Which treatment for acute nonspecific low back pain? A network meta-analysis

Hintergrund Bis zu 85% aller Menschen leiden zumindest einmal im Leben an Kreuzschmerzen. Akuter unspezifischer Kreuzschmerz umfasst Schmerzen zwischen den 12. Rippen und der Glutealfalte über höchstens 4 Wochen, wobei hierfür keine eindeutige Ursache gefunden werden kann (keine „Red Flags“). Studien zeigten bislang widersprüchliche Effekte medikamentöser und nicht-medikamentöser Interventionen. Ziel Ziel ist es, die Effekte aller pharmakologischen und nicht-pharmakologischen Behandlungsmethoden für akuten unspezifischen Kreuzschmerz auf Schmerz und Funktion mittels systematischem Review, konventioneller Metaanalyse, Netzwerkmetaanalyse und Analyse der externen Validität zu erfassen. Suchstrategien Wir durchsuchten die Plattformen MEDLINE, EMBASE und CENTRAL mit dem Stand von Juli 2016. Graue Literatur wurde nicht eingeschlossen. Einschlusskriterien Alle randomisiert kontrollierten Studien über die Behandlung von akutem unspezifischem Kreuzschmerz wurden eingeschlossen. Datenerhebung und Analyse Zwei Autoren prüften die gefundenen Studien unabhängig voneinander auf Erfüllung der Einschlusskriterien und extrahierten die Daten. Wir beurteilten die Heterogenität der Studienkollektive und erfassten skalare Endpunkte mittels standardisierter Mittelwertdifferenzen. Es erfolgte eine Netzwerkmetaanalyse mit SUCRA. Die Pragmatik wurde mittels PRECIS-2-Beurteilung analysiert. Ergebnisse Siebenundvierzig randomisiert kontrollierte Studien mit 9020 Patienten wurden eingeschlossen. Die Studienqualität war im Allgemeinen unklar bis schlecht. Im Rahmen der konventionellen Metaanalyse zeigte sich, dass Medikation, topische Therapie und Physiotherapie Placebo in der Schmerztherapie signifikant überlegen sind. Physiotherapie und andere NSAR waren Diclofenac in dieser Indikation überlegen. Physiotherapie scheint Placebo hinsichtlich der Wiederherstellung der Funktionalität überlegen zu sein, wobei Diclofenac diesbezüglich besser zu sein scheint als andere NSAR. Alle untersuchten Interventionen zeigten im Rahmen der Netzwerkmetaanalyse bessere Ergebnisse als Placebo. Nicht-medikamentöse Interventionen scheinen Medikamenten und Placebo überlegen zu sein, wobei die Qualität der Evidenz sehr schlecht ist. Die eingeschlossenen Studien erreichten im Rahmen der PRECIS-2-Beurteilung im Mittel 323 von 45 Punkten, was pragmatischen Arbeiten entspricht. Schlussfolgerung Die meisten Interventionen scheinen Placebo überlegen zu sein, wobei nicht-pharmakologische Therapien Schmerzen besser lindern als Medikamente. Hinsichtlich Funktionsverbesserung scheint Physiotherapie Placebo überlegen zu sein, wobei diesbezüglich keine Netzwerkmetaanalyse durchgeführt werden konnte. Die unklare bis schlechte methodologische Qualität der eingeschlossenen Studien verlangt nach weiteren, gut geplanten und pragmatischen Arbeiten.Background Up to 85% of all humans suffer from back pain at least once in their lives. Acute nonspecific low back pain is located between the 12th ribs and the gluteal fold and of undetermined cause (absence of “red flags”) for a duration of 4 weeks or less. Studies have revealed conflicting effects of pharmacologic and non-pharmacologic interventions. Aim of this project is to determine the effects of all available treatments for acute nonspecific low back pain on pain and function. Objectives To analyse the effect of pharmacologic and non-pharmacologic interventions for low back pain using systematic review, standard meta-analysis, network-meta analysis, and analysis of external validity. Search methods We searched MEDLINE, EMBASE and CENTRAL as of July 2016. We excluded grey literature from our analysis. Selection criteria We included all randomized controlled trials on interventions for acute nonspecific low back pain. Data collection and analysis Two authors independently assessed studies for eligibility and extracted the data. We assessed heterogeneity and used standardized mean differences to summarize continuous outcomes. Network meta-analysis, including SUCRA, was performed. The pragmatism was assessed using the PRECIS-2 tool. Main results Forty-seven randomized controlled trials enrolling 9020 participants were included. Risk of bias was generally moderate to high and concerned manifold domains of the risk of bias assessment without a clear pattern. In standard meta-analysis, we found that medication, topical therapy and physiotherapy are significantly superior to placebo regarding pain relief. Physiotherapy and other NSARs were superior to diclofenac. Regarding improvement in function physiotherapy seems to be superior to placebo. For improvement in function diclofenac is likely superior to other NSARs. In network meta-analysis for the outcome pain all interventions were found to be superior to placebo. Non-pharmacological therapies generally appeared superior to pharmacological interventions and placebo. The quality of the estimates was generally very low. PRECIS-2-rating yielded a mean of 323 out of 45 points, indicating a tendency towards pragmatic trials. Authors conclusions Most interventions seem to be superior to placebo with non-pharmacological therapies being superior over pharmacological therapy in terms of pain relief. Regarding function, physiotherapy seems to be superior to placebo but network meta-analysis was not possible. Poor methodological quality of the included studies reveals need for further, well designed and pragmatic trials.submitted by Calvin Lukas KienbacherAbweichender Titel laut Übersetzung der Verfasserin/des VerfassersMedizinische Universität Wien, Diss., 2018(VLID)286904

Socioeconomic Risk Factors for Pediatric Out-of-Hospital Cardiac Arrest: A Statewide Analysis.

IntroductionEconomic hardship is a major threat to children’s health, implying that pediatric out-of-hospital cardiac arrest (pOHCA) might be promoted by lower incomes and child poverty. To target resources, it is helpful to identify geographical hotspots. Rhode Island is area-wise the smallest state in the United States of America. It has one million inhabitants and is comparable to many larger cities worldwide. We aimed to investigate possible associations of pOHCA with economic factors and the COVID-19 pandemic. We tried to identify high-risk areas and evaluated whether the COVID-19 pandemic had an influence on delays in prehospital care.MethodsWe analyzed all pOHCA cases (patients under 18 years of age) in Rhode Island between March 1st, 2018, and February 28th, 2022. We performed Poisson regression with pOHCA as dependent and economic risk factors (median household income and child poverty rate from the United States Census Bureau) as well as the COVID-19 pandemic as independent variables. Hotspots were identified utilizing Local Indicators of Spatial Association (LISA) statistics in ArcGIS Pro (Esri Corp., Redlands). We used linear regression to assess the association of EMS related times with economic risk factors and COVID-19.ResultsFifty-one cases met our inclusion criteria. Lower median household incomes (incidence-rate ratio (IRR) 0.99 per 1,000$ MHI; p=0.01) and higher child poverty rates (IRR 1.02 per percent; p=0.02) were significantly associated with higher numbers of ambulance calls due to pOHCA. The pandemic did not have a significant influence (IRR 0.9; p=0.7). LISA identified 12 census tracts as hotspots (p<0.01). The pandemic was not associated with delays in prehospital care.ConclusionLower median household income and higher child poverty rate are associated with higher numbers of pOHCA

Increases in Ambulance Call Volume Are an Early Warning Sign of Major COVID-19 Surges in Children

Background: Infectious diseases, including COVID-19, have a severe impact on child health globally. We investigated whether emergency medical service (EMS) calls are a bellwether for future COVID-19 caseloads. We elaborated on geographical hotspots and socioeconomic risk factors. Methods: All EMS calls for suspected infectious disease in the pediatric population (under 18 years of age) in Rhode Island between 1 March 2018 and 28 February 2022 were included in this quasi-experimental ecological study. The first of March 2020 was the beginning of the COVID-19 pandemic. We used the 2020 census tract and the most recent COVID-19 data. We investigated associations between pediatric EMS calls and positive COVID-19 tests with time series analysis and identified geographical clusters using local indicators of spatial association. Economic risk factors were examined using Poisson regression. Results: We included 980 pediatric ambulance calls. Calls during the omicron wave were significantly associated with increases in positive COVID-19 tests one week later (p < 0.001). Lower median household income (IRR 0.99, 95% CI [0.99, 0.99]; p < 0.001) and a higher child poverty rate (IRR 1.02, 95% CI [1.02, 1.02]; p < 0.001) were associated with increased EMS calls. Neighborhood hotspots changed over time. Conclusion: Ambulance calls might be a predictor for major surges of COVID-19 in children

Table_2_Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey.docx

BackgroundSocioeconomic factors and the COVID-19 pandemic influence children’s physical and mental health. We aimed to investigate the association between a census tract’s median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.MethodsThis study is a retrospective analysis of ambulance calls for pediatric (ResultsInclusion criteria were met by 208 incidents (48$ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.ConclusionHigher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.</p

Lower serum cholesterol levels as a risk factor for critical illness polyneuropathy: a matched case–control study

Abstract Critical illness polyneuropathy (CIP) is a frequent and underdiagnosed phenomenon among intensive care unit patients. The lipophilic nature of neuronal synapses may result in the association of low serum cholesterol levels with a higher rate of CIP development. We aimed to investigate this issue in critically ill patients. All cases diagnosed with CIP in our tertiary care hospital between 2013 and 2017 were 1:1 matched with controls without the condition by age, sex, and ICD diagnoses. The main risk factors examined were the differences in change between initial and minimum serum total cholesterol levels, and minimum serum total cholesterol levels between matched pairs. Other predictors were serum markers of acute inflammation. We included 67 cases and 67 controls (134 critically ill patients, 49% female, 46% medical). Serum total cholesterol levels decreased more profoundly in cases than controls (median: −74 (IQR −115 to −24) vs. −39 (IQR −82 to −4), median difference: −28, 95% CI [−51, −5]), mg/dl). Minimum serum total cholesterol levels were lower in the cases (median difference: −24, 95% CI [−39, −9], mg/dl). We found significant median differences across matched pairs in maximum serum C-reactive protein (8.9, 95% CI [4.6, 13.2], mg/dl), minimum albumin (−4.2, 95% CI [−6.7, −1.7], g/l), decrease in albumin (−3.9, 95% CI [−7.6, −0.2], g/l), and lowest cholinesterase levels (−0.72, 95% CI [−1.05, −0.39], U/l). Subsequently, more pronounced decreases in serum total cholesterol levels and lower minimum total cholesterol levels during critical care unit hospitalizations may be a risk factor for CIP

Table_1_Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey.docx

BackgroundSocioeconomic factors and the COVID-19 pandemic influence children’s physical and mental health. We aimed to investigate the association between a census tract’s median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.MethodsThis study is a retrospective analysis of ambulance calls for pediatric (ResultsInclusion criteria were met by 208 incidents (48$ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.ConclusionHigher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.</p