Institut für Sportmedizin und Prävention
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Background: Recent studies have demonstrated a superior diagnostic accuracy of cardiovascular magnetic resonance (CMR) for the detection of coronary artery disease (CAD). We aimed to determine the comparative cost-effectiveness of CMR versus single-photon emission computed tomography (SPECT).
Methods: Based on Bayes' theorem, a mathematical model was developed to compare the cost-effectiveness and utility of CMR with SPECT in patients with suspected CAD. Invasive coronary angiography served as the standard of reference. Effectiveness was defined as the accurate detection of CAD, and utility as the number of quality-adjusted life-years (QALYs) gained. Model input parameters were derived from the literature, and the cost analysis was conducted from a German health care payer's perspective. Extensive sensitivity analyses were performed.
Results: Reimbursement fees represented only a minor fraction of the total costs incurred by a diagnostic strategy. Increases in the prevalence of CAD were generally associated with improved cost-effectiveness and decreased costs per utility unit (Delta QALY). By comparison, CMR was consistently more cost-effective than SPECT, and showed lower costs per QALY gained. Given a CAD prevalence of 0.50, CMR was associated with total costs of (sic)6,120 for one patient correctly diagnosed as having CAD and with (sic)2,246 per Delta QALY gained versus (sic)7,065 and (sic)2,931 for SPECT, respectively. Above a threshold value of CAD prevalence of 0.60, proceeding directly to invasive angiography was the most cost-effective approach.
Conclusions: In patients with low to intermediate CAD probabilities, CMR is more cost-effective than SPECT. Moreover, lower costs per utility unit indicate a superior clinical utility of CMR.
The purpose of this study was to investigate the association between variables of lower extremity muscle strength, balance, and mobility assessed under various task conditions.
Twenty-one healthy children (mean age: 9 +/- 1 years) were tested for their isometric and dynamic strength as well as for their steady-state, proactive, and reactive balance and mobility. Balance and mobility tests were conducted under single and dual task conditions.
Significant positive correlations were detected between measures of isometric and dynamic leg muscle strength. Hardly any significant associations were observed between variables of strength and balance/mobility and between measures of steady-state, proactive, and reactive balance. Additionally, no significant correlations were detected between balance/mobility tests performed under single and dual task conditions.
The predominately non-significant correlations between different balance components and mobility imply that balance and mobility performance is task specific. Further, strength and balance/mobility as well as balance under single and dual task conditions seem to be independent of each other and may have to be tested and trained complementarily.
Background: Age-related postural misalignment, balance deficits and strength/power losses are associated with impaired functional mobility and an increased risk of falling in seniors. Core instability strength training (CIT) involves exercises that are challenging for both trunk muscles and postural control and may thus have the potential to induce benefits in trunk muscle strength, spinal mobility and balance performance. Objective: The objective was to investigate the effects of CIT on measures of trunk muscle strength, spinal mobility, dynamic balance and functional mobility in seniors. Methods: Thirty-two older adults were randomly assigned to an intervention group (INT; n = 16, aged 70.8 +/- 4.1 years) that conducted a 9-week progressive CIT or to a control group (n = 16, aged 70.2 +/- 4.5 years). Maximal isometric strength of the trunk flexors/extensors/lateral flexors (right, left)/rotators (right, left) as well as of spinal mobility in the sagittal and the coronal plane was measured before and after the intervention program. Dynamic balance (i.e. walking 10 m on an optoelectric walkway, the Functional Reach test) and functional mobility (Timed Up and Go test) were additionally tested. Results: Program compliance was excellent with participants of the INT group completing 92% of the training sessions. Significant group x test interactions were found for the maximal isometric strength of the trunk flexors (34%, p < 0.001), extensors (21%, p < 0.001), lateral flexors (right: 48%, p < 0.001; left: 53%, p < 0.001) and left rotators (42%, p < 0.001) in favor of the INT group. Further, training-related improvements were found for spinal mobility in the sagittal (11%, p < 0.001) and coronal plane (11%, p = 0.06) directions, for stride velocity (9%, p < 0.05), the coefficient of variation in stride velocity (31%, p < 0.05), the Functional Reach test (20%, p < 0.05) and the Timed Up and Go test (4%, p < 0.05) in favor of the INT group. Conclusion: CIT proved to be a feasible exercise program for seniors with a high adherence rate. Age-related deficits in measures of trunk muscle strength, spinal mobility, dynamic balance and functional mobility can be mitigated by CIT. This training regimen could be used as an adjunct or even alternative to traditional balance and/or resistance training.
Publication Bias in meta-analyses of the efficacy of psychotherapeutic interventions for depression
(2013)
Objective: The aim of this study was to assess whether systematic reviews investigating psychotherapeutic interventions for depression are affected by publication bias. Only homogeneous data sets were included, as heterogeneous data sets can distort statistical tests of publication bias. Method: We applied Begg and Mazumdar's adjusted rank correlation test, Egger's regression analysis, and the trim and fill procedure to assess the presence and magnitude of publication bias in all homogeneous data sets of systematic reviews published up to September 2010. Results: Thirty-one data sets reported in 19 meta-analyses fulfilled our inclusion criteria. Significant bias was detected in 5 (16.13%; rank correlation test) and 6 (19.35%; Egger's regression analysis) of these data sets. Applying the trim and fill procedure to amend presumably missing studies rarely changed the assessment of the efficacy of therapeutic interventions, with 2 exceptions. In 1 data set psychotherapy was no longer found to be significantly more efficacious than pharmacotherapy in reducing dropout at posttreatment when publication bias was taken into account. In the 2nd data set, after correcting for publication bias, there was no longer evidence that depressed patients without comorbid personality disorder profited more from psychotherapy and pharmacotherapy than patients with comorbid personality disorder. Conclusions: The results suggest that taken together, psychotherapy research for depression is only marginally affected by the selective reporting of positive outcomes. With 2 notable exceptions, correcting for publication bias did not change the evaluation of the efficacy of psychotherapeutic interventions.
Aims Recent studies have demonstrated the safety and efficacy of catheter-based renal sympathetic denervation (RDN) for the treatment of resistant hypertension. We aimed to determine the cost-effectiveness of this approach separately for men and women of different ages.
Methods and results A Markov state-transition model accounting for costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness was developed to compare RDN with best medical therapy (BMT) in patients with resistant hypertension. The model ran from age 30 to 100 years or death, with a cycle length of 1 year. The efficacy of RDN was modelled as a reduction in the risk of hypertension-related disease events and death. Analyses were conducted from a payer's perspective. Costs and QALYs were discounted at 3% annually. Both deterministic and probabilistic sensitivity analyses were performed. When compared with BMT, RDN gained 0.98 QALYs in men and 0.88 QALYs in women 60 years of age at an additional cost of (sic)2589 and (sic)2044, respectively. As the incremental cost-effectiveness ratios increased with patient age, RDN consistently yielded more QALYs at lower costs in lower age groups. Considering a willingness-to-pay threshold of (sic)35 000/QALY, there was a 95% probability that RDN would remain cost-effective up to an age of 78 and 76 years in men and women, respectively. Cost-effectiveness was influenced mostly by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN non-responders, and the procedure costs of RDN.
Conclusion Renal sympathetic denervation is a cost-effective intervention for patients with resistant hypertension. Earlier treatment produces better cost-effectiveness ratios.
Maintaining and increasing walking speed in old age is clinically important because this activity of daily living predicts functional and clinical state. We reviewed evidence for the biomechanical mechanisms of how strength and power training increase gait speed in old adults. A systematic search yielded only four studies that reported changes in selected gait biomechanical variables after an intervention. A secondary analysis of 20 studies revealed an association of r(2) = 0.21 between the 22% and 12% increase, respectively, in quadriceps strength and gait velocity in 815 individuals age 72. In 6 studies, there was a correlation of r(2) = 0.16 between the 19% and 9% gains in plantarflexion strength and gait speed in 240 old volunteers age 75. In 8 studies, there was zero association between the 35% and 13% gains in leg mechanical power and gait speed in 150 old adults age 73. To increase the efficacy of intervention studies designed to improve gait speed and other critical mobility functions in old adults, there is a need for a paradigm shift from conventional (clinical) outcome assessments to more sophisticated biomechanical analyses that examine joint kinematics, kinetics, energetics, muscle-tendon function, and musculoskeletal modeling before and after interventions.
Objective: To compare lateralized cerebral activations elicited during self-initiated movement mirroring and observation of movements.
Subjects: A total of 15 right-handed healthy subjects, age range 22-56 years.
Methods: Functional imaging study comparing movement mirroring with movement observation, in both hands, in an otherwise identical setting. Imaging data were analysed using statistical parametric mapping software, with significance threshold set at p<0.01 (false discovery rate) and a minimum cluster size of 20 voxels.
Results: Movement mirroring induced additional activation in primary and higher-order visual areas strictly contralateral to the limb seen by the subject. There was no significant difference of brain activity when comparing movement observation of somebody else's right hand with left hand.
Conclusion: Lateralized cerebral activations are elicited by inversion of visual feedback (movement mirroring), but not by movement observation.
In dynamic H-reflex measurements, the standardisation of the nerve stimulation to the gait cycle is crucial to avoid misinterpretation due to altered pre-synaptic inhibition. In this pilot study, a plantar pressure sole was used to trigger the stimulation of the tibialis nerve with respect to the gait cycle. Consequently, the intersession reliability of the soleus muscle H-reflex during treadmill walking was investigated.
Seven young participants performed walking trials on a treadmill at 5 km/h. The stimulating electrode was placed on the tibial nerve in the popliteal fossa. An EMG was recorded from the soleus muscle. To synchronize the stimulus to the gait cycle, initial heel strike was detected with a plantar pressure sole. Maximum H-reflex amplitude and M-wave amplitude were obtained and the Hmax/Mmax ratio was calculated.
Data reveals excellent reliability, ICC = 0.89. Test-retest variability was 13.0% (+/- 11.8). The Bland-Altman analysis showed a systematic error of 2.4%.
The plantar pressure sole was capable of triggering the stimulation of the tibialis nerve in a reliable way and offers a simple technique for the evaluation of reflex activity during walking.
Background: Recent studies have demonstrated a superior diagnostic accuracy of cardiovascular magnetic resonance (CMR) for the detection of coronary artery disease (CAD). We aimed to determine the comparative cost-effectiveness of CMR versus single-photon emission computed tomography (SPECT).
Methods: Based on Bayes' theorem, a mathematical model was developed to compare the cost-effectiveness and utility of CMR with SPECT in patients with suspected CAD. Invasive coronary angiography served as the standard of reference. Effectiveness was defined as the accurate detection of CAD, and utility as the number of quality-adjusted life-years (QALYs) gained. Model input parameters were derived from the literature, and the cost analysis was conducted from a German health care payer's perspective. Extensive sensitivity analyses were performed.
Results: Reimbursement fees represented only a minor fraction of the total costs incurred by a diagnostic strategy. Increases in the prevalence of CAD were generally associated with improved cost-effectiveness and decreased costs per utility unit (Delta QALY). By comparison, CMR was consistently more cost-effective than SPECT, and showed lower costs per QALY gained. Given a CAD prevalence of 0.50, CMR was associated with total costs of (sic)6,120 for one patient correctly diagnosed as having CAD and with (sic)2,246 per Delta QALY gained versus (sic)7,065 and (sic)2,931 for SPECT, respectively. Above a threshold value of CAD prevalence of 0.60, proceeding directly to invasive angiography was the most cost-effective approach.
Conclusions: In patients with low to intermediate CAD probabilities, CMR is more cost-effective than SPECT. Moreover, lower costs per utility unit indicate a superior clinical utility of CMR.