Facet joint injections for people with persistent non-specific low back pain (Facet injection study) : A feasibility study for a randomised controlled trial

All NIHR Journals Library reports have been produced under the terms of a commissioning contract issued by the Secretary of State for Health. Reports may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Permission to reproduce material from a published report is covered by the UK government’s non-commercial licence for public sector information. Applications for commercial reproduction should be addressed to the editorial office at: [email protected]: The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. Objectives: To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. Design: The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. Setting: Five NHS acute trusts in England. Participants: Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with ‘best usual care’ (BUC) or BUC alone. Interventions: All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. Main outcome measures: Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. Results: Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. Limitations: Poor recruitment was a limiting factor. Conclusions: This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain.Peer reviewe

Farlige tegn fra gudene -en studie av haruspicene i den romerske senrepublikk

Til tross for at romersk historie har vært grundig studert i mange år, er likevel haruspicene et presteskap som har blitt oversett i mange studier. Deres posisjon i den offentlige religion er på mange måter spesiell. Ikke bare er de opprinnelig et utenlandsk presteskap, men deres manglende tilknytning til den politiske elite er også særegent i et romersk-religiøst perspektiv. Kildematerialet forteller oss lite om detaljene rundt deres organisering, divinasjonsmetoder og rolle i den romerske divinasjon. Prosjektet har som formål å oppklare noen av de problematiske forhold knyttet til haruspicene. Haruspicene er i denne sammenheng belyst ut i fra to ulike perspektiver. Det første viser haruspicene som en egen gruppe religiøse spesialister, deres kunnskap, divinasjonsmetoder og organisering. Det andre belyser haruspicenes virke i en bredere religiøs kontekst, hvor relasjoner og strukturer knyttet til divinasjon blir nærmere analysert. Dette åpner for en mer utfyllende forståelse av haruspicene i den romerske religion

Uncovering key transcription factors in breast cancer subtypes using matrix factorization

Breast cancer is the most common cancer type in women, and response to treatment varies immensely between subtypes. As of today, patients with Basal- like breast cancer lacks targeted treatment, which leads to poor prognosis for this group. Also other subtypes could benefit from a more targeted treatment. The molecular characteristics of each subtype remains an active area of research, and transcription factors that drive the subtypes need to be investigated in order to provide potential targets for more effective treatments. The molecular characteristics of each breast cancer subtype were inferred from ATAC-seq and RNA-seq data from 70 breast cancer patients, using two different matrix factorization methods. The first analysis used non-negative matrix factorization (NMF) on two separate data sets: One for ATAC-seq data, and one for RNA-seq data. The samples were clustered into five groups, based on molecular patterns shared within the groups, for both data sets. The DNA regions that were specifically open for each group were investigated for enriched transcription factor binding sites. The same was done for the promoter regions of the genes that were highly expressed in each group. The Basal-like subtype achieved the most successful clustering, and transcription factors likely to drive this subtype were uncovered. Also transcription factors responsible for driving a collective group of estrogen positive (ER+) subtypes were uncovered. The second analysis used Multi-Omics Factor Analysis (MOFA) to integrate the ATAC-seq and RNA-seq data in one combined analysis. The main purpose of this analysis was to support the findings of the first analysis, and possibly improve the clustering. The integration of multi- omics data resulted in two clusters, separating the Basal-like subtype from the rest of the subtypes. The clustering was not improved. However, some of the key transcription factors found for each group supported the results of the NMF analysis

Deteksjon av viktige transkripsjonsfaktorer i ulike subtyper av brystkreft ved bruk av matrisefaktorisering

Breast cancer is the most common cancer type in women, and response to treatment varies immensely between subtypes. As of today, patients with Basal- like breast cancer lacks targeted treatment, which leads to poor prognosis for this group. Also other subtypes could benefit from a more targeted treatment. The molecular characteristics of each subtype remains an active area of research, and transcription factors that drive the subtypes need to be investigated in order to provide potential targets for more effective treatments. The molecular characteristics of each breast cancer subtype were inferred from ATAC-seq and RNA-seq data from 70 breast cancer patients, using two different matrix factorization methods. The first analysis used non-negative matrix factorization (NMF) on two separate data sets: One for ATAC-seq data, and one for RNA-seq data. The samples were clustered into five groups, based on molecular patterns shared within the groups, for both data sets. The DNA regions that were specifically open for each group were investigated for enriched transcription factor binding sites. The same was done for the promoter regions of the genes that were highly expressed in each group. The Basal-like subtype achieved the most successful clustering, and transcription factors likely to drive this subtype were uncovered. Also transcription factors responsible for driving a collective group of estrogen positive (ER+) subtypes were uncovered. The second analysis used Multi-Omics Factor Analysis (MOFA) to integrate the ATAC-seq and RNA-seq data in one combined analysis. The main purpose of this analysis was to support the findings of the first analysis, and possibly improve the clustering. The integration of multi- omics data resulted in two clusters, separating the Basal-like subtype from the rest of the subtypes. The clustering was not improved. However, some of the key transcription factors found for each group supported the results of the NMF analysis.Brystkreft er den krefttypen som rammer flest kvinner, og effekten pasienter har av behandling er svært avhengig av subtype. Fortsatt mangler pasienter med Basal brystkreft behandlingsalternativer som er målrettet mot denne subtypen, og prognosen er derfor dårlig for disse pasientene. Også pasienter med andre subtyper kunne ha dratt nytte av mer målrettet behandling. De molekylære egenskapene som kjennetegner hver subtype er et felt det forskes mye på, og transkripsjonsfaktorer som kan være viktige for hver av disse subtypene må undersøkes som potensielle mål for behandling. De molekylære egenskapene som kjennetegner de ulike subtypene ble funnet fra RNA-seq og ATAC-seq data fra 70 brystkreftpasienter, ved bruk av to ulike matrisefaktoriseringsteknikker. Den første analysen brukte ikke-negativ matrisefaktorisering (NMF) på to ulike datasett: Ett for ATAC-seq data, og ett for RNA-seq data. Prøvene ble gruppert i fem grupper, basert på de molekylære mønstrene som var felles for hver gruppe, for hvert datasett. DNA-regionene som var spesifikt åpne for hver gruppe ble undersøkt for å finne transkripsjonsfaktorbindingssetene som opptrådte oftest for hver gruppe. Det samme ble gjort for promoter-regionene til genene som var høyest uttrykt i hver gruppe. Den beste seperasjonen ble oppnådd for den Basale subtypen, og for denne gruppen ble det funnet en rekke transkripsjonsfaktorer som trolig er viktige. Det ble også funnet transkripsjonsfaktorer som kan være viktige i subtyper som er drevet av østrogenreseptorer (ER+). Den andre analysen brukte «multi-omics» faktoranalyse (MOFA) for å integrere ATAC-seq og RNAseq data i en kombinert analyse. Hovedmålet med denne analysen var å understøtte funnene fra den første analysen, og å forbedre grupperingene om mulig. Integreringen av «multi-omics» data resulterte i to grupper, som separerte den Basale subtypen fra resten av subtypene. Grupperingene ble ikke forbedret. Likevel kunne noen av transkripsjonsfaktorene som ble funnet for hver gruppe brukes til å støtte opp om resultatene fra NMF-analysen.M-BIA

Validation of World Health Organization Assessment Schedule 2.0 in specialized somatic rehabilitation services in Norway

Purpose The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 is a generic instrument to assess disability covering six domains. The purpose of this study was to investigate the potential of the instrument for monitoring disability in specialized somatic rehabilitation by testing reliability, construct validity and responsiveness of WHODAS 2.0, Norwegian version, among patients with various health conditions. Methods For taxonomy, terminology and definitions, the Consensus-based Standards for the Selection of Health Measurement Instruments were followed. Reproducibility was investigated by the intra-class correlation coefficient (ICC) in a randomly selected sample. Internal consistency was assessed by Cronbach’s alpha. Construct validity was evaluated by correlations between WHODAS 2.0 and the Medical Outcomes Study 36-item Short Form, and fit of the hypothesized structure using confirmatory factor analysis (CFA). Responsiveness was evaluated in another randomly selected sample by testing a priori formulated hypotheses. Results Nine hundred seventy patients were included in the study. Reproducibility and responsiveness were evaluated in 53 and 104 patients, respectively. The ICC for the WHODAS 2.0 domains ranged from 0.63 to 0.84 and was 0.87 for total score. Cronbach’s alpha for domains ranged from 0.75 to 0.94 and was 0.93 for total score. For construct validity, 6 of 12 expected correlations were confirmed and CFA did not achieve satisfactory fit indices. For responsiveness, 3 of 8 hypotheses were confirmed. Conclusion The Norwegian version of WHODAS 2.0 showed moderate to satisfactory reliability and moderate validity in rehabilitation patients. However, the present study indicated possible limitations in terms of responsiveness

A qualitative study exploring contributors to the success of a community of practice in rehabilitation

Background Communities of Practice (CoPs) focus on learning, knowledge sharing, and creation, and research indicates they can improve healthcare performance. This article describes the development of a CoP that focused on synthesizing and adapting evidence in Physical Medicine and Rehabilitation (PM&R). This study aimed to investigate the CoP members’ experiences and perceived barriers and enablers of CoP success in the early phase of a CoP. Methods Physical therapists and a physician (n = 10) volunteered for a CoP that synthesized literature of PM&R evidence. CoP members participated in education and training on critical appraisal and knowledge synthesis, practiced critical appraisal skills, and summarized literature. Three months after CoP initiation, semi-structured interviews were conducted to understand the CoP members’ experiences and reflections. Members also completed an online survey that included the Evidence-Based Practice Confidence scale (EPIC), questions related to CoP activities, and demographics before CoP initiation. We utilized the Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to explore how these experiences related to the behavioral adaptation and participation. Results Ten themes related to the potential contributors to CoP success and failure were identified. These included project management, technological solutions, efficacy, organizational support, interaction, the bigger picture, self-development, time, and motivation. Conclusions Contributors to CoP success may include clearly articulated project goals and participant expectations, education and training, reliable technology solutions, organizational support, face-to-face communication, and good project management. Importantly, CoP members need time to participate in activities

Development of a Framework Identifying Domains and Elements of Importance for Arthritis Rehabilitation

Background: Rehabilitation is effective and beneficial for patients with arthritis. The lack of a common structure for describing the content of rehabilitation makes it difficult to compare, transfer and implement research evidence into clinical practice. Objective: To develop a framework comprising domains and elements of importance when describing arthritis rehabilitation. Methods: On the basis of a systematic literature search and review, the framework was developed through a 9-step development process, including 5 Delphi consensus rounds within the Scandinavian Team Arthritis Register - European Team Initiative for Care Research (STAR-ETIC) collaboration, a group of clinicians, researchers and patients from northern Europe. Results: Based on Donabedian's healthcare model, the International Classification of Function, Disability and Health, and a rehabilitation model by D. T. Wade, 4 domains (context, structure, process and outcome) were defined. Within each domain, the most important and relevant key elements for describing rehabilitation were selected. This framework contains 1 key element under context, 9 under structure, 3 under process, and 9 under outcome. Conclusion: The STAR-ETIC framework can be used to describe arthritis rehabilitation, by emphasizing key elements in 4 main domains. A common framework may facilitate comparisons of rehabilitation programmes across countries and different levels of care, and may improve the implementation of rehabilitation research in clinical practice