Clinical pathways for the management of low back pain from primary to specialised care: a systematic review

Purpose: Clinical pathways for low back pain (LBP) have potential to improve clinical outcomes and health service efficiency. This systematic review aimed to synthesise the evidence for clinical pathways for LBP and/or radicular leg pain from primary to specialised care and to describe key pathway components. Methods: Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) from 2006 onwards were conducted with further manual and citation searching. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. A narrative synthesis of findings is presented. Results: From 18,443 identified studies, 28 papers met inclusion criteria. Pathways were developed primarily to address over-burdened secondary care services in high-income countries and almost universally used interface services with a triage remit at the primary-secondary care boundary. Accordingly, evaluation of healthcare resource use and patient flow predominated, with interface services associated with enhanced service efficiency through decreased wait times and appropriate use of consultant appointments. Low quality study designs, heterogeneous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical- and cost-effectiveness. Pathways demonstrated basic levels of care integration across the primary-secondary care boundary. Conclusions: The limited volume of research evaluating clinical pathways for LBP/radicular leg pain and spanning primary and specialised care predominantly used interface services to ensure appropriate specialised care referrals with associated increased efficiency of care delivery. Pathways demonstrated basic levels of care integration across healthcare boundaries. Well-designed randomised controlled trials to explore the potential of clinical pathways to improve clinical outcomes, deliver cost-effective, guideline-concordant care and enhance care integration are required.</p

The association of serum levels of brain-derived neurotrophic factor with the occurrence of and recovery from delirium in older medical inpatients

Limited studies of the association between BDNF levels and delirium have given inconclusive results. This prospective, longitudinal study examined the relationship between BDNF levels and the occurrence of and recovery from delirium. Participants were assessed twice weekly using MoCA, DRS-R98, and APACHE II scales. BDNF levels were estimated using an ELISA method. Delirium was defined with DRS-R98 (score > 16) and recovery from delirium as ≥2 consecutive assessments without delirium prior to discharge. We identified no difference in BDNF levels between those with and without delirium. Excluding those who never developed delirium ( = 140), we examined the association of BDNF levels and other variables with delirium recovery. Of 58 who experienced delirium, 39 remained delirious while 19 recovered. Using Generalized Estimating Equations models we found that BDNF levels (Wald 2 = 7.155; df: 1, = 0.007) and MoCA (Wald 2 = 4.933; df: 1, = 0.026) were associated with recovery. No significant association was found for APACHE II, dementia, age, or gender. BDNF levels do not appear to be directly linked to the occurrence of delirium but recovery was less likely in those with continuously lower levels. No previous study has investigated the role of BDNF in delirium recovery and these findings warrant replication in other populations

Comparison of verbal and computerised months backwards tests in a hospitalized older population

Background Delirium is extremely prevalent, yet underdiagnosed, in older patients and is associated with prolonged length of hospital stay and higher mortality rates. Impaired attention is the cardinal defcit in delirium and is a required feature in diagnostic criteria. The verbal months backwards test (MBT) is the most sensitive bedside test of attention, however, hospital staf occasionally have difculty with its administration and interpretation. We hypothesise that the MBT on an electronic tablet may be easier and more consistent to use for both experienced and unexperienced medical professionals and, if the diagnostic efcacy was similar, aid delirium diagnosis. Aim We aim to investigate the correlation of the verbal MBT with a computerised MBT application. Methods Participants recruited (age>65, n=75) were allocated to diferent cohorts (Dementia and Delirium (DMDL), Dementia (DM), Delirium (DL), No Neurocognitive Disorder (NNCD)) and were administered both the verbal and electronic versions. Results Correlation between measurements were: overall Spearman’s rho= 0.772 (p Discussion Overall, and for the delirious subset, statistically signifcant agreement was present. Poor inter-test correlation existed in the groups without delirium (DM, NNCD). Conclusions The MBTc correlates well with the MBTv in patients who are clinically suspected to have delirium but has poor correlation in patients without delirium. Visuospatial cognition and psychomotor defcits in a dementia cohort and mechanical factors (such as tremor, poor fngernail hygiene and visual impairment) in a group with no neurocognitive disorder may limit the utility of the MBTc in a hospitalised older population.</p

Agreement and conversion formula between mini-mental state examination and montreal cognitive assessment in an outpatient sample

AIM To explore the agreement between the mini-mental state examination (MMSE) and montreal cognitive assessment (MoCA) within community dwelling older patients attending an old age psychiatry service and to derive and test a conversion formula between the two scales. METHODS Prospective study of consecutive patients attending outpatient services. Both tests were administered by the same researcher on the same day in random order. RESULTS The total sample (n = 135) was randomly divided into two groups. One to derive a conversion rule (n = 70), and a second (n = 65) in which this rule was tested. The agreement (Pearson’s r) of MMSE and MoCA was 0.86 (P < 0.001), and Lin’s concordance correlation coefficient (CCC) was 0.57 (95%CI: 0.45-0.66). In the second sample MoCA scores were converted to MMSE scores according to a conversion rule from the first sample which achieved agreement with the original MMSE scores of 0.89 (Pearson’s r, P < 0.001) and CCC of 0.88 (95%CI: 0.82-0.92). CONCLUSION Although the two scales overlap considerably, the agreement is modest. The conversion rule derived herein demonstrated promising accuracy and warrants further testing in other populations

Subsyndromal delirium compared to delirium, dementia, and subjects without delirium or dementia in elderly general hospital admissions and nursing home residents

Introduction: Subsyndromal delirium (SSD) complicates diagnosis of delirium and dementia, although there is little research comparing their symptom profiles. Methods: Cross-sectional study of 400 elderly patients’ admission to a general hospital or nursing home diagnosed with delirium, SSD, dementia, or no-delirium/no-dementia (NDND). Symptom profiles were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98). Results: Twenty percent patients had delirium, 19.3% had SSD, 29.8% had dementia-only, and 31% had NDND. Eighty-one percent of subsyndromal and 76% of delirium groups had comorbid dementia. DRS-R98 scores showed ascending severity from NDND , dementia-only , SSD , delirium. DRS-R98 scores for items evaluating the three core symptom domains (cognitive, higher-order thinking, and circadian) distinguished SSD from delirium and both from nondelirium groups. DRS-R98 profiles were essentially the same in delirium and SSD subgroups with or without dementia, although total scale scores were generally higher when in comorbid subgroups. Discussion: SSD shared characteristic core domain symptoms with delirium, which distinguished each from nondelirium groups, although severity was intermediate in the subsyndromal group. Delirium core symptoms overshadowed the dementia phenotype when comorbid. Milder disturbances of delirium core domain symptoms are highly suggestive of SSD

Nurses knowledge of advance directives and perceived confidence in end-of a life care in Hong Kong, Ireland, Israel, Italy and the U.S.

Nurses’ knowledge regarding advance directives may affect their administration and completion in end-of-life care. Confidence among nurses is a barrier to the provision of quality end-of-life care. This study investigated nurses’ knowledge of advance directives and perceived confidence in end-of-life care, in Hong Kong, Ireland, Israel, Italy and the USA using a cross-sectional descriptive design (n=1089). In all countries, older nurses and those who had more professional experience felt more confidentmanaging patients’ symptoms at end-of-life and more comfortable stopping preventivemedications at endof- life. Nurses in the USA reported that they have more knowledge and experience of advance directives compared with other countries. In addition, they reported the highest levels of confidence and comfort in dealing with end-of-life care. Although legislation for advance directives does not yet exist in Ireland, nurses reported high levels of confidence in end-of-life care

OCP crystals induce macrophage expression of genes involved in inflammation and cartilage degradation.

<p>Bone marrow derived macrophages were stimulated <i>in vitro</i> with 500 µg/ml of OCP crystals for 4 hours. RNA was extracted, reverse transcribed and qRT-PCR performed using gene specific primers with Tbp, and Gapdh as reference genes. Results are expressed as the fold induction of OCP treated over unstimulated macrophages, using the mean ± S.E.M of triplicate samples.</p

OCP crystal-induced inflammation and cartilage degradation is NLRP3 inflammasome- and IL-1 independent.

<p>WT (n = 6), ASC-/- (n = 4), NLRP3-/- (n = 6), IL-1α-/- (n = 5) and IL-1β-/- (n = 6) mice were injected i.a. with OCP crystals (200 µg in 20 µl) or PBS. In a second set of experiment, anakinra, the recombinant form of IL-1Ra, or PBS were injected for 4 days (7 mice per group), the first injection being 30 min prior to OCP injection into the knee of WT (F). Ratio of isotope uptake into OCP injected knee versus PBS-injected ones was calculated at different time points (A). Synovial inflammation (B, E, F), cartilage PG loss (C, E, F) and VDIPEN immunohistochemistries (D, F) were assessed. Results are expressed as % of scores against WT (B,C,D) or in arbitrary units (E, F), and represent mean ± S.E.M. of at least n = 4 mice per group. For p values, *  =  p<0.05, **  =  p<0.01, ***  =  p<0.001.</p

OCP crystals induce cartilage degradation.

<p>C57BL/6 mice were injected with OCP crystals (OCP+) or PBS (OCP-). Knees harvested at different times (day 4, 17 and 30 n = 8 mice per group) were assessed for cartilage PGs with Safranin-O (A), aggrecan degradation via VDIPEN immunohistochemistry (B) and apoptosis (C). Since at all time points, data from PBS-injected control knees were similar, only data from PBS-injected knees at day 4 were shown in D, E, and F. Scoring of PG loss and VDIPEN staining was performed on sections, using a scale of 0 to 6 and 0 to 3, respectively (D and E). Apoptotic chondrocytes were counted per field of view (F). Results are expressed as mean ± S.E.M with significance being at * p<0.05, ** p<0.01, *** p<0.001</p

Intra-articular BCP crystals induce synovial inflammation and cartilage proteoglycan loss in mice.

<p>OCP crystals (200 µg/20 µl) were injected into right knees of C57BL/6 mice whereas 20 µl PBS was injected into the left knees (A–E). Knees were harvested at different times (day 4, 17 and 30 n = 8 mice per group). Sections were stained with fast green/iron hematoxylin (A) and the degree of inflammation was assessed at the different time points (B). Since the inflammation was very low and similar at all time points in the PBS-injected control knees, only data from PBS-injected knees at day 4 was shown in B. OCP crystal deposition in the synovial membrane was evidenced at day 30 after OCP crystals injection by Von Kossa staining (see arrows) (C). Macrophage, endothelial and PMN cells were detected using antibodies for MAC-2, ICAM, and MPO, respectively, at day 4 after OCP injection (D). Isotype controls allowed the identification of giant cells that had engulfed tissue crystal deposits (*) (D). Ratio of Tc uptake between OCP-injected (n = 8) versus PBS controls was calculated (E). Fast green/iron hematoxylin staining of knees injected with 20 µg/20 µl of HA or OCP crystal at day 4 (F). Results are expressed as mean ± S.E.M with significance being at * p<0.05, ** p<0.01, *** p<0.001.</p