Appropriateness of referrals from primary care for lumbar MRI

BACKGROUND: International guidelines do not recommend routine imaging, including magnetic resonance imaging (MRI), and seek to guide clinicians only to refer for imaging based on specific indications. Despite this, several studies show an increase in the use of MRI among patients with low back pain (LBP) and an imbalance between appropriate versus inappropriate use of MRI for LBP. This study aimed to investigate to what extent referrals from general practice for lumbar MRI complied with clinical guideline recommendations in a Danish setting, contributing to the understanding and approaches to lumbar MRI for all clinicians managing LBP in the primary sector. MATERIALS AND METHODS: From 2014 to 2018, all referrals for lumbar MRI were included from general practitioners in the Central Denmark Region for diagnostic imaging at a public regional hospital. A modified version of the American College of Radiology Imaging Appropriateness Criteria for LBP was used to classify referrals as appropriate or inappropriate, based on the unstructured text in the GPs’ referrals. Appropriate referrals included fractures, cancer, symptoms persisting for more than 6 weeks of non-surgical treatment, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals were sub-classified as lacking information about previous non-surgical treatment and duration. RESULTS: Of the 3772 retrieved referrals for MRI of the lumbar spine, 55% were selected and a total of 2051 referrals were categorised. Approximately one quarter (24.5%) were categorised as appropriate, and 75.5% were deemed inappropriate. 51% of the inappropriate referrals lacked information about previous non-surgical treatment, and 49% had no information about the duration of non-surgical treatment. Apart from minor yearly fluctuations, there was no change in the distribution of appropriate and inappropriate MRI referrals from 2014 to 2018. CONCLUSION: The majority of lumbar MRI referrals (75.5%) from general practitioners for lumbar MRI did not fulfil the ACR Imaging Appropriateness Criteria for LBP based on the unstructured text of their referrals. There is a need for referrers to include all guideline-relevant information in referrals for imaging. More research is needed to determine whether this is due to patients not fulfilling guideline recommendations or simply the content of the referrals

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Energy efficient freight transport from a national systems perspective : a methodology for evaluation of potential for decreased energy use

Målet med rapporten är att bidra till ett energieffektivt transportsystem genom att presentera en ny approach för analys av energianvändning i godstransportsystemet som kan komplettera konventionella metoder och bidra till bättre beslutsunderlag. Energianvändningen i transportsektorn är central för Sveriges möjligheter att nå uppsatta mål om minskad klimatpåverkan. Här presenteras en metod för att skatta minimal energianvändning i ett godstransportsystem från ett nationellt systemperspektiv. Detta problem definieras här som Minimalenergiproblemet (MEP). Rapporten presenterar en metod för MEP och tillämpar metoden för en analys av det svenska godstransportsystemet. Analys av MEP möjliggör skattning av en teoretisk potential för minskad energianvändning i godstransportsystemet och ger en referens för att kvantitativt utvärdera olika typer av åtgärder. Grundidén är att använda en befintlig nationell godstransportmodell som bygger på kostnads[1]minimerande principer som ett optimeringsverktyg och ersätta kostnadsparametrar med värden för energianvändning. Metoden tillämpas för analys av det svenska godstransportsystemet genom att använda Samgods. Samgods är Trafikverkets nationella godsmodell som används för analyser av godstransportsystemet och framtagning av beslutsunderlag för till exempel infrastrukturinvesteringar, policyåtgärder och prognoser. Det svenska godstransportsystemet studeras med avseende på minimal energianvändning med fokus på scenarier som beskriver dagens förutsättningar med befintlig infrastruktur, fordonsflotta, energibärare och transportefterfrågan, enligt Samgodsmodellen. Resultaten jämförs med scenarier för ett kostnadsminimalt system som kan antas simulera godstransportsystemet i praktiken. Rapporten illustrerar även möjliga tillämpningar genom scenarioanalyser där förändrade förutsättningar för vägtransporter simuleras samt fall för minimering med avseende på koldioxidutsläpp.The objective of this study is to contribute to an energy-efficient transport system by presenting a new approach for analysis of energy use which could be a complement to conventional decision support systems. Energy use in the transport sector is a central aspect to consider in order to meet national goals of reduced climate impact. This study presents a method for estimating minimal energy use in a goods transport system from a national system perspective. In this study, this problem is defined as the Minimum Energy Problem (MEP). The purpose is to describe a method for MEP and apply the method for an analysis of the Swedish goods transport system. Study of MEP gives an estimation of a theoretical potential for reduced energy use in the goods transport system and a reference for evaluations of different types of measures.  The basic idea is to use a national freight model as an optimisation tool by replacing cost parameters with parameter values for energy use and CO2 emissions. The principle means that an existing model can be reused. The method is applied for analysis of the Swedish goods transport system by using Samgods. Samgods is the Swedish national freight model, owned by the Swedish Transport Administration, and used for analyses of the goods transport system to give decision basis for e.g., infrastructure investments, policy changes and long-term forecasts.  The Swedish goods transport system is studied with respect to scenarios for minimal energy use with a focus on today’s existing infrastructure, vehicles and transport demand, as specified in Samgods. The results are compared with cost-minimisation scenarios which could be assumed to simulate the goods transport system in practice. Scenarios could be used to analyse system effects of different measures. The general applicability of the proposed methodology is illustrated by scenario analyses representing changed conditions for road transport and a case of minimization with respect to carbon dioxide emissions

Glycosyalted chromogranin A in heart faiure. Implications for processing and cardiomyocyte calcium homeostasis

Background—Chromogranin A (CgA) levels have previously been found to predict mortality in heart failure (HF), but currently no information is available regarding CgA processing in HF and whether the CgA fragment catestatin (CST) may directly influence cardiomyocyte function. Methods and Results—CgA processing was characterized in postinfarction HF mice and in patients with acute HF, and the functional role of CST was explored in experimental models. Myocardial biopsies from HF, but not sham-operated mice, demonstrated high molecular weight CgA bands. Deglycosylation treatment attenuated high molecular weight bands, induced a mobility shift, and increased shorter CgA fragments. Adjusting for established risk indices and biomarkers, circulating CgA levels were found to be associated with mortality in patients with acute HF, but not in patients with acute exacerbation of chronic obstructive pulmonary disease. Low CgA-to-CST conversion was also associated with increased mortality in acute HF, thus, supporting functional relevance of impaired CgA processing in cardiovascular disease. CST was identified as a direct inhibitor of CaMKIIδ (Ca2+/calmodulin-dependent protein kinase IIδ) activity, and CST reduced CaMKIIδ-dependent phosphorylation of phospholamban and the ryanodine receptor 2. In line with CaMKIIδ inhibition, CST reduced Ca2+ spark and wave frequency, reduced Ca2+ spark dimensions, increased sarcoplasmic reticulum Ca2+ content, and augmented the magnitude and kinetics of cardiomyocyte Ca2+ transients and contractions. Conclusions—CgA-to-CST conversion in HF is impaired because of hyperglycosylation, which is associated with clinical outcomes in acute HF. The mechanism for increased mortality may be dysregulated cardiomyocyte Ca2+ handling because of reduced CaMKIIδ inhibition