Which treatment for low back pain? A factorial randomised controlled trial comparing intravenous analgesics with oral analgesics in the emergency department and a centrally acting muscle relaxant with placebo over three days [ISRCTN09719705]

BACKGROUND: About two thirds of adults suffer from backpain at some time during their life. In the emergency room many patients with acute back pain are treated with intravenous non-steroidal analgesics. Whether this treatment is superior to oral administration of non-steroidal analgesics is unknown. Intravenous administration, however, requires considerable amounts of resources and accounts for high workload in busy clinics. In the further course centrally acting muscle relaxants are prescribed but the effectiveness remains unclear. The objective of this study is on the one hand to compare the effectiveness of intravenous with oral non-steroidal analgesics for acute treatment and on the other hand to compare the effectiveness of a centrally active muscle relaxant with placebo given for three days after presentation to the ED (emergency department). METHODS/DESIGN: This study is intended as a randomised controlled factorial trial mainly for two reasons: (1) the sequence of treatments resembles the actual proceedings in every-day clinical practice, which is important for the generalisability of the results and (2) this design allows to take interactions between the two sequential treatment strategies into account. There is a patient preference arm included because patients preference is an important issue providing valuable information: (1) it allows to assess the interaction between desired treatment and outcome, (2) results can be extrapolated to a wider group while (3) conserving the advantages of a fully randomised controlled trial. CONCLUSION: We hope to shed more light on the effectiveness of treatment modalities available for acute low back pain

Determinants of physical activity behaviour in patients with chronic obstructive pulmonary disease

Background: Although physical activity is key to improve prognosis in patients with chronic obstructive pulmonary disease (COPD), information to tailor interventions individually is still required. This thesis aims to understand physical activity progression and explore its determinants in COPD patients. Methods: We used baseline and 12-month data from 643 COPD patients with stable mild-to very severe disease from two European multicenter studies. We assessed: physical activity (Dynaport MoveMonitor), physical activity experience (Clinical visit-PROactive physical activity in COPD [C-PPAC]), functional exercise capacity (6-minutes walk distance [6MWD]), as well as sociodemographic, interpersonal, environmental, clinical and psychological variables. Results: (1) The natural progression in physical activity over time was heterogeneous and three distinct patterns could be identified: Inactive, Active Improvers and Active Decliners. While Inactive patients related to worse scores for clinical COPD characteristics, Active Improvers and Decliners could not be predicted at baseline; (2) Higher population density and long-term NO2 exposure were associated with lower physical activity, while a steeper slope of the terrain related to better exercise capacity; (3) twelve-month completion of a behavioral physical activity intervention was determined by previous physical activity habits as well as interpersonal and environmental facilitators, while response to the intervention was related to diverse factors associated with motivation to change to an active lifestyle. Conclusions: This thesis shows that the natural progression of physical activity in COPD patients is heterogeneous and highlights that environmental, interpersonal and psychological factors are important determinants of physical activity behaviour in COPD patients, beyond clinical factors.Antecedentes: Aunque la actividad física es clave para mejorar el pronóstico en pacientes con enfermedad pulmonar obstructiva crónica (EPOC), todavía no se dispone de información que permita adaptar las intervenciones de manera individualizada. El objetivo de la presente tesis es comprender la progresión de la actividad física y explorar sus determinantes en pacientes con EPOC. Métodos: Utilizamos datos basales y de seguimiento (12 meses) de 643 pacientes con EPOC estable de estadio leve a muy grave, procedentes de dos estudios europeos multicéntricos. Evaluamos: actividad física (Dynaport MoveMonitor), experiencia de actividad física (Clinical visit-PROactive physical activity in COPD [C-PPAC]), capacidad funcional de ejercicio (distancia caminada en la prueba de la marcha de 6 minutos [6MWD]) y variables sociodemográficas, interpersonales, ambientales, clínicas y psicológicas. Resultados: (1) La progresión natural de la actividad física a lo largo del tiempo fue heterogénea y se pudieron identificar tres patrones distintos: inactivo, activo que aumenta y activo que reduce. Mientras que el patrón de pacientes inactivo se relacionaba con peores características clínicas de la EPOC, no se pudo predecir la evolución de los activos a aumentar o reducir; (2) la mayor densidad de población y la exposición a largo plazo al NO2 se asociaron desfavorablemente con la actividad física, mientras que una mayor pendiente del terreno se relacionó con una mejor capacidad de ejercicio; (3) la compleción a los 12 meses con una intervención de actividad física conductual estuvo determinada por los hábitos de actividad física previos, así como por facilitadores interpersonales y ambientales, mientras que la respuesta a la intervención se relacionó con diversos factores asociados a la motivación para cambiar a un estilo de vida activo. Conclusiones: Esta tesis muestra que la progresión natural de la actividad física en los pacientes con EPOC es heterogénea y destaca que los factores ambientales, interpersonales y psicológicos son importantes determinantes de la actividad física en los pacientes con EPOC, más allá de los factores clínicos. Resum Antecedents: Malgrat el paper clau de l’activitat física per millorar el pronòstic en pacients amb malaltia pulmonar obstructiva crònica (MPOC), encara no disposem d’informació que permeti individualitzar les intervencions. L’objectiu d’aquesta tesi és entendre la progressió de l’activitat física i explorar-ne els determinants en pacients amb MPOC

Urban environment and physical activity and capacity in patients with chronic obstructive pulmonary disease

Background Physical activity and exercise capacity are key prognostic factors in chronic obstructive pulmonary disease (COPD) but their environmental determinants are unknown. Objectives To test the association between urban environment and objective physical activity, physical activity experience and exercise capacity in COPD. Methods We studied 404 patients with mild-to-very severe COPD from a multi-city study in Catalonia, Spain. We measured objective physical activity (step count and sedentary time) by the Dynaport MoveMonitor, physical activity experience (difficulty with physical activity) by the Clinical visit-PROactive (C-PPAC) instrument, and exercise capacity by the 6-min walk distance (6MWD). We estimated individually (geocoded to the residential address) population density, pedestrian street length, slope of terrain, and long-term (i.e., annual) exposure to road traffic noise, nitrogen dioxide (NO2) and particulate matter (PM2.5). We built single- and multi-exposure mixed-effects linear regressions with a random intercept for city, adjusting for confounders. Results Patients were 85% male, had mean (SD) age 69 (9) years and walked 7524 (4045) steps/day. In multi-exposure models, higher population density was associated with fewer steps, more sedentary time and worse exercise capacity (−507 [95% CI: 1135, 121] steps, +0.2 [0.0, 0.4] h/day and −13 [-25, 0] m per IQR). Pedestrian street length related with more steps and less sedentary time (156 [9, 304] steps and −0.1 [-0.1, 0.0] h/day per IQR). Steeper slope was associated with better exercise capacity (15 [3, 27] m per IQR). Higher NO2 levels related with more sedentary time and more difficulty in physical activity. PM2.5 and noise were not associated with physical activity or exercise capacity. Discussion Population density, pedestrian street length, slope and NO2 exposure relate to physical activity and capacity of COPD patients living in highly populated areas. These findings support the consideration of neighbourhood environmental factors during COPD management and the attention to patients with chronic diseases when developing urban and transport planning policies

The First Case(s) of Botulism in Vienna in 21 Years: A Case Report

We describe two linked cases of botulinum toxin intoxication to provide the clinician with a better idea about how botulism cases may present since early diagnosis and treatment are crucial in botulism. Botulinum toxin is the strongest neurotoxin known. Methods: We review the available literature, the compiled clinical data, and observations. Results: After a slow onset of clinical signs a married couple living in Vienna presented with dysphagia, difficulties in accommodation, inability to sweat, urinary and stool retention, dizziness, and nausea. They suffered intoxication with botulinum toxin type B. Botulism is a rarely occurring disease in Austria. In the last 21 years there were only twelve reported cases. Conclusion: Both patients went to a general practitioner as well as several specialists before they were sent to and correctly diagnosed at our outpatient department. To avoid long delays between intoxication and diagnosis we think it is crucial to advert to the complex symptoms a nonsevere intoxication with botulinum toxin can produce, especially since intoxications have become rare occurrences in the industrialized societies due to the high quality of industrial food production

Roles of the physical environment in health-related quality of life in patients with chronic obstructive pulmonary disease

Rationale: Many clinical and psychological factors are known to influence the health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD). However, research on whether environmental factors, such as air pollution, noise, temperature, and blue/green spaces also influence HRQL in COPD has not been systematically investigated. Objective: To assess the relationship between air pollution, road traffic noise, temperature, and distance to blue/green spaces and respiratory-specific HRQL in COPD. Methods: We used cross-sectional data from a multicenter study in 407 stable mild-to-very severe COPD patients from Barcelona (Catalonia). Patients answered the COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Individual residential exposure to air pollutants (nitrogen dioxide [NO2] and particulate matters of varying aerodynamic diameters [PM2.5, PM10, and PM2.5absorbance]), road traffic noise (Lden), and land surface temperature were estimated using long-term averages from land-use regression models, 24-h noise maps, and land surface temperature maps, respectively. We measured residential distances to blue/green spaces from the Urban Atlas. We used mixed-effect negative binomial (for CAT) and linear (for CCQ) regression models, adjusted for potential confounders, with a random effect by center. Results: Of those patients, 85 % were male and had a mean (SD) age of 69 (9) years, CAT score of 12 (7), CCQ-total score of 1.4 (1.0), and post-bronchodilator forced expiratory volume in 1 s (FEV1) of 57 (18) %predicted. We found that NO2 and PM2.5absorbance were associated with worsened CAT and CCQ-mental scores, e.g., 0.15-unit change in CAT score [regression coefficient (β) = 0.15; 95 % confidence interval (CI) = 0.03, 0.26] per interquartile range in NO2 [13.7 μg/m3]. Greater distances to blue/green spaces were associated with worsened CCQ-mental scores [0.08; 0.002, 0.15]. Conclusions: Our study showed that increased air pollution, particularly NO2 and PM2.5absorbance and greater distances to blue/green spaces negatively influence HRQL in COPD patients. These findings have important implications for the WHO promotion to develop healthy cities for our future

Urban environment and physical activity and capacity in patients with chronic obstructive pulmonary disease

Background: Physical activity and exercise capacity are key prognostic factors in chronic obstructive pulmonary disease (COPD) but their environmental determinants are unknown. Objectives: To test the association between urban environment and objective physical activity, physical activity experience and exercise capacity in COPD. Methods: We studied 404 patients with mild-to-very severe COPD from a multi-city study in Catalonia, Spain. We measured objective physical activity (step count and sedentary time) by the Dynaport MoveMonitor, physical activity experience (difficulty with physical activity) by the Clinical visit-PROactive (C-PPAC) instrument, and exercise capacity by the 6-min walk distance (6MWD). We estimated individually (geocoded to the residential address) population density, pedestrian street length, slope of terrain, and long-term (i.e., annual) exposure to road traffic noise, nitrogen dioxide (NO2) and particulate matter (PM2.5). We built single- and multi-exposure mixed-effects linear regressions with a random intercept for city, adjusting for confounders. Results: Patients were 85% male, had mean (SD) age 69 (9) years and walked 7524 (4045) steps/day. In multi-exposure models, higher population density was associated with fewer steps, more sedentary time and worse exercise capacity (-507 [95% CI: 1135, 121] steps, +0.2 [0.0, 0.4] h/day and -13 [-25, 0] m per IQR). Pedestrian street length related with more steps and less sedentary time (156 [9, 304] steps and -0.1 [-0.1, 0.0] h/day per IQR). Steeper slope was associated with better exercise capacity (15 [3, 27] m per IQR). Higher NO2 levels related with more sedentary time and more difficulty in physical activity. PM2.5 and noise were not associated with physical activity or exercise capacity. Discussion: Population density, pedestrian street length, slope and NO2 exposure relate to physical activity and capacity of COPD patients living in highly populated areas. These findings support the consideration of neighbourhood environmental factors during COPD management and the attention to patients with chronic diseases when developing urban and transport planning policies