information are high, patients' wishes for participation seem to vary widely, though. Both physicians and patients require the ability to make shared decisions. Structural restraints include time and institutional inflexibility. To conclude, shared decision making is a promising approach to enhance patient participation in rehabilitative care.

German short musculoskeletal function assessment questionnaire (SMFA-D): comparison with the SF-36 and WOMAC in a prospective evaluation in patients with primary osteoarthritis undergoing total knee arthroplasty

In a prospective clinical trial, the German short musculoskeletal function assessment (SMFA-D), the short form (SF)-36, and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) were evaluated in 63 patients with primary osteoarthritis undergoing total knee arthroplasty. All instruments were sensitive to change, demonstrating the effect of total knee arthroplasty at 1-year follow-up. The SMFA-D effect sizes in comparable scales were bigger than in the SF-36 and similar to those of the WOMAC. Significant correlations of the SMFA-D indices with the SF-36 and WOMAC scales preoperatively could be shown. After 1-year follow-up, all correlations between the SMFA-D indices and SF-36 scales were significant. In other comparison, only the correlation between the SMFA-D function index and the WOMAC function scales remained significant. The correlation of the SMFA-D function index with external validation criteria was higher than that using the other instruments. We recommend the SMFA-D for assessing change in functional status of patients with primary osteoarthritis of the knee following arthroplasty.

Expression of tumor necrosis factor-alpha and interferon-gamma mRNA in blood cells correlates with depression scores during an acute attack in patients with multiple sclerosis

Depression is a common problem in multiple sclerosis (MS) and affects about 50% of MS patients. Since a dysregulation of cytokine levels has been implicated in the pathogenesis of MS and alterations in cytokine serum levels have been found in depressive illness, we examined the relationship between depressive symptoms, cytokine mRNA expression levels of Th1-type and Th2-type cytokines and neurological disability among early diagnosed MS patients in a prospective study. Sixteen patients with clinically or laboratory supported MS were assessed using the Beck Depression Inventory (BDI) and the Kurtzke Expanded Disability Status Scale (EDSS). Cytokine mRNA in whole blood was serially determined by a new quantitative polymerase chain reaction (PCR) method. BDI sum scores (2,9 fold) and the expression levels of tumor necrosis factor-alpha (TNF-alpha; 4 fold), interferon-gamma (IFN-gamma; 4,6 fold) and interleukin-10 (IL-10; 6,1 fold) mRNA were increased in MS patients during an acute attack compared to age and sex matched healthy controls. We detected a significant positive correlation between TNF-alpha (r=0.55) and interferon-gamma (r=0.54) mRNA expression and the BDI sum scores during an acute attack in MS patients. At follow-up after 3-6 months, only TNF-alpha mRNA expression was correlated with BDI sum scores (r=0.62 resp. r=0.31). No correlation of the BDI sum scores with Th2-type cytokine mRNA expression for interleukin-4 (IL-4) and interleukin-10 (IL-10) or with the extent of neurological disability was observed. The possible contribution of Th1-type cytokines to the development of depression in MS is discussed.

Paroxetine for the treatment of interferon-alpha-induced depression in chronic hepatitis C

BACKGROUND

Psychiatric side-effects may require dose reduction or premature discontinuation of interferon therapy in chronic hepatitis C. New strategies are needed in order to prevent the premature termination of interferon therapy.

AIM

To evaluate prospectively the efficacy and tolerability of antidepressant therapy (paroxetine, a selective serotonin reuptake inhibitor) in patients with chronic hepatitis C treated with interferon-alpha who have developed interferon-induced major depression.

METHODS

A sub-group of 14 individuals from 121 consecutively treated hepatitis C patients developed substance-induced major depression without suicidal ideation during interferon-alpha treatment. The individuals in this sub-group received paroxetine after the occurrence of depression (20 mg daily until termination of interferon therapy). Diagnostic scores for depression (and anger-hostility) were obtained in a repeated measures design (Hospital Anxiety and Depression Scale and Symptom Checklist 90 Items Revised).

RESULTS

Eleven of the 14 patients (78.6%) with interferon-induced major depression were able to complete interferon-alpha therapy as scheduled under concomitant paroxetine treatment (three dropouts: insufficient improvement of depression, occurrence of epileptic seizures, paroxetine-induced nausea/dizziness). Within 4 weeks after the start of paroxetine medication, depression scores declined significantly in all patients.

CONCLUSIONS

Our data suggest that concomitant therapy with paroxetine is an effective way to treat interferon-induced depression in patients with chronic hepatitis C.

[Causal attribution and personality in psychotherapy patients]

The present study addressed the relationship between patients' causal attributions of their disorders on one hand and their personality traits on the other. The investigation was based on the self-reports of 197 psychotherapy patients who presented at a university outpatient department for diagnostic evaluation. Personality traits were measured using the Giessen-Test (Beckmann et al., 1991), causal attributions were assessed by a check list (Faller 1997). Intrapsychic causal factors were rated highest; after those, interpersonal and social factors followed next, while somatic factors were judged to be least important. Psychosocial attributions showed strong correlations with the self-report of depressed mood in the Giessen-Test. Similar relations were found with other personality traits such as low ratings of social resonance, low openness, and low social potency. The reported interrelations suggest that psychological symptoms, personality and causal atttributions are closely intertwined.

Compliance with therapy in patients with chronic hepatitis C: associations with psychiatric symptoms, interpersonal problems, and mode of acquisition

Tolerance of interferon-a therapy for hepatitis C is often poor and medication is expensive. Compliance with diagnostic procedures and, even more important, with medical treatment is obviously critical to minimize the rate of dropouts and to maximize cost efficiency. Moreover, a good concordance with scheduled follow-ups is important for early recognition and treatment of interferon-associated side effects. Therefore, we investigated psychiatric symptoms, interpersonal problems, different modes of acquisition, and sociodemographic factors in HCV-infected patients as possible predictor variables of good versus poor compliance. In a longitudinal study, 74 patients with chronic hepatitis C (CHC) who fulfilled the criteria for treatment with interferon (IFN)-alpha-2b with or without ribavirin were investigated prospectively to identify those at risk for poor compliance during IFN medication. To assess predictive factors, we used both IIP-C (Inventory of Interpersonal Problems) and SCL-90-R (Symptom Check List 90 Items Revised) as psychometric instruments. Sociodemographic and somatic variables as well as compliance during IFN therapy were also evaluated. Poor compliance before or during medication was demonstrated by 23% (N = 17) of HCV patients. Sociodemographic factors and mode of acquisition, particularly former intravenous drug (IVD) abuse were not significantly linked with compliance. Logistic regression analysis demonstrated that the subgroup of patients with compliance problems was best identified by both pretherapeutic psychiatric symptoms and interpersonal problems. Predictive value was best and significant for anger-hostility (P = 0.009), intrusive (P = 0.014), depression (P = 0.015), and phobic anxiety (P = 0.049). Adopting this statistical prediction model, sensitivity was 47.1%, but specificity reached 98.3%. In total, 86.5% of cases were classified correctly. In situations of unclear indication for IFN therapy, psychological variables assessment of before the beginning of treatment may represent an additional decision-making factor.

Simultaneous interdisciplinary counseling in German breast/ovarian cancer families: first experiences with patient perceptions, surveillance behavior and acceptance of genetic testing

As part of a multicenter study supported by the German Mildred Scheel foundation we have established an interdisciplinary counseling setting for members of breast and/or ovarian cancer families. We offer simultaneous counseling by a team consisting of a geneticist, a gynecologist and a psycho-oncologist. Here we describe our counseling protocol and our first short-term experience with this interdisciplinary approach. Preliminary data on patient perceptions and behaviors in the context of DNA testing are reported. Overall, our counseling approach was perceived as beneficial both by the counselors and the consultants. A marked overestimation of the risk to develop breast and/or ovarian cancer was noted in the group of unaffected individuals from medium to low risk breast cancer families in contrast to an appropriate risk perception in members from high risk families. All participants shared many of the same expectations about genetic testing and counseling and appeared to base their decision-making about testing on the risk classification given by the genetic counselor. The reported participation in gynecological cancer prevention programs was high in all families at risk, but was less sufficient in unaffected as compared to affected persons. Although current data on BRCA1/BRCA2 mutation analyses render testing in medium to low risk individuals questionable, our findings emphasize the importance of genetic counseling and education in all risk categories of breast and/or ovarian cancer families.

[Not Available]

Although treatment selection in psychotherapy can be conceptualized as an interactive process, as yet there is few empirical research that aimed at addressing the significance of therapists' emotional reactions to their patients when selecting appropriate psychotherapeutic treatments. The present naturalistic-observational cross-sectional study investigates therapists' countertransference which was assessed after the completion of the intake interview. 13 psychotherapists rated their countertransference feelings regarding 237 patients who presented at a psychotherapy outpatient university department, using a 17-items feeling word checklist. By means of factor analysis, three dimensions of the countertransference ratings could be found: 1. sympathy; 2. helpfulness; 3. anger. Clusteranalytically, patients could be assigned to four groups that are characterized by specific countertransference patterns: 1. positive countertranference (n = 82); 2. weak countertransference (n=124); 3. ambivalent countertransference (n=16); and 4. negative countertransference (n=13). The frequencies of both diagnostic categories and selected treatments proved to differ between the clusters. In the positive countertransference cluster, patients with depressive disorders were more frequent and patients with somatoform disorders less frequent. In the positive countertransference cluster, the indication of cognitive-behavioral therapy was especially frequent. Regarding the combination of positive countertransference and selection of cognitive treatment, the result of a previous study could be replicated. This finding proved to reflect different countertransference attitudes and indication preferences of therapists with different therapeutic philosophy orientations (psychodynamic vs. cognitive-behavioral).

Emotional state, coping styles, and somatic variables in patients with chronic hepatitis C

The authors in a cross-sectional study examined 113 patients with chronic hepatitis C (CHC) without widely progressed or decompensated liver disease. The patients were investigated for emotional state (depression, anxiety, coping styles) and somatic/sociodemographic variables. A high percentage of patients had positive scores for depression (22.4%) and anxiety (15.2%). Mode of acquisition (e.g., former drug abuse) and histological grade of liver damage had no significant influence on emotional state or coping strategies. Older patients (> or = 50 years) were significantly more depressed (P = 0.024). Patients with a recently diagnosed CHC (> 4 weeks, < 6 months) had significantly lower scores for depression (P = 0.003) and anxiety (P = 0.001) than the subgroup with a time interval since initial diagnosis of more than 5 years. Recently diagnosed CHC patients also showed the highest levels of problem-solving behavior. Patients who were advised not to undergo an interferon therapy were significantly more depressed (P = 0.001) and anxious (P = 0.028). Older patients with CHC and patients with a long period since CHC diagnosis or who were advised not to undergo interferon therapy should be carefully and regularly assessed for depression, anxiety, and inappropriate coping styles.