The Nordic maintenance care program: what are the indications for maintenance care in patients with low back pain? A survey of the members of the Danish Chiropractors' Association

<p>Abstract</p> <p>Background</p> <p>Maintenance care (MC) is relatively commonly used among chiropractors. However, factual information is needed on its indications for use.</p> <p>Objectives</p> <p>This study had two objectives: 1) to describe which role patients' past history and treatment outcome play in chiropractors' decision to use MC in patients with low back pain, 2) to investigate if the chiropractors' clinical/educational background has an effect on the frequency of using MC and their indications for use of MC.</p> <p>Method</p> <p>An anonymous questionnaire was sent to all 413 chiropractors practising in Denmark. Its main part consisted of 3 sets of 4 questions relating to one basic case of low back pain. For each case, the chiropractors were asked if they would use MC as they self-defined the term (no/perhaps/yes). There were questions also on gender, age, educational and clinical background, and on the number of MC patients seen by these chiropractors. Their decision to recommend MC was reported. Associations between the demographic variables and 1) the frequency of MC-use and 2) their indications for use of MC were tested through multivariate analysis.</p> <p>Results</p> <p>The response rate was 72%. Non-indications for MC were: 1) a good outcome combined with no previous events, or 2) a past history of LBP and gradual worsening with treatment. Indications for MC were a good outcome combined with a previous history of low back pain between once a month and once a year. The mean proportion of MC patients per week were 22% (SD 19), ranging from 0% to 100%. The use of MC was highest among experienced chiropractors, those who were educated in North America, and clinic owners. However, in Denmark most chiropractors graduated before 1999, are educated abroad, whereas most chiropractors thereafter are educated in Denmark. Therefore, we cannot conclude whether this difference relates to education or years of experience. There were no associations detected between demographic variables and the indications for MC.</p> <p>Conclusions</p> <p>There is relatively high consensus on when MC should and should not be used. A history of prior low back pain combined with a positive response to treatment encourages the use of MC, whereas no previous history of back pain or a worsening of symptoms discourages the use of MC. There seems to be a difference in the proportional use of MC between chiropractors with more experience educated in North America and those with less experience educated in Denmark.</p

Organ Support Therapy in the Intensive Care Unit and Return to Work in Out-of-Hospital Cardiac Arrest Survivors:a Nationwide Cohort Study

AIM: With increased survival after out-of-hospital cardiac arrest (OHCA), impact of the post-resuscitation course has become important. Among 30-day OHCA survivors, we investigated associations between organ support therapy in the Intensive Care Unit (ICU) and return to work.METHODS: This Danish nationwide cohort-study included 30-day-OHCA-survivors who were employed prior to arrest. We linked OHCA data to information on in-hospital care and return to work. For patients admitted to an ICU and based on renal replacement therapy (RRT), cardiovascular support and mechanical ventilation, we assessed the prognostic value of organ support therapies in multivariable Cox regression models.RESULTS: Of 1,087 30-day survivors, 212 (19.5%) were treated in an ICU with 0-1 types of organ support, 494 (45.4%) with support of two organs, 26 (2.4%) with support of three organs and 355 (32.7%) were not admitted to an ICU. Return to work increased with decreasing number of organs supported, from 53.8% (95% CI: 49.5-70.1%) in patients treated with both RRT, cardiovascular support and mechanical ventilation to 88.5% (95% CI: 85.1-91.8%) in non-ICU-patients. In 732 ICU-patients, ICU-patients with support of 3 organs had significantly lower adjusted hazard ratios (HR) of returning to work (0.50 [95% CI: 0.30-0.85] compared to ICU-patients with support of 0-1 organ. The corresponding HR was 0.48 [95% CI: 0.30-0.78] for RRT alone.CONCLUSIONS: In 30-day survivors of OHCA, number of organ support therapies and in particular need of RRT were associated with reduced rate of return to work, although more than half of these latter patients still returned to work.</p

Association of LPA Variants With Risk of Coronary Disease and the Implications for Lipoprotein(a)-Lowering Therapies: A Mendelian Randomization Analysis.

IMPORTANCE: Human genetic studies have indicated that plasma lipoprotein(a) (Lp[a]) is causally associated with the risk of coronary heart disease (CHD), but randomized trials of several therapies that reduce Lp(a) levels by 25% to 35% have not provided any evidence that lowering Lp(a) level reduces CHD risk. OBJECTIVE: To estimate the magnitude of the change in plasma Lp(a) levels needed to have the same evidence of an association with CHD risk as a 38.67-mg/dL (ie, 1-mmol/L) change in low-density lipoprotein cholesterol (LDL-C) level, a change that has been shown to produce a clinically meaningful reduction in the risk of CHD. DESIGN, SETTING, AND PARTICIPANTS: A mendelian randomization analysis was conducted using individual participant data from 5 studies and with external validation using summarized data from 48 studies. Population-based prospective cohort and case-control studies featured 20 793 individuals with CHD and 27 540 controls with individual participant data, whereas summarized data included 62 240 patients with CHD and 127 299 controls. Data were analyzed from November 2016 to March 2018. EXPOSURES: Genetic LPA score and plasma Lp(a) mass concentration. MAIN OUTCOMES AND MEASURES: Coronary heart disease. RESULTS: Of the included study participants, 53% were men, all were of white European ancestry, and the mean age was 57.5 years. The association of genetically predicted Lp(a) with CHD risk was linearly proportional to the absolute change in Lp(a) concentration. A 10-mg/dL lower genetically predicted Lp(a) concentration was associated with a 5.8% lower CHD risk (odds ratio [OR], 0.942; 95% CI, 0.933-0.951; P = 3 × 10-37), whereas a 10-mg/dL lower genetically predicted LDL-C level estimated using an LDL-C genetic score was associated with a 14.5% lower CHD risk (OR, 0.855; 95% CI, 0.818-0.893; P = 2 × 10-12). Thus, a 101.5-mg/dL change (95% CI, 71.0-137.0) in Lp(a) concentration had the same association with CHD risk as a 38.67-mg/dL change in LDL-C level. The association of genetically predicted Lp(a) concentration with CHD risk appeared to be independent of changes in LDL-C level owing to genetic variants that mimic the relationship of statins, PCSK9 inhibitors, and ezetimibe with CHD risk. CONCLUSIONS AND RELEVANCE: The clinical benefit of lowering Lp(a) is likely to be proportional to the absolute reduction in Lp(a) concentration. Large absolute reductions in Lp(a) of approximately 100 mg/dL may be required to produce a clinically meaningful reduction in the risk of CHD similar in magnitude to what can be achieved by lowering LDL-C level by 38.67 mg/dL (ie, 1 mmol/L)

Growth rings show limited evidence for ungulates' potential to suppress shrubs across the Arctic

Global warming has pronounced effects on tundra vegetation, and rising mean temperatures increase plant growth potential across the Arctic biome. Herbivores may counteract the warming impacts by reducing plant growth, but the strength of this effect may depend on prevailing regional climatic conditions. To study how ungulates interact with temperature to influence growth of tundra shrubs across the Arctic tundra biome, we assembled dendroecological data from 20 sites, comprising 1153 individual shrubs and 223 63 annual growth rings. Evidence for ungulates suppressing shrub radial growth was only observed at intermediate summer temperatures (6.5 degrees C-9 degrees C), and even at these temperatures the effect was not strong. Multiple factors, including forage preferences and landscape use by the ungulates, and favourable climatic conditions enabling effective compensatory growth of shrubs, may weaken the effects of ungulates on shrubs, possibly explaining the weakness of observed ungulate effects. Earlier local studies have shown that ungulates may counteract the impacts of warming on tundra shrub growth, but we demonstrate that ungulates' potential to suppress shrub radial growth is not always evident, and may be limited to certain climatic conditions

Growth rings show limited evidence for ungulates’ potential to suppress shrubs across the Arctic

Global warming has pronounced effects on tundra vegetation, and rising mean temperatures increase plant growth potential across the Arctic biome. Herbivores may counteract the warming impacts by reducing plant growth, but the strength of this effect may depend on prevailing regional climatic conditions. To study how ungulates interact with temperature to influence growth of tundra shrubs across the Arctic tundra biome, we assembled dendroecological data from 20 sites, comprising 1153 individual shrubs and 223 63 annual growth rings. Evidence for ungulates suppressing shrub radial growth was only observed at intermediate summer temperatures (6.5 ◦C–9 ◦C), and even at these temperatures the effect was not strong. Multiple factors, including forage preferences and landscape use by the ungulates, and favourable climatic conditions enabling effective compensatory growth of shrubs, may weaken the effects of ungulates on shrubs, possibly explaining the weakness of observed ungulate effects. Earlier local studies have shown that ungulates may counteract the impacts of warming on tundra shrub growth, but we demonstrate that ungulates’ potential to suppress shrub radial growth is not always evident, and may be limited to certain climatic conditions.Research Council of Norwayhttp://iopscience.iop.org/1748-9326dm2022Mammal Research InstituteZoology and Entomolog