[Rehabilitation of the chronically ill and handicapped. Survey and perspectives].
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Chronic Disease↗
Biomedical subjects
H H Raspe
Publications and source records attributed to H H Raspe.
[Checklist for methodological quality of guidelines. A contribution to quality promotion of medical guidelines].
The society of physicians of Germany and the society of panel physicians laid down in the "assessment criteria for guidelines in medical care" what kind of demands the medical selfadministration makes on guidelines. This measure also had the goal to support and strengthen the efforts of the AWMF for guidelines of high value. On the basis of these assessment criteria, a tool was compiled for the systematic registration and documentation of quality criteria for good guidelines for the first time in areas of German language. This check list is guided by the structure and content of the "Criteria for Appraisal for National Guidelines" by the Scottish Intercollegiate Guidelines Network.
Germany↗
[Minimum requirements in medical expert assessment of occupational disability of patients with chronic nonspecific pain].
Assessing working capacity in patients with chronic nonspecific pain disorders applying for disability pensions is a core tasks of practical social medicine. Traditionally the evaluation focused on the nosological classification and clinical description of the pain disorder with rather vague concepts of its consequences in terms of disabilities and handicaps. The author proposes to reverse the sequence. Following the International Classification of Impairments, Disabilities and Handicaps (WHO 1980) work incapacity can be seen as an "occupational handicap". Its qualities, severity and credibility depend on the existence of objectifyable disabilities (especially behaviour, locomotor, body disposition, dexterity and situational disabilities). These may be attributed to clinical impairments and an underlying disease process. Among impairments pain has to be assessed multidimensionally. As in clinical medicine a nosological diagnosis is a useful but neither necessary nor sufficient prerequisite for a sociomedical evaluation of pain patients.
Chronic Disease↗
Prediction of permanent work disability in a follow-up study of early rheumatoid arthritis: results of a tree structured analysis using RECPAM.
The objectives of this study are: (a) to determine the occurrence of permanent work disability (PWD) in early rheumatoid arthritis (RA); (b) to identify prognostic groups of patients; (c) to assess the employment rates for these groups over time. Seventy-three gainfully employed consecutive out-patients with early RA (> or = 5 ARA 1958 criteria, disease duration < or = 12 months) at time one (T1) were re-examined at time two (T2) after a mean follow-up of 6 yr (S.D. +/- 2 yr). Potential risk factors, identified at T1, for PWD at T2 were entered in a tree structured survival analysis using RECPAM (RECursive Partition and AMalgamation). Cumulative 3 yr employment rates (3-yrER +/- S.E.M.) were computed from the resulting Kaplan-Meier curves. At T2, PWD occurred in 27 of the 73 patients (37%). The fastest decline in the employment rate was found within the first 3 yr of the disease onset, with a 3-yrER reduced to 73 +/- 5%. The group with the poorest prognosis (n = 14; 3-yrER 14 +/- 9%) was defined by age > or = 50 yr with either ESR > or = 60 mm/h or the combination of modified functional class (1-7) > or = 4 with a disease duration > or = 7 months. An intermediate group (n = 38; 3-yrER 79 +/- 6%) was defined by (a) age > or = 50 yr and low or moderate disease activity, (b) age < 50 yr and more strenuous job-related physical requirements, (c) age < 50 yr and less strenuous work, but joint count > or = 15. No case of PWD occurred in 21 individuals aged < 50 yr with a joint count < 15 and less physically demanding jobs. PWD occurs early in a substantial number of patients with RA. RECPAM defines risk profiles that can readily be applied in actual clinical situations and allow an estimation of the risk of PWD at different time points using the resulting Kaplan-Meier curves.
Adult↗
[The current backache epidemic].
All available data presented show that we are confronted with a back-pain (BP) epidemic; it affects numerous industrialized countries. More severe forms of BP make up one fifth of the prevalence. The greater part of BP seems to be mild, especially among persons aged 25 to 54. The social insurance statistics, too, show an alarming trend. Cases of work incapacity and medical rehabilitation have increased drastically: one sixth of all cases of work incapacity as well as one third of all medical rehabilitations are to be accounted to BP. It is not easy to interpret the data. Do they represent an increasing BP epidemic? A long-term secular trend towards higher BP prevalences at the population level is to be assumed but cannot be proven at the moment. Is there any evidence that BP-related risk factors have increased? To our knowledge there are no reliable data. It is also to be considered that the 'natural' course of BP may have changed. Is the epidemic a consequence of an increasing 'chronification' of BP due to physical, psychosocial or medical influences? Do 'back-schools' and other factors regarding the BP business have only health-promoting effects? Does the date represent a changing perception and appraisal of pain and/or a changing 'pain-reporting behaviour'? Is 'pain' today what would have been 'discomfort' in former times? Does one complain about BP today when one would have been silent in former times? There are no valid data for these hypotheses, either. Finally, has the transition probability from pain to disability and to social benefits changed?(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Grading of backache].
Back pain is occurring in a broad spectrum of severity; therefore, a grading procedure which is derived from a sound conceptual basis and can be easily applied is of crucial importance in clinical research and in epidemiologic studies. Following a grading procedure which has been developed in epidemiologic studies in the U.S., a hierarchical model for grading is proposed. This comprises pain intensity and functional limitation as basic criteria as well as aspects of time, pain-related cognitions/emotions and concomitant complaints. An application of a simple grading procedure is used to illustrate the predictive utility of the proposed model.
Activities of Daily Living↗
[Report of the 28th Annual Congress of the German Society of Social Medicine and Prevention--Lübeck, 29 September-3 October 1992].
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Germany↗
[Measuring work capacity in rheumatic diseases: functional disability, pain, pain-related cognitions and affects].
Rheumatic diseases, particularly those affecting the back, cervical spine, and the joints, are widespread in the general population. The general costs, especially those associated with social medical services, show constant increases. Time and effectiveness lost from work due to back problems in the FRG accounted for most of the days off the job because of disability, time spent in the hospital or at a health spa facility. Therefore, the appropriate evaluation of the degree of disability plays an increasingly important role in the area of social benefits. Yet unambiguous and objective physical measurements of the disease and the degree of associated disability are lacking in most cases of rheumatic diseases. More attempts to address the subjective aspects of the disease should be included in such evaluations. For recent years, models of measurement have been developed and tested, which are suited to the multidimensional nature of rheumatic illnesses. It is recommended that these be introduced in routine use for physical evaluations.
Affect↗
[Clinical instruction for preclinical students].
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Clinical Medicine↗
The outcome of traditional or comprehensive outpatient care for rheumatoid arthritis (RA). Results of an open, non-randomized, 2-year prospective study.
This work presents results of a quasiexperimental prospective cohort study of the medium-term course of chronic rheumatoid arthritis (RA) under two different conditions of care. During 1984-1986 a total of 262 patients was recruited. All were new referrals to a university outpatient department. 121 came from the city of Hannover, FRG, and were assigned to comprehensive team care (cc) provided by two rheumatologists, a nurse, physician's assistant, occupational therapist, psychologist, and social worker; 141 came from outside Hannover and received care from a physician in training for internal medicine/rheumatology and a nurse, supervised by a senior registrar (TC). The patients in the first group were significantly older (57 vs 51 years), had more active disease (ESR 44 vs 31 mm/h), were more disabled (functional capacity 69 vs 78%), more often lived alone (27 vs 10%) and were more depressed compared with patients in the second group. There were no significant differences in gender (80% female), number of Rome criteria (5.2), and disease duration (6 years) between the two groups. 179 patients were followed for 2 years. There was no demonstrable difference between those who dropped out and those who continued in the study. Patients from both groups showed significant and clinically important improvements in ESR and number of swollen joints, whereas functional capacity and pain intensity did not change. Depression and patients' global self-rating improved only in the CC-group. Analyses adjusting for differences between the two groups were unable to show a different efficacy for either form of care.(ABSTRACT TRUNCATED AT 250 WORDS)
Ambulatory Care↗
[Population epidemiologic evaluation of the Hannover Mobile Rheumatoid Health Service].
The aim of the study was the evaluation of a potential selection process for patients with rheumatoid arthritis (RA) referred to the Mobile Service for Rheumatics in Hannover (MSRH). The MSRH is the only referral center for patients with inflammatory rheumatic diseases in Hannover. A comparison of the health status was made between 58 individuals with RA identified in a population study, and 103 RA patients from the MSRH. The following disease parameters were less favorable in the clinical group: duration of morning stiffness, functional capacity, number of swollen joints, rheumatoid factor, ESR, disease activity, and classical RA according to the Rome-criteria. Only 22% of the individuals with RA identified in the population study have been referred to the MSRH. These patients more frequently had definite or classical RA (statistically not significant: p = 0.17, p = 0.11, respectively). It was shown that the clinical group comprised more severe RA cases. Thus, data from such patients may not be generalized for the entire group of RA cases in the population.
Ambulatory Care Facilities↗
[Fibromyalgia syndrome. Current contributions to the etiology, diagnosis and therapy of so-called "soft tissue rheumatism"].
The fibromyalgia syndrome (FMS) is an extraarticular rheumatic disease. Typical features are the chronic, polytopic pain in the musculoskeletal system and the provocation of pain by pressure on defined tender points. Mainly medium age women are affected by the disease. In histomorphological studies of muscle tissue non-specific changes were demonstrated, which were thought to be due to ischemia. Furthermore, sleep disturbance and a reduced pain threshold, which may be related to psychological factors, are discussed in the etiology. In FMS a primary and a secondary form related to other diseases can be differentiated. The treatment consists mainly of behaviour therapy and physiotherapy.
Adult↗
Human fibroblasts release reactive oxygen species in response to treatment with synovial fluids from patients suffering from arthritis.
Human fibroblasts in primary culture released reactive oxygen species upon exposure to synovial fluid obtained by joint aspiration from twelve patients suffering from rheumatoid arthritis. The primary radical produced was O2- as determined by ESR spin trapping and cytochrome c reduction. In contrast to the oxidative burst in granulocytes and monocytes, radical formation proceeded continuously for at least four hours. Low-level chemiluminescence was increased upon exposure to inflammatory human synovial fluids. Spectral characteristics and effects of azide and 1,4-diazabicyclo-(2,2,2)-octane led to the conclusion that the photoemissive species were excited carbonyls. Radical production and light emission were not altered either by xanthine or allopurinol, nor by azide, cyanide or rotenone. The O2- production increased in the presence of NADH or NADPH, making an NAD(P)H oxidase a likely source. The liberation of reactive oxygen species correlated with the number of leukocytes present in the inflammatory joint fluids, but not with the concentrations of immunoglobulins and complement factor C3.
Arthritis, Rheumatoid↗
Early arthritides: nosography, nosology, and diagnostic criteria.
Follow-up studies of patients with early arthritides are sparse and they are usually restricted to certain diagnostic groups. Therefore 141 unselected patients suffering from arthritis since no more than 12 months were entered into a prospective study. The largest group (n = 57, 40%) consisted of patients with definite rheumatoid arthritis. Forty individuals (28%) were judged to have undifferentiated arthritis since they could not be classified according to established diagnostic criteria initially. After 9 +/- 3 months mean follow-up only 21 of 45 patients (47%) fulfilling criteria for definite rheumatoid arthritis at the onset of the study remained in this category, 9 (20%) still suffered from arthritis but they met less than 5 ARA criteria, and 15 (33%) went into remission. Among 50 patients with undifferentiated arthritis or spondylarthropathy an even smaller proportion of 16 individuals (32%) still had arthritis, which could not be classified, whereas 34 (68%) showed no signs of persisting peripheral arthritis. Thus, criteria diagnoses are inadequate for the selection of the patients at the onset of the disease since they are frequently false positive and they omit other arthritides important for differentiation. Further disadvantages of criteria diagnoses are evident: they imply a large spectrum of manifestations of the disease, they overlap with other entities, they do not provide sufficient information regarding the prognosis and adequate treatment. To improve the prognostic value of a nosological classification a concept of descriptive diagnoses is discussed.
Arthritis, Infectious↗
Activity and severity of rheumatoid arthritis in Hannover/FRG and in one regional referral center.
Between November 1984 and July 1988 a total of 8044 randomly selected German residents of the city of Hannover/FRG, aged 25 to 74, have been screened for rheumatic complaints by means of a postal questionnaire. An average 87% of the probands contacted returned completed questionnaires. Respondents with a "positive" questionnaire, i.e. suggestive of the existence of an inflammatory joint disease were invited for a rheumatological examination at the Hannover Medical School. 72% participated. 45 of a total of 1291 participants were identified as suffering from active or inactive, mostly rheumatoid arthritis. This yields a minimum prevalence of 0.56% (+/- 0.19%). The true prevalence is estimated to be 0.91% (99%-confidence interval 0.64-1.18). In 1985 and 1986 103 German RA sufferers aged 25 to 74, all citizens of Hannover, were referred to our outpatient rheumatology clinic for a first consultation. A comparison between the two groups revealed a higher disease activity in terms of "objective" criteria (joint swellings, ESR, rheumatoid factor) in the group of the referred patients as opposed to RA suffers from the community. Both groups were comparable in respect to "subjective" symptoms (morning stiffness, joint pain, pain intensity), functional capacity and degree of erosive joint lesions. The rheumatological outpatient clinic at the Hannover Medical School, providing the only specialized service in the region, actually covers less than 20% of all RA sufferers within the municipal area of Hannover and less than 50% of those with a "classical" RA according to the ARA-criteria.
Adult↗
Treatment profiles in different groups of RA-sufferers: description, analysis, evaluation.
(1) 50 to 80% of all rA-sufferers treated by rheumatologists have received second line therapy in contrast to 7 to 27% at the community level. (2) Disease duration and disease activity do not seem to affect the treatment regimens of primary and other physicians working in or around Hannover. The same holds true for social and demographic characteristics of the patients. (3) RA-sufferers are generally undertreated by community based doctors with regard to RiD-therapy and disease activity. Approximately 80% of patients with formal indication for the use of RiDs have not received these drugs, despite the fact that a rheumatological department with an outpatient clinic providing more than 3500 consultations per year has existed for more than 20 years at the Medizinische Hochschule Hannover. This outpatient clinic is utilized by more than 60% of all general practitioners as well as internal and orthopedic physicians working in the city of Hannover. We thus have to admit a rather low community effectiveness of our service. (4) A sensitivity of the formal evaluation-scheme of 0.70 and a specificity of 0.80 imply 30% false-negative and 20% false-positive assessments. In view of the larger number of false-negative judgements one must assume an even greater difference between treatment-reality and rheumatological concepts. (5) Sofar we cannot offer any safe explanation for the reasons underlying this unsatisfactory situation. The predictors we have investigated up to now have not proven to be selective. (6) Nevertheless, practical steps are urgently required, in order to be rheumatologically more effective at the community level--at least in Hannover/FRG.
Adult↗
[Do patients with active chronic polyarthritis get "basic therapy"?].
The determination of the adequacy of an individual therapeutical regimen is part of the process evaluation of medical care. To evaluate the adequacy of individual antirheumatic therapy, we developed a five step procedure: 1. Assessment of the patient's health status; 2. assessment of his/her former and current therapy; 3. determination of the adequate antirheumatic therapy following an explicit norm; 4. formal comparison of current and adequate treatment; 5. clinical evaluation of possible differences between norm and reality. Due to methodological reasons we concentrated on the current treatment of rheumatoid arthritis (rA) patients with remission inducing drugs (RIDs; e.g. Chloroquine, Gold). The study analyzed the RID treatment of 75 rA-sufferers; 25 patients were referred to our outpatient department for the first time in late 1986; 25 patients were recruited from a social-medical study covering employed but actually disabled members of a major health insurance (AOK) in Hannover; 25 subjects were derived from an ongoing population study ("prevalence and care of rheumatoid arthritis in Hannover"). Only 9 out of 49 (18%) patients with an active disease, formally in need of treatment, were currently treated with RIDs. Thus 40 out of 49 (82%) seemed to be under an inadequate treatment. From the clinical point of view this formal judgement was assumed to be false positive in 5 and false negative in 15 cases. In relation to the clinical judgements we found for the formal procedure a sensitivity of 0.70 with a specificity of 0.80 and an overall agreement of 73% (kappa 0.44).
Adult↗