Biomedical subjects

Antonius Schneider

Publications and source records attributed to Antonius Schneider.

15 recordsLinked to original sources

PubMed2006

[Acupuncture--needle-pricking within a complex intervention].

The results of the large acupuncture studies initiated by the German Federal Committee of Physicians and Health Insurers raised several new questions concerning acupuncture effects. Based on the current evidence it is postulated that not yet entirely defined specific und unspecific factors contribute to outcome in acupuncture treatment. Consequently, acupuncture has to be regarded as a 'complex intervention' consisting of several components. A phased approach to evaluate 'complex intervention' is presented and transferred to acupuncture research. According to this phased approach unspecific factors contributing to acupuncture effects have to be identified and increasingly considered in future acupuncture research. Thus, several research methods to identify and evaluate unspecific acupuncture effects are suggested, e.g. qualitative methods. Therefore, the particular German situation of acupuncture, provided by physicians and state-licensed non-medical therapists ('Heilpraktiker'), is taken into account. Furthermore, it is discussed to what extent unspecific acupuncture effects can be assessed within randomized controlled trials.

Acupuncture Therapy↗

PubMed2006

Acupuncture for nausea and vomiting: an update of clinical and experimental studies.

The objective of this overview is to summarize existing knowledge about the effects of acupuncture-point stimulation on nausea and vomiting. Systematic reviews on postoperative nausea and vomiting, chemotherapy-induced nausea and vomiting, and pregnancy-related nausea and vomiting exist. Several randomised trials, but no reviews, exist for motion sickness. For postoperative nausea and vomiting, results from 26 trials showed acupuncture-point stimulation was effective for both nausea and vomiting. For chemotherapy-induced nausea and vomiting, results of 11 trials differed according to modality with acupressure appearing effective for first-day nausea, electroacupuncture appearing effective for first-day vomiting, and noninvasive electrostimulation appearing no more effective than placebo for any outcome. For pregnancy-related nausea and vomiting, results were mixed. Experimental studies showed effects of P6-stimulation on gastric myoelectrical activity, vagal modulation and cerebellar vestibular activities in functional magnetic resonance imaging. There is good clinical evidence from more than 40 randomised controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting. A growing number of experimental studies suggest mechanisms of action.

Acupuncture Therapy↗

PubMed2006

Long-term effects of a shared decision-making intervention on physician-patient interaction and outcome in fibromyalgia. A qualitative and quantitative 1 year follow-up of a randomized controlled trial.

OBJECTIVE: Fibromyalgia syndrome (FMS) patients and their doctors frequently complain on interaction difficulties. We investigated the effects of a shared decision-making (SDM) intervention on physician-patient interaction and health outcome. METHODS: Sixty-seven FMS patients of an outpatient university setting that had been included in a randomized controlled trial were followed up. They were either treated in an SDM group or in an information group. Both groups saw a computer based information tool on FMS, but only the SDM group was treated by doctors which underwent a special SDM communication training. A comparison group of 44 FMS patients receiving treatment as usual was recruited in rheumatological practices. We assessed patients and their doctors using a combined qualitative and quantitative approach. Patients and doctors were followed-up after 3 months (T2) and after 1 year (T3). RESULTS: The significantly best quality of physician-patient interaction was reported by patients and doctors of the SDM group, followed by the information group. Coping had more often improved in the SDM group than in the information group. However directly health related outcome variables had not improved in any of the groups at T3. CONCLUSION: An SDM intervention can lead to an improved physician-patient relationship from the patients' and from the doctors' perspective. PRACTICE IMPLICATIONS: It should be considered to include SDM in standard care for FMS patients.

Adaptation, Psychological↗

PubMed2006

The added value of C-reactive protein to clinical signs and symptoms in patients with obstructive airway disease: results of a diagnostic study in primary care.

BACKGROUND: To evaluate the diagnostic accuracy of clinical signs and symptoms, C-reactive protein (CRP) and spirometric parameters and determine their interrelation in patients suspected to have an obstructive airway disease (OAD) in primary care. METHODS: In a cross sectional diagnostic study, 60 adult patients coming to the general practitioner (GP) for the first-time with complaints suspicious for obstructive airway disease (OAD) underwent spirometry. Peak expiratory flow (PEF)-variability within two weeks was determined in patients with inconspicuous spirometry. Structured medical histories were documented and CRP was measured. The reference standard was the Tiffeneau ratio (FEV1/VC) in spirometry and the PEF-variability. OAD was diagnosed when FEV1/VC < or = 70% or PEF-variability > 20%. RESULTS: 37 (62%) patients had OAD. The best cut-off value for CRP was found at 2 mg/l with a diagnostic odds ratio (OR) of 4.4 (95% CI 1.4-13.8). Self-reported wheezing was significantly related with OAD (OR 3.4; CI 1.1-10.3), whereas coughing was inversely related (OR 0.2; CI 0.1-0.7). The diagnostic OR of CRP increased when combined with dyspnea (OR 8.5; 95% CI 1.7-42.3) or smoking history (OR 8.4; 95% CI 1.5-48.9). CRP (p = 0.004), FEV1 (p = 0.001) and FIV1 (p = 0.023) were related with the severity of dyspnea. CRP increased with the number of cigarettes, expressed in pack years (p = 0.001). CONCLUSION: The diagnostic accuracy of clinical signs and symptoms was low. The diagnostic accuracy of CRP improved in combination with dyspnea and smoking history. Due to their coherence with the severity of dyspnea and number of cigarettes respectively, CRP and spirometry might allow risk stratification of patients with OAD in primary care. Further studies need to be done to confirm these findings.

Adult↗

PubMed2006

Impact of age, health locus of control and psychological co-morbidity on patients' preferences for shared decision making in general practice.

OBJECTIVE: The aim of this study was to explore if patients' preferences to be involved in decision making correlates with reasons for encounter, psychological or demographic characteristics and with the physicians' estimation of the patients' preferred communication styles. METHODS: Two hundred and thirty-four patients in general practice completed a questionnaire, which included the 'Autonomy Preference Index' (API), 'health locus of control' and 'hospital anxiety and depression'. The physicians documented the diagnoses and estimated the patients' preference for an autonomous, paternalistic or shared decision communication style. RESULTS: The preference for involvement varied across the reason for encounter (range 36.6-50.6), but this effect is explained by the patients' age (p<0.01). The participation preferences and the external and internal health locus of control declined with age whereas depression scores rose (p<0.01). The physicians estimation corresponded with patient API scores (p<0.05). CONCLUSION: It must be questioned if the preference for involvement is really a stable characteristic. The physicians were able to estimate the preferred communication style of their patients presumably on the basis of the patients' age and education. PRACTICE IMPLICATIONS: It appears that not every situation in general practice requires SDM, though different communication styles could be useful if adapted to the individual situation.

Adolescent↗

PubMed2006

Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting.

BACKGROUND: In 1998, the National Institutes of Health Consensus Statement on Acupuncture concluded that promising results have emerged showing the efficacy of acupuncture in adult postoperative and chemotherapy induced nausea and vomiting. The acupuncture point, P6 had been the point used in most of the trials. OBJECTIVES: To summarize Cochrane systematic reviews assessing P6 stimulation for nausea and vomiting. RESULTS: Reviews were found on postoperative sickness, chemotherapy-induced nausea and vomiting, and pregnancy-related nausea and vomiting. Results for postoperative nausea and vomiting show the most consistent results with 26 trials and more than 3000 patients showing the superiority of real P6 stimulation over sham for both adults and children and for both nausea and vomiting. Pooled data of trials including different antiemetics showed that P6 stimulation seems to be superior to antiemetic medication for nausea and equivalent for vomiting. P6 stimulation was similarly effective across the different methods of stimulation, both invasive or noninvasive. Results for chemotherapy-induced nausea and vomiting showed 11 trials and over 1200 patients. Electroacupuncture, but not manual acupuncture, was beneficial for first-day vomiting. Acupressure was effective for first-day nausea but not vomiting. Wristwatch-like electrical devices were not effective for any outcome. Results for pregnancy-related nausea and vomiting comprised six trials and approximately 1150 patients. Results were mixed with some trials showing positive and other trials equivocal results with no favor to a certain kind of method. CONCLUSIONS: P6 stimulation may be beneficial for various conditions involving nausea and vomiting. The added value to modern antiemetics remains unclear. In patients on chemotherapy, future research should focus on patients for whom the problems are refractory. The next steps in research should include investigating whether acupuncture points added to P6 or individualizing treatment based on a Traditional Chinese Medicine diagnosis increases treatment effectiveness. It would also be worthwhile to identify predictors of response across the different conditions so that the individual patients can optimize acupuncture point therapy.

Acupuncture Points↗

PubMed2006

[Stepwise diagnostic workup in general practice as a consequence of the Bayesian reasoning].

The dependency of the predictive values of tests on the prevalence of diseases is an escrow issue of clinical diagnostics. The relation between pre-test probability and post-test probability is well explained by Bayes' theorem, and the relation between prevalence and false diagnoses can be described well by modifying this theorem. In cases of low prevalence the positive predictive value (PPV) is lower and the false-positive predictive value (FPPV) higher. These aspects mainly depend on the test specificity. But basically, in cases of low prevalence there is a higher negative predictive value (NPV) and a lower false negative predictive value (FNVP). Depending on the sensitivity and specificity, NPV and FNPV vary only slightly in low prevalence ranges. These statistical relations are able to explain the typical mode of operation of general practitioners with their unselected patients. In order to increase PPV and decrease FPPV in the diagnostic workup, the GP must use his clinical experience, time and stepwise diagnostic procedures. More diagnostic studies are necessary to improve the diagnostic workup in patient care.

Bayes Theorem↗

PubMed2006

[The National Disease Management Guideline for Asthma--what's new from the point of view of general practice].

The National Disease Management Guideline for Asthma was developed through a consensus process that involved different medical societies, thus constituting a novelty in the improvement of the care for asthma patients in Germany. The German Association of General Practitioners (DEGAM) also participated in the development of the asthma guideline. The implementability of this new guideline in general practice will be discussed on the basis of the chapters that are most important to primary care physicians. The guideline offers many relevant aspects for the management of asthma in general practice. In future editions, the levels of evidence underlying the statements about diagnosis and therapy should be more elaborate, thus providing more concise decision aids for physicians in daily practice. In particular, the implementation aids on the guideline's website could be used to translate the content of the guidelines into practice. Continuous quality improvement and the further development of the implementation process would be most important in overcoming the cross-sectoral barriers of the German healthcare system and thus optimizing the quality of care.

Asthma↗

PubMed2005

Physicians perceived usefulness of high-cost diagnostic imaging studies: results of a referral study in a German medical quality network.

BACKGROUND: Medical and technological progress has led to increased numbers of diagnostic tests, some of them inducing high financial costs. In Germany, high-cost diagnostic imaging is performed by a medical specialist after referral by a general practitioner (GP) or specialist in primary care. The aim of this study was to evaluate the physicians' perceived usefulness of high-cost diagnostic imaging in patients with different clinical conditions. METHODS: Thirty-four GPs, one neurologist and one orthopaedic specialist in ambulatory care from a Medical Quality Network documented 234 referrals concerning 97 MRIs, 96 CTs-scan and 41 intracardiac catheters in a three month period. After having received the test results, they indicated if these were useful for diagnosis and treatment of the patient. RESULTS: The physicians' perceived usefulness of tests was lowest in suspected cerebral disease (40% of test results were seen as useful), cervical spine problems (64%) and unexplained abdominal complaints (67%). The perceived usefulness was highest in musculoskeletal symptoms (94%) and second best in cardiological diseases (82%). CONCLUSION: The perceived usefulness of high-cost diagnostic imaging was lower in unexplained complaints than in specific diseases. Interventions to improve the effectiveness and efficiency of test ordering should focus on clinical decision making in conditions where GPs perceived low usefulness.

Aged↗

PubMed2005

Are ICD-10 codes appropriate for performance assessment in asthma and COPD in general practice? Results of a cross sectional observational study.

BACKGROUND: The increasing prevalence and impact of obstructive lung diseases and new insights, reflected in clinical guidelines, have led to concerns about the diagnosis and therapy of asthma and COPD in primary care. In Germany diagnoses written in medical records are used for reimbursement, which may influence physicians' documentation behaviour. For that reason it is unclear to what respect ICD-10 codes reflect the real problems of the patients in general practice. The aim of this study was to assess the appropriateness of the recorded diagnoses and to determine what diagnostic information is used to guide medical treatment. METHODS: All patients with lower airway symptoms (n = 857) who had attended six general practices between January and June 2003 were included into this cross sectional observational study. Patients were selected from the computerised medical record systems, focusing on ICD-10-codes concerning lower airway diseases (J20-J22, J40-J47, J98 and R05). The performed diagnostic procedures and actual medication for each identified patient were extracted manually. Then we examined the associations between recorded diagnoses, diagnostic procedures and prescribed treatment for asthma and COPD in general practice. RESULTS: Spirometry was used in 30% of the patients with a recorded diagnosis of asthma and in 58% of the patients with a recorded diagnosis of COPD. Logistic regression analysis showed an improved use of spirometry when inhaled corticosteroids were prescribed for asthma (OR = 5.2; CI 2.9-9.2) or COPD (OR = 4.7; CI 2.0-10.6). Spirometry was also used more often when sympathomimetics were prescribed (asthma: OR = 2.3; CI 1.2-4.2; COPD: OR = 4.1; CI 1.8-9.4). CONCLUSIONS: This study revealed that spirometry was used more often when corticosteroids or sympathomimetics were prescribed. The findings suggest that treatment was based on diagnostic test results rather than on recorded diagnoses. The documented ICD-10 codes may not always reflect the real status of the patients. Thus medical care for asthma and COPD in general practice may be better than initially found on the basis of recorded diagnoses, although further improvement of practice patterns in asthma and COPD is still necessary.

Adolescent↗

PubMed2005

Perception of bodily sensation as a predictor of treatment response to acupuncture for postoperative nausea and vomiting prophylaxis.

OBJECTIVES: Conditions associated with the response to acupuncture treatment remain widely elusive. This study aimed to identify predictors of treatment response in patients undergoing acupuncture treatment for prevention of postoperative nausea and vomiting (PONV). An intervention-specific questionnaire was developed to assess perception of bodily sensations (PBS) in patients undergoing acupuncture treatment. DESIGN: Exploratory study in addition to an observer-blinded randomized controlled trial. SETTINGS/LOCATION: The departments of anesthesiology and of gynecology, University of Heidelberg, Germany. SUBJECTS: Two hundred and twenty (220) female patients scheduled for breast or gynecologic surgery. INTERVENTIONS: True acupuncture on point P6 (Neiguan) or placebo/sham acupuncture on a virtual point 1 cm proximal and lateral to P6. OUTCOME MEASURES: Of 220 female patients scheduled for breast or gynecologic surgery who were included in the trial, 202 completed the newly developed PBS questionnaire before the intervention. The main outcome was incidence of PONV in relationship with PBS and the kind of acupuncture applied. Logistic regression analyses were performed to identify predictors of treatment response for those receiving surgery (n = 195). RESULTS: High PBS predicted low treatment response in patients receiving breast surgery (odds ratio [OR] = 1.6; p = 0.039 for each 10-point increase). The PBS questionnaire showed good item difficulty, internal consistency, and divergent validity. Treatment response in patients receiving gynecologic surgery was predicted by the kind of acupuncture applied (OR = 0.4; p = 0.027), whereas PBS played no role in this group. CONCLUSIONS: The incidence of PONV after breast surgery seems to be influenced by some psychological mechanisms. In this group of patients, acupuncture might be more effective in patients who have low PBS.

Acupuncture Therapy↗

PubMed2005

[Suspicion of COPD--development of an algorithm for stepwise diagnosis in primary care].

The implementation of the disease management programme (DMP) for asthma and COPD in the German health system in 2005 requires an optimal and evidence-based work-up of patients by general practitioners in routine daily practice. The German and international guidelines for COPD do not provide recommendations for a stepwise diagnostic work-up in primary care. Therefore, an evidence-based algorithm was developed for a stepwise diagnosis of COPD and its different stages in general practice, based on national and foreign guidelines that provide specific advice on diagnostic procedures.

Algorithms↗

PubMed2003

[Between individuality and "evidence-based medicine"--the role of the general practitioner within the scope of disease management programs].

In Germany, the change from the "traditional", experience-based general practitioner (GP) to the evidence-based practising co-ordinator may be accelerated by the introduction of disease management programmes. Here, we will discuss some tools that can help to meet this challenge. Also, a set of requirements will be defined that the health care system will have to provide in support of GPs. Maintaining the relationship between doctor and patient and also allowing for individual care on the basis of evidence-based medicine will remain a challenge.

Evidence-Based Medicine↗

PubMed2003

[Suspected diagnosis of bronchial asthma--development of an algorithm for diagnosis of asthma in general practice].

In 2003, the German Ministry of Health will publish a legal document that will allow for the implementation of disease management programmes for asthma and COPD. Examination of German asthma guidelines reveals that they do not include recommendations for a stepwise diagnostic work-up of patients with relevant symptoms in general practice. Therefore an algorithm was developed for the diagnosis of asthma in general practice, based on both national and the most important foreign guidelines providing specific advice on diagnostic procedures.

Algorithms↗

PubMedDate not supplied

Effect of depressive symptoms on survival after heart transplantation.

OBJECTIVE: This study explored the value of preoperative self-reported assessment for depression and anxiety in patients who had undergone heart transplantation (HTx). The initial sample was divided into subgroups of patients with ischemic (ICMP) and dilated cardiomyopathy (DCMP). Patient depression and anxiety scores were measured in both subgroups and their impact on pre- and postoperative mortality investigated. METHOD: An initial sample of 152 patients with either ICMP (N = 57) or DCMP (N = 95) and end-stage heart disease awaiting heart transplantation were assessed in a multidimensional longitudinal study, including psychological and somatic variables. One hundred and three patients received a HTx and were followed up for a mean of 4.4 years. Proportional hazard models were computed to test for the influence of psychosocial and somatic factors on outcome. RESULTS: Preoperative depression and state anxiety scores were significantly higher in the ICMP group. In addition to donor and recipient age, ICMP patients in the preoperative high depression group also showed a significantly higher mortality after HTx. This result remained significant even after controlling for sociodemographic and somatic variables. CONCLUSIONS: Patient self-reported depression, but not anxiety, can contribute to the identification of subgroups of patients with an unfavorable outcome after HTx. It therefore may be helpful to screen for depression, particularly in patients with an ischemic cause of their end-stage heart disease. Specific intervention programs should be further developed and evaluated.

Anxiety↗