Diagnostic clinical prediction rules for categorising low back pain: A systematic review

Background: Low back pain (LBP) is a common complex condition, where specific diagnoses are hard to identify. Diagnostic clinical prediction rules (CPRs) are known to improve clinical decision‐making. A review of LBP diagnostic‐CPRs by Haskins et al. (2015) identified six diagnostic‐CPRs in derivation phases of development, with one tool ready for implementation. Recent progress on these tools is unknown. Therefore, this review aimed to investigate developments in LBP diagnostic‐CPRs and evaluate their readiness for implementation. Methods: A systematic review was performed on five databases (Medline, Amed, Cochrane Library, PsycInfo, and CINAHL) combined with hand‐searching and citation‐tracking to identify eligible studies. Study and tool quality were appraised for risk of bias (Quality Assessment of Diagnostic Accuracy Studies‐2), methodological quality (checklist using accepted CPR methodological standards), and CPR tool appraisal (GRade and ASsess Predictive). Results: Of 5021 studies screened, 11 diagnostic‐CPRs were identified. Of the six previously known, three have been externally validated but not yet undergone impact analysis. Five new tools have been identified since Haskin et al. (2015); all are still in derivation stages. The most validated diagnostic‐CPRs include the Lumbar‐Spinal‐Stenosis‐Self‐Administered‐Self‐Reported‐History‐Questionnaire and Diagnosis‐Support‐Tool‐to‐Identify‐Lumbar‐Spinal‐Stenosis, and the StEP‐tool which differentiates radicular from axial‐LBP. Conclusions: This updated review of LBP diagnostic CPRs found five new tools, all in the early stages of development. Three previously known tools have now been externally validated but should be used with caution until impact evaluation studies are undertaken. Future funding should focus on externally validating and assessing the impact of existing CPRs on clinical decision‐making

Training healthcare professionals to be ready for practice in an era of social distancing: A realist evaluation

Background Programme changes due to the COVID-19 pandemic have impacted variably on preparation for practice of healthcare professional students. Explanations for such variability in outcomes between institutions and healthcare professions have yet to be explored. The aim of our study was to understand what clinical learning, whilst under socially distanced restrictions, worked and why (or why not). Methods We conducted a realist evaluation of the undergraduate healthcare programmes at one UK university in 2020-21. The initial programme theories to be tested in this study were derived from discussions with programme leads about the changes they implemented due to the pandemic. Study participants were students and teaching faculty. Online interview transcripts were coded, identifying why the interventions in the programme had worked or not. This resulted in a set of ‘context-mechanism-outcome’ (CMO) statements about each intervention. The initial programme theories were refined as a result. Results and discussion 29 students and 22 faculty members participated. 18 CMO configurations were identified relating to clinical skills learning and 25 relating to clinical placements. Clinical skills learning was successful whether in person, remote or hybrid if it followed the steps of: demonstration – explanation – mental rehearsal – attempt with feedback. Where it didn’t work there was usually a lack of observation and corrective feedback. Placements were generally highly valued despite gaps in experience. Being useful on placements was felt to be good preparation for practice. Participant explanations from junior students about the value of various modes of induction to clinical workplace activity may also be relevant post-pandemic

The impact of donor and recipient common clinical and genetic variation on estimated glomerular filtration rate in a European renal transplant population

Genetic variation across the HLA is known to influence renal‐transplant outcome. However, the impact of genetic variation beyond the HLA is less clear. We tested the association of common genetic variation and clinical characteristics, from both the donor and recipient, with post‐transplant eGFR at different time‐points, out to 5‐years post‐transplantation. We conducted GWAS meta‐analyses across 10,844 donors and recipients from five European ancestry cohorts. We also analysed the impact of polygenic risk scores (PRS), calculated using genetic variants associated with non‐transplant eGFR, on post‐transplant eGFR. PRS calculated using the recipient genotype alone, as well as combined donor and recipient genotypes were significantly associated with eGFR at 1‐year post‐transplant. 32% of the variability in eGFR at 1‐year post‐transplant was explained by our model containing clinical covariates (including weights for death/graft‐failure), principal components and combined donor‐recipient PRS, with 0.3% contributed by the PRS. No individual genetic variant was significantly associated with eGFR post‐transplant in the GWAS. This is the first study to examine PRS, composed of variants that impact kidney function in the general population, in a post‐transplant context. Despite PRS being a significant predictor of eGFR post‐transplant, the effect size of common genetic factors is limited compared to clinical variables

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Sonographic investigations into the diagnosis, and cause, of abnormal upper limb haemoynamics, and its effect on arterial health in asymptomatic individuals

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Acquiring Antiquity: The Future of Cultural Heritage Collecting and Stewardship in the United States

During the first decade of the twenty-first century, the number of repatriation requests from foreign governments to museums in the United States greatly increased, and several landmark cases involving looted cultural heritage were decided in favor of the source nation. These transactions have been changing how American museums, private collectors, and art dealers acquire cultural heritage material, particularly when it has an archaeological origin. This study examines the history of collecting, discusses how efforts to prohibit the trade in illicit antiquities are affecting the way in which institutions and individuals acquire cultural heritage material, and supports a broader goal of identifying future strategies for collecting and stewardship. Chinese antiquities that are popular with art collectors are used as a sample group to represent the trade in archaeological material. Three general questions form the cornerstone of this research: (1) What is the impact of the increased use of cultural heritage legislation on the trade in archaeological objects, and can it be quantified? (2) What does the future of collecting look like for American museums and private collectors? How are museums and collectors changing their policies and approaches as a reaction to new legal actions and changing ethics? (3) What role does China play in the protection and consumption of Chinese cultural heritage? Qualitative data are drawn from interviews with 31 stakeholders. To ground the stakeholders’ concerns in fact-based research; quantitative data are collected from 86 auctions of Chinese antiquities held between 2000 and 2016. Both data sets show that stakeholders interested in acquiring Chinese antiquities are increasingly concerned with provenance, that verifiable provenance increases the value of an object, and that Chinese buyers play a significant role in auctions in the United States. It will be challenging to curb the demand for archaeological materials, and this study concludes with a discussion of the future of collecting in the United States, outlining current programs and examining new strategies aimed at changing how collectors view antiquities. Three potential approaches for reducing the demand for illicit antiquities are evaluated: government-controlled markets, reproductions, and long-term loans

Tune out pain: Agency and active engagement predict decreases in pain intensity after music listening

Music is increasingly being recognised as an adjuvant treatment for pain management. Music can help to decrease the experience of both chronic and experimental pain. Cognitive agency has been identified as a specific mechanism that may mediate the analgesic benefits of music engagement however, it is unclear if this specific mechanism translates to acute pain. Previous attempts to understand the cognitive mechanisms that underpin music analgesia have been predominantly lab-based, limiting the extent to which observed effects may apply to participants\u27 everyday lives. Addressing these gaps, in naturalistic settings, the present study examined the degree to which cognitive agency (i.e., perceived choice in music), music features (i.e., complexity), and individual levels of musical sophistication were related to perceived pain. In an online global experiment, using a randomised between groups experimental design with two levels for choice (no choice and perceived choice) and two levels for music (high and low complexity), a sample of 286 adults experiencing acute pain reported their pain intensity and pain unpleasantness pre- and post-music listening. A bespoke piece of music was co-created with a commercial artist to enable the manipulation of music complexity while controlling for familiarity, while facilitating an authentic music listening experience. Overall, findings demonstrated that increased perceived control over music is associated with analgesic benefits, and that perceived choice is more important than music complexity. Highlighting the importance of listener engagement, people who reported higher levels of active engagement experienced greater decreases of pain intensity in the perceived choice condition, than those who reported lower levels of active engagement. These findings have implications for both research and practice, emphasising the importance of facilitating freedom of choice, and sustained engagement with music throughout music listening interventions

Diabetic Foot Infections: A Team-oriented Review of Medical and Surgical Management.

As the domestic and international incidence of diabetes and metabolic syndrome continues to rise, health care providers need to continue improving management of the long-term complications of the disease. Emergency department visits and hospital admissions for diabetic foot infections are increasingly commonplace, and a like-minded multidisciplinary team approach is needed to optimize patient care. Early recognition of severe infections, medical stabilization, appropriate antibiotic selection, early surgical intervention, and strategic plans for delayed reconstruction are crucial components of managing diabetic foot infections. The authors review initial medical and surgical management and staged surgical reconstruction of diabetic foot infections in the inpatient setting