LIFESTYLE INTERVENTIONS TO SUPPORT PEOPLE WITH CHRONIC NON-SPECIFIC LOW BACK PAIN

The broad aim of this thesis was to investigate the health and lifestyle factors influencing health care utilisation for low back pain, and to examine the role of psychological interventions (including lifestyle interventions) for improving health outcomes and/or reducing health service utilisation in people with chronic non-specific low back pain. To address the broad aim, the studies included in this thesis were conducted and organised according to three aims: (i) to identify health and lifestyle factors associated with patients seeking care for low back pain, (ii) to investigate the comparative effectiveness and safety of psychological interventions for improving health outcomes in patients with chronic low back pain, and (iii) to evaluate the effectiveness of introducing a lifestyle intervention, involving health coaching, into the discharge care pathway for patients with low back pain to reduce the use of health services for low back pain and improve health outcomes. Chapter One provided an overview of current literature related to the epidemiology and global patterns of health care utilisation for low back pain, as well as an introduction to the relevance of lifestyle interventions for improving health outcomes in people with chronic non-specific low back pain. Chapters Two and Three addressed the first aim. Chapter Two investigated the relationship between various anthropometric, sociodemographic, health, and lifestyle factors, and the use of medical care for chronic non-specific low back pain. A co-twin case-control design was used to adjust for the potential confounding influence of aggregated familial factors (e.g., genetics and the early shared environment) on the relationship between these factors and the use of medical care for chronic non-specific low back pain. Poor sleep quality was identified as the only factor associated with seeking medical care for low back pain in the long term, with the relationship being independent of aggregated familial factors. Chapter Three examined the relationship between different intensities, volumes, and/or domains of physical activity and sedentary behaviour, on various care-seeking behaviours for low back pain. The study in Chapter Three discovered that different intensities, volumes, and/or domains of physical activity and sedentary behaviour, at baseline, have different effects on varying patterns of health care utilisation for low back pain. Specifically, engagement in medium-to-high volumes of household domain physical activity at baseline significantly increases the risk of the overall utilisation of care, and the utilisation of self-management strategies, for low back pain over one year. Further, people who engage in medium-to-high volumes of physically demanding tasks at work at baseline utilise more overall care for low back pain, whilst people who engage in medium-to-high volumes of sedentary behaviour at baseline utilise more self-management strategies for low back pain, over a one-year period. In contrast, engagement in medium-to-high volumes of moderate-to-vigorous intensity physical activity appears to halve the risk of overall care utilisation for low back pain. No physical activity or sedentary behaviour variables demonstrated any significant associations with the utilisation of health services for low back pain. Chapters Four and Five addressed the second aim. Chapter Four described the protocol of a systematic review including a network meta-analysis of psychological interventions for chronic non-specific low back pain. The primary outcomes were patients’ physical function and pain intensity, and the secondary outcomes were fear avoidance, health-related quality of life and intervention compliance, and safety. The results of the systematic review and meta-analysis are presented in Chapter Five. In total, 97 randomised controlled trials involving 13,136 participants and 17 treatment nodes were included. Results of the network meta-analysis demonstrated that compared with physiotherapy care alone (mainly structured exercise), pain education programs delivered with physiotherapy care (mainly structured exercise) offer the most sustainable effects of treatment for physical function and fear avoidance. Differently, behavioural therapy delivered with physiotherapy care (mainly structured exercise) results in the most sustainable effects of treatment for pain intensity. There is uncertainty surrounding their long-term effectiveness (12 months post-intervention) because of a lack of studies with long-term follow-up periods. However, limited but consistent evidence suggests psychological interventions are safe for people with chronic non-specific low back pain, given that the occurrence of adverse events related to the intervention is rare (i.e., only reported in three of 20 studies). Even when reported, the adverse events are not considered serious in nature. The review also confirmed a prevailing lack of high-quality randomised clinical trials investigating the effectiveness of mindfulness-based interventions (i.e., mindfulness-based stress reduction), and counselling-based interventions (i.e., lifestyle interventions) for this population. Building on the evidence gaps identified in Chapters Four and Five, Chapters Six, Seven, and Eight addressed the final aim of this thesis. Chapter Six described the protocol of a randomised controlled trial designed to evaluate the effectiveness of introducing a support system, involving a lifestyle intervention (i.e., a health coaching program), into the discharge care pathway for patients with chronic non-specific low back pain (Get Back to Healthy trial). The comparison intervention is usual care provided at discharge from treatment, and the primary outcome is the use of health services for low back pain, over one year. The trial will recruit 374 adults in Australia. However, the unprecedented COVID-19 pandemic has caused significant delays in the progress of the trial. Disruptions to recruitment and data collection have precluded the completion of an additional study, which was intended for inclusion in this thesis. The proposed study was designed to investigate the joint association between physical activity and sleep on various care-seeking behaviours for low back pain. In the absence of sufficient data to complete the proposed study, Chapter Seven reports on the progress made during the early implementation phase of the trial, summarises preliminary findings to date, and describes the intended interim statistical analysis plan. To conclude, Chapter Eight provides a narrative summary of the specific challenges and key lessons learned during the implementation of the Get Back to Healthy trial, described in Chapter Six. Chapter Eight aimed to bring greater awareness to the complexity of conducting a large, pragmatic, multi-site randomised clinical trial of a lifestyle intervention, delivered by an established public health service, during a global pandemic. Practical recommendations to improve the conduct and implementation of clinical trials, in any context in the future, are presented in this chapter. Finally, Chapter Nine summarised the key findings, clinical implications, and strengths and limitations of this thesis, and also provided recommendations for future research

Selection of reference genes for quantitative real-time PCR normalization in Ganoderma-infected oil palm (Elaies guineensis) seedlings

African oil palm (Elaeis guineensis) is an important oil bearing tree commercially cultivated in Malaysia. Palm oil is an important product for local consumption, provides enormous socio-economic benefits of trade and employment opportunities, and fulfilling the growing global demand for vegetable oils. The monoculture system has fostered the outbreak of basal stem rot (BSR) disease caused by the fungus Ganoderma boninense. Quantitative real-time PCR (qRT-PCR) is a widely used molecular technique to examine the infection effect on gene expression in oil palm. The selection of appropriate reference genes is vital for accurate data normalization. In this study, the expression stability of six housekeeping genes- β-actin, cyclophilin, GAPDH, MSD, NAD and ubiquitin were validated in oil palm root tissue after fungal infection. NormFinder and BestKeeper algorithms were used to cross-validate the expression stability of the candidate reference genes. MSD, NAD and ubiquitin were shown to exhibit the highest expression stability. These genes were recommended as reference genes for gene expression studies of oil palm root tissue at early fungal infection stage

Expression and functional characterization of the putative protein 8b of the severe acute respiratory syndrome-associated coronavirus

AbstractSARS 8b is one of the putative accessory proteins of the severe acute respiratory syndrome-associated coronavirus (SARS-CoV) with unknown functions. In this study, the cellular localization and activity of this estimated 9.6kDa protein were examined. Confocal microscopy results indicated that SARS 8b is localized in both nucleus and cytoplasm of mammalian cells. Functional study revealed that overexpression of SARS 8b induced DNA synthesis. Coexpression of SARS 8b and SARS 6, a previously characterized SARS-CoV accessory protein, did not elicit synergistic effects on DNA synthesis

Cloning of nitric oxide associated 1 (NOA1) transcript from oil palm (Elaeis guineensis) and its expression during Ganoderma infection

Nitric oxide associated 1 (NOA1) protein is implicated in plant disease resistance and nitric oxide (NO) biosynthesis. A full-length cDNA encoding of NOA1 protein from oil palm (Elaeis guineensis) was isolated and designated as EgNOA1. Sequence analysis suggested that EgNOA1 was a circular permutated GTPase with high similarity to the bacterial YqeH protein of the YawG/YlqF family. The gene expression of EgNOA1 and NO production in oil palm root tissues treated with Ganoderma boninense, the causal agent of basal stem rot (BSR) disease were profiled to investigate the involvement of EgNOA1 during fungal infection and association with NO biosynthesis. Real-time PCR (qPCR) analysis revealed that the transcript abundance of EgNOA1 in root tissues was increased by G. boninense treatment. NO burst in Ganoderma-treated root tissue was detected using Griess reagent, in advance of the up-regulation of the EgNOA1 transcript. This indicates that NO production was independent of EgNOA1. However, the induced expression of EgNOA1 in Ganoderma-treated root tissues implies that it might be involved in plant defense responses against pathogen infection

Sex-based differences in risk of ischaemic stroke or systemic embolism after BNT162b2 or CoronaVac COVID-19 vaccination in patients with atrial fibrillation: a self-controlled case series and nested case-control study

AIMS: Patients with atrial fibrillation (AF) have a higher risk of ischemic stroke or systemic embolism with a greater risk for female patients. This study aims to evaluate the risk of ischemic stroke or systemic embolism and bleeding following COVID-19 vaccination in patients with AF and the sex differences. METHODS AND RESULTS: Self-controlled case series (SCCS) analysis was conducted to evaluate the risk of ischemic stroke or systemic embolism and bleeding following BNT162b2 or CoronaVac in patients with AF, using the territory-wide electronic medical records from the Hospital Authority and vaccination records from the Department of Health in Hong Kong. Patients with a primary diagnosis of ischemic stroke or systemic embolism or bleeding in the inpatient setting between February 23, 2021 and March 31, 2022 were included. A nested case-control analysis was also conducted with each case randomly matched with ten controls according to sex, age, Charlson comorbidity index and date of hospital admission. Conditional Poisson regression was used in the SCCS analysis and conditional logistic regression was used in nested case-control analysis to assess the risks and all analyses were stratified by sex and type of vaccines. Among 51 158 patients with AF, we identified an increased risk of ischemic stroke or systemic embolism after the first dose of BNT162b2 in SCCS analysis during 0-13 days (incidence rate ratio 6.60[95% CI 1.51-28.77]) and 14-27 days (6.53[95% CI 1.31-32.51]), and nested case-control analysis during 0-13 days (adjusted odds ratio 6.21 [95% CI 1.14-33.91]) and 14-27 days (5.52 [95% CI 1.12-27.26]) only in female patients. The increased risk in female patients following the first dose of CoronaVac was only detected during 0-13 days (3.88 [95% CI 1.67-9.03]) in the nested case-control analysis. No increased risk of ischemic stroke or systemic embolism was identified in male patients and no increased risk of bleeding was detected in all patients with AF for both vaccines. An increased risk of ischemic stroke or systemic embolism after COVID-19 was also observed in both females (17.42 [95% CI 5.08-59.73]) and males (6.63 [95% CI 2.02-21.79]). CONCLUSIONS: The risk of ischemic stroke or systemic embolism after COVID-19 vaccination was only increased in female patients with AF. However, as the risk after COVID-19 was even higher, proactive uptake of COVID-19 vaccines is recommended to prevent the potential severe outcomes after infection

Efficacy, safety and immunogenicity of a human rotavirus vaccine (RIX4414) in Hong Kong children up to three years of age: A randomized, controlled trial

AbstractBackgroundA phase III, double-blind, randomized, controlled trial was conducted in Hong Kong to evaluate the efficacy, safety and immunogenicity of a human rotavirus vaccine, RIX4414 (Rotarix™) against severe rotavirus gastroenteritis in children up to three years of age.MethodsHealthy infants aged 6–12 weeks were enrolled between 08-December-2003 and 31-August-2005 and received two oral doses of either RIX4414 vaccine (N=1513) or placebo (N=1512) given 2 months apart. Vaccine efficacy was assessed from two weeks post-Dose 2 until the children were two and three years of age. Anti-rotavirus IgA seroconversion rate was calculated pre-vaccination and 1–2 months post-Dose 2 using ELISA (cut-off=20U/mL) for 100 infants. Safety was assessed until the children were two years of age; serious adverse events (SAEs) were recorded throughout the study period.ResultsIn children aged two and three years of life, vaccine efficacy against severe rotavirus gastroenteritis was 95.6% (95% CI: 73.1%–99.9%) and 96.1% (95% CI: 76.5%–99.9%), respectively. The seroconversion rate 1–2 months after the second dose of RIX4414 was 97.5% (95% CI: 86.8%–99.9%). At least one SAE was recorded in 439 and 477 infants who were administered RIX4414 and placebo, respectively (p-value=0.130). Six intussusception cases were reported (RIX4414=4; placebo=2) and none was assessed to be vaccine-related.ConclusionRIX4414 was efficacious, immunogenic and safe in the prevention of rotavirus gastroenteritis for at least two years post-vaccination in Hong Kong children

Towards a global partnership model in interprofessional education for cross-sector problem-solving

Objectives A partnership model in interprofessional education (IPE) is important in promoting a sense of global citizenship while preparing students for cross-sector problem-solving. However, the literature remains scant in providing useful guidance for the development of an IPE programme co-implemented by external partners. In this pioneering study, we describe the processes of forging global partnerships in co-implementing IPE and evaluate the programme in light of the preliminary data available. Methods This study is generally quantitative. We collected data from a total of 747 health and social care students from four higher education institutions. We utilized a descriptive narrative format and a quantitative design to present our experiences of running IPE with external partners and performed independent t-tests and analysis of variance to examine pretest and posttest mean differences in students’ data. Results We identified factors in establishing a cross-institutional IPE programme. These factors include complementarity of expertise, mutual benefits, internet connectivity, interactivity of design, and time difference. We found significant pretest–posttest differences in students’ readiness for interprofessional learning (teamwork and collaboration, positive professional identity, roles, and responsibilities). We also found a significant decrease in students’ social interaction anxiety after the IPE simulation. Conclusions The narrative of our experiences described in this manuscript could be considered by higher education institutions seeking to forge meaningful external partnerships in their effort to establish interprofessional global health education

Sex-based differences in risk of ischaemic stroke or systemic embolism after BNT162b2 or CoronaVac COVID-19 vaccination in patients with atrial fibrillation: a self-controlled case series and nested case-control study

AimsPatients with atrial fibrillation (AF) have a higher risk of ischaemic stroke or systemic embolism, with a greater risk for female patients. This study aims to evaluate the risk of ischaemic stroke or systemic embolism and bleeding following COVID-19 vaccination in patients with AF and the sex differences.Methods and resultsSelf-controlled case series (SCCS) analysis was conducted to evaluate the risk of ischaemic stroke or systemic embolism and bleeding following BNT162b2 or CoronaVac in patients with AF, using the territory-wide electronic medical records from the Hospital Authority and vaccination records from the Department of Health in Hong Kong. Patients with a primary diagnosis of ischaemic stroke, systemic embolism, or bleeding in the inpatient setting between 23 February 2021 and 31 March 2022 were included. A nested case-control analysis was also conducted with each case randomly matched with 10 controls according to sex, age, Charlson comorbidity index, and date of hospital admission. Conditional Poisson regression was used in the SCCS analysis, and conditional logistic regression was used in the nested case-control analysis to assess the risks, and all analyses were stratified by sex and type of vaccines. Among 51 158 patients with AF, we identified an increased risk of ischaemic stroke or systemic embolism after the first dose of BNT162b2 in SCCS analysis during 0-13 days [incidence rate ratio 6.60, 95% confidence interval (CI) 1.51-28.77] and 14-27 days (6.53, 95% CI 1.31-32.51), and nested case-control analysis during 0-13 days (adjusted odds ratio 6.21, 95% CI 1.14-33.91) and 14-27 days (5.52, 95% CI 1.12-27.26) only in female patients. The increased risk in female patients following the first dose of CoronaVac was only detected during 0-13 days (3.88, 95% CI 1.67-9.03) in the nested case-control analysis. No increased risk of ischaemic stroke or systemic embolism was identified in male patients, and no increased risk of bleeding was detected in all patients with AF for both vaccines. An increased risk of ischaemic stroke or systemic embolism after COVID-19 was also observed in both females (17.42, 95% CI 5.08-59.73) and males (6.63, 95% CI 2.02-21.79).ConclusionsThe risk of ischaemic stroke or systemic embolism after COVID-19 vaccination was only increased in female patients with AF. However, as the risk after COVID-19 was even higher, proactive uptake of COVID-19 vaccines is recommended to prevent the potential severe outcomes after infection