Clinical course and prognostic factors across different musculoskeletal pain sites: A secondary analysis of individual patient data from randomised clinical trials

Background Previous research has identified similar prognostic factors in patients with musculoskeletal (MSK) conditions regardless of pain presentation, generating opportunities for management based on prognosis rather than specific pain presentation. Methods Data from seven RCTs (2483 participants) evaluating a range of primary care interventions for different MSK pain conditions were used to investigate the course of symptoms and explore similarities and differences in predictors of outcome. The value of pain site for predicting changes in pain and function was investigated and compared with that of age, gender, social class, pain duration, widespread pain and level of anxiety/depression. Results Over the initial three months of follow‐up, changes in mean pain intensity reflected an improvement, with little change occurring after this period. Participants with knee pain due to osteoarthritis (OA) showed poorer long‐term outcome (mean difference in pain reduction at 12 months −1.85, 95% CI −2.12 to −1.57, compared to low back pain). Increasing age, manual work, longer pain duration, widespread pain and increasing anxiety/depression scores were significantly associated with poorer outcome regardless of pain site. Testing of interactions showed some variation between pain sites, particularly for knee OA, where age, manual work and pain duration were most strongly associated with outcome. Conclusions Despite some differences in prognostic factors for trial participants with knee OA who were older and had more chronic conditions, similarity of outcome predictors across regional MSK pain sites provides evidence to support targeting of treatment based on prognostic factors rather than site of pain. Significance Individual patient data analysis of trials across different regional musculoskeletal pain sites was used to evaluate course and prognostic factors associated with pain and disability. Overall, similarity of outcome predictors across these different pain sites supports targeting of treatment based on prognostic factors rather than pain site alone

The associations of sedentary time and breaks in sedentary time with 24-hour glycaemic control in type 2 diabetes

The aim of this study was to investigate the associations of accelerometer-assessed sedentary time and breaks in sedentary time with 24-h events and duration of hypoglycaemia (7.8 mmol/l) and above target glucose (>9 mmol/l). Thirty-seven participants with type 2 diabetes (age, 62.8 ± 10.5 years; body mass index, 29.6 ± 6.8 kg/m2) in Glasgow, United Kingdom were enrolled between February 2016 and February 2017. Participants wore an activity monitor (activPAL3) recording the time and pattern of sedentary behaviour and a continuous glucose monitoring (CGM, Abbott FreeStyle Libre) for up to 14 days. Linear regression analyses were used to investigate the associations. Participants spent 3.7%, 64.7%, 32.1% and 19.2% of recording h/day in hypoglycaemia, euglycaemia, hyperglycaemia and above target, respectively. There was a negative association between sedentary time and time in euglycaemia (β = -0.44, 95% CI -0.86; -0.03, p = 0.04). There was a trend towards a positive association between sedentary time and time in hyperglycaemia (β = 0.36, 95% CI -0.05; 0.78, p = 0.08). Breaks in sedentary time was associated with higher time in euglycaemia (β = 0.38, 95% CI 0.00; 0.75, p = 0.04). To conclude, in individuals with type 2 diabetes, more time spent in unbroken and continuous sedentary behaviour was associated with poorer glucose control. Conversely, interrupting sedentary time with frequent breaks appears to improve glycaemic control. Therefore, this should be considered as a simple adjunct therapy to improve clinical outcomes in type 2 diabetes

Nets, Spray or Both? The Effectiveness of Insecticide-Treated Nets and Indoor Residual Spraying in Reducing Malaria Morbidity and Child Mortality in sub-Saharan Africa.

Malaria control programmes currently face the challenge of maintaining, as well as accelerating, the progress made against malaria with fewer resources and uncertain funding. There is a critical need to determine what combination of malaria interventions confers the greatest protection against malaria morbidity and child mortality under routine conditions. This study assesses intervention effectiveness experienced by children under the age of five exposed to both insecticide-treated nets (ITNs) and indoor residual spraying (IRS), as compared to each intervention alone, based on nationally representative survey data collected from 17 countries in sub-Saharan Africa. Living in households with both ITNs and IRS was associated with a significant risk reduction against parasitaemia in medium and high transmission areas, 53% (95% CI 37% to 67%) and 31% (95% CI 11% to 47%) respectively. For medium transmission areas, an additional 36% (95% CI 7% to 53%) protection was garnered by having both interventions compared with exposure to only ITNs or only IRS. Having both ITNs and IRS was not significantly more protective against parasitaemia than either intervention alone in low and high malaria transmission areas. In rural and urban areas, exposure to both interventions provided significant protection against parasitaemia, 57% (95% CI 48% to 65%) and 39% (95% CI 10% to 61%) respectively; however, this effect was not significantly greater than having a singular intervention. Statistically, risk for all-cause child mortality was not significantly reduced by having both ITNs and IRS, and no additional protectiveness was detected for having dual intervention coverage over a singular intervention. These findings suggest that greater reductions in malaria morbidity and health gains for children may be achieved with ITNs and IRS combined beyond the protection offered by IRS or ITNs alone

Serious bacterial infections and antibiotic prescribing in primary care: cohort study using electronic health records in the UK

Objective This study evaluated whether serious bacterial infections are more frequent at family practices with lower antibiotic prescribing rates. Design Cohort study. Setting 706 UK family practices in the Clinical Practice Research Datalink from 2002 to 2017. Participants 10.1 million registered patients with 69.3 million patient-years' follow-up. Exposures All antibiotic prescriptions, subgroups of acute and repeat antibiotic prescriptions, and proportion of antibiotic prescriptions associated with specific-coded indications. Main outcome measures First episodes of serious bacterial infections. Poisson models were fitted adjusting for age group, gender, comorbidity, deprivation, region and calendar year, with random intercepts representing family practice-specific estimates. Results The age-standardised antibiotic prescribing rate per 1000 patient-years increased from 2002 (male 423; female 621) to 2012 (male 530; female 842) before declining to 2017 (male 449; female 753). The median family practice had an antibiotic prescribing rate of 648 per 1000 patient-years with 95% range for different practices of 430-1038 antibiotic prescriptions per 1000 patient-years. Specific coded indications were recorded for 58% of antibiotic prescriptions at the median family practice, the 95% range at different family practices was from 10% to 75%. There were 139 759 first episodes of serious bacterial infection. After adjusting for covariates and the proportion of coded consultations, there was no evidence that serious bacterial infections were lower at family practices with higher total antibiotic prescribing. The adjusted rate ratio for 20% higher total antibiotic prescribing was 1.03, (95% CI 1.00 to 1.06, p=0.074). Conclusions We did not find population-level evidence that family practices with lower total antibiotic prescribing might have more frequent occurrence of serious bacterial infections overall. Improving the recording of infection episodes has potential to inform better antimicrobial stewardship in primary care.</p

Sparticle Spectra and LHC Signatures for Large Volume String Compactifications

We study the supersymmetric particle spectra and LHC collider observables for the large-volume string models with a fundamental scale of 10^{11} GeV that arise in moduli-fixed string compactifications with branes and fluxes. The presence of magnetic fluxes on the brane world volume, required for chirality, perturb the soft terms away from those previously computed in the dilute-flux limit. We use the difference in high-scale gauge couplings to estimate the magnitude of this perturbation and study the potential effects of the magnetic fluxes by generating many random spectra with the soft terms perturbed around the dilute flux limit. Even with a 40% variation in the high-scale soft terms the low-energy spectra take a clear and predictive form. The resulting spectra are broadly similar to those arising on the SPS1a slope, but more degenerate. In their minimal version the models predict the ratios of gaugino masses to be M_1 : M_2 : M_3=(1.5 - 2) : 2 : 6, different to both mSUGRA and mirage mediation. Among the scalars, the squarks tend to be lighter and the sleptons heavier than for comparable mSUGRA models. We generate 10 fb^{-1} of sample LHC data for the random spectra in order to study the range of collider phenomenology that can occur. We perform a detailed mass reconstruction on one example large-volume string model spectrum. 100 fb^{-1} of integrated luminosity is sufficient to discriminate the model from mSUGRA and aspects of the sparticle spectrum can be accurately reconstructed.Comment: 42 pages, 21 figures. Added references and discussion for section 3. Slight changes in the tex

SARS-CoV-2 positivity in asymptomatic-screened dental patients

Enhanced community surveillance is a key pillar of the public health response to COVID-19. Asymptomatic carriage of SARS-CoV-2 is a potentially significant source of transmission, yet remains relatively poorly understood. Disruption of dental services continues with significantly reduced capacity. Ongoing precautions include pre- and/or at appointment COVID-19 symptom screening and use of enhanced personal protective equipment (PPE). This study aimed to investigate SARS-CoV-2 infection in dental patients to inform community surveillance and improve understanding of risks in the dental setting. Thirty-one dental care centres across Scotland invited asymptomatic screened patients over 5-years-old to participate. Following verbal consent and completion of sociodemographic and symptom history questionnaire, trained dental teams took a combined oropharyngeal and nasal swab sample using standardised VTM-containing testkits. Samples were processed by the Lighthouse Lab and patients informed of their results by SMS/e-mail with appropriate self-isolation guidance in the event of a positive test. All positive cases were successfully followed up by the national contact tracing program. Over a 13-week period (from 3August to 31October2020) n=4,032 patients, largely representative of the population, were tested. Of these n=22 (0.5%; 95%CI 0.5%, 0.8%) tested positive for SARS-CoV-2. The positivity rate increased over the period, commensurate with uptick in community prevalence identified across all national testing monitoring data streams. To the best of our knowledge this is the first report of a COVID-19 testing survey in asymptomatic-screened patients presenting in a dental setting. The positivity rate in this patient group reflects the underlying prevalence in community at the time. These data are a salient reminder, particularly when community infection levels are rising, of the importance of appropriate ongoing Infection Prevention Control and PPE vigilance, which is relevant as healthcare team fatigue increases as the pandemic continues. Dental settings are a valuable location for public health surveillance

Linking Relief and Development: A Case Study of Botswana

Summary During the prolonged drought in Botswana in the 1980s, the government launched a large?scale drought relief programme (DRP). It successfully prevented famine, but its performance in terms of linking relief and development was mixed. Institutionally, Botswana succeeded in integrating the administration of the DRP into existing government structures. The DRP attempted to meet both welfare needs and long term development goals. It met the first objective most successfully by expanding existing welfare systems. The second objective was harder to achieve: on the public works programme, relief and development objectives sometimes conflicted; and the design of some components of the agricultural relief programme proved to be at odds with longer term development interests. The DRP also masked underlying structural problems of rural poverty. Although Botswana is a ‘special case’, lessons can be learned from its experience for other African countries. Resumé Allier l'aide d'urgence au développement: une étude de cas au Botswana Durant la sécheresse prolongée qui s'est produite au Botswana durant les années 1980, le gouvernement a instauré un programme de grande envergure pour aide d'urgence pour lutter contre la sécheresse – le programme DRP. Ce programme a effectivement empêché la famine; or sa performance en termes des liens éventuels entre l'aide d'urgence et le développement laissait à désirer. Au niveau des institutions, le Botswana a pourtant réussi à intégrer l'administration du DRP dans les structures gouvernementales existantes. Le programme DRP visait à répondre, dans un même temps, aux besoins en aide sociale et à des objectifs à plus long terme. Le DRP rencontra un très grand succès relatif au premier de ses objectifs grâce à l'expansion des services d'aide sociale existants. Il fut par contre plus difficile de réaliser le deuxième objectif: car parfois, dans les programmes de travaux publics, les objectifs d'aide d'urgence et de développement s'entravaient réciproquement; la conception de certains éléments du programme d'aide d'urgence agricole faussait même certains aspects du développement à plus long terme. Le programme DRP cachait également certains problèmes d'ordre structurel qui relevaient de la pauvreté rurale. Bien que le Botswana ait été un “cas spécial”, son expérience offre néanmoins certaines leçons aux autres pays de l'Afrique. Resumen La relación asistencia?desarrollo: el caso Botswana En el curso de la prolongado sequía de los años 80 en Botswana, el gobierno lanzó un programa de ayuda (DRP) de gran envergadura. Este programa evitó exitosamente una hambruna general, pero en cuanto al establecimiento de la relación asistencia?desarrollo, los resultados no fueron tan positivos. Institucionalmente, Botswana consiguió integrar la administración del DRP dentro de estructuras gubernamentales existentes. El DRP intentó satisfacer tanto las necesidades de asistencia social como las metas de desarrollo a largo plazo. El primer objetivo fue alcanzado con la expansión de los sistemas de asistencia social existentes. El segundo objetivo fue más difícil de alcanzar: en el programa de obras públicas se encontró que los objetivos de asistencia y desarrollo eran a veces opuestos; algunos componentes del programa de asistencia a la agricultura chocaban con los intereses desarrollistas a largo plazo. El DRP también escondía problemas estructurales subyacentes de probreza rural. Aunque Botswana es un ‘caso especial’, es útil para otros países africanos tener en cuenta su experiencia

Estimating high risk cannabis and opiate use in Ankara, Istanbul and Izmir

Aims. Information on high risk drug use in Turkey particularly at the regional level is lacking. The present analysis aims at estimating high risk cannabis (HRCU) and high risk opiate use (HROU) in the cities of Ankara, Istanbul and Izmir. Design and Methods. Capture-recapture (CRC) and multiplier methods (MM) were applied based on treatment and police data stratified by age and gender in the years 2009 and 2010. Case definitions refer to ICD-10 cannabis (F.12) and opiate (F.11) disorder diagnoses from out- and inpatient treatment records and illegal possession of these drugs as recorded by the police. Results. HRCU was estimated at 28,500 (8.5 per 1,000; 95%-CI: 7.3-10.3) and 33,400 (11.9 per 1,000; 95%-CI: 10.7-13.5) in Ankara and Izmir, respectively. Using multipliers based on CRC estimates for Izmir, HRCU in Istanbul was estimated up to 166,000 (18.0 per 1,000; range: 2.8-18.0). CRC estimates of HROU resulted in 4,800 (1.4 per 1,000; 95% CI: 0.9-1.9) in Ankara and multipliers based on these gave estimates up to 20,000 (2.2 per 1,000; range: 0.9-1-7) in Istanbul. HROU in Izmir was not estimated due to the low absolute numbers of opiate users. Discussion and Conclusions. While HRCU prevalence in both Ankara and Izmir was considerably lower in comparison to an estimate for Berlin, the rate for Istanbul was only slightly lower. Compared to the majority of European cities HROU in these three Turkish cities may be considered rather low

IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT) : cluster randomised controlled trial study protocol

Background: Evidence generated from reliable research is not frequently implemented into clinical practice. Evidence-based clinical practice guidelines are a potential vehicle to achieve this. A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines. Recommendations from this review, and other studies, have suggested the use of interventions that are theoretically based because these may be more effective than those that are not. An evidencebased clinical practice guideline for the management of acute low back pain was recently developed in Australia. This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common, has a high burden, and for which there is an evidence-practice gap in the primary care setting. Aim: This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria, Australia. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray, and improving mean level of disability for patients three months post-consultation. Methods/Design: This study protocol describes the details of a cluster randomised controlled trial. Ninety-two general practices (clusters), which include at least one consenting general practitioner, will be randomised to an intervention or control arm using restricted randomisation. Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion. An average of twenty-five patients per general practice will be recruited, providing a total of 2,300 patient participants. General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy. Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory. Investigators (not involved in the delivery of the intervention), patients, outcome assessors and the study statistician will be blinded to group allocation. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN012606000098538 (date registered 14/03/2006).The trial is funded by the NHMRC by way of a Primary Health Care Project Grant (334060). JF has 50% of her time funded by the Chief Scientist Office3/2006). of the Scottish Government Health Directorate and 50% by the University of Aberdeen. PK is supported by a NHMRC Health Professional Fellowship (384366) and RB by a NHMRC Practitioner Fellowship (334010). JG holds a Canada Research Chair in Health Knowledge Transfer and Uptake. All other authors are funded by their own institutions