Help-seeking behaviour among people living with chronic hip or knee pain in the community

<p>Abstract</p> <p>Background</p> <p>A large proportion of people living with hip or knee pain do not consult health care professionals. Pain severity is often believed to be the main reason for help seeking in this population; however the evidence for this is contradictory. This study explores the importance of several potential risk factors on help seeking across different practitioner groups, among adults living with chronic hip or knee pain in a large community sample.</p> <p>Methods</p> <p>Health care utilization, defined as having seen a family doctor (GP) during the past 12 months; or an allied health professional (AHP) or alternative therapist during the past 3 months, was assessed in a community based sample aged 35 or over and reporting pain in hip or knee. Adjusted odds ratios were determined for social deprivation, rurality, pain severity, mobility, anxiety/depression, co-morbidities, and body mass index.</p> <p>Results</p> <p>Of 1119 persons reporting hip or knee pain, 52% had pain in both sites.</p> <p>Twenty-five percent of them had seen a doctor only, 3% an AHP only, and 4% an alternative therapist only. Thirteen percent had seen more than one category of health care professionals, and 55% had not seen any health care professional. In the multivariate model, factors associated with consulting a GP were mobility problems (OR 2.62 (1.64-4.17)), urban living (OR 2.40 (1.14-5.04) and pain severity (1.28 (1.13-1.44)). There was also some evidence that obesity was associated with increased consultation (OR 1.72 (1.00-2.93)). Factors were similar for consultation with a combination of several health care professionals. In contrast, seeing an alternative therapist was negatively associated with pain severity, anxiety and mobility problems (adjusting for age and sex).</p> <p>Conclusion</p> <p>Disability appears to be a more important determinant of help-seeking than pain severity or anxiety and depression, for adults with chronic pain in hip or knee. The determinants of seeking help from alternative practitioners are different from determinants of consulting GPs, AHPs or a combination of different health care providers.</p

The SANAD II study of the effectiveness and cost-effectiveness of levetiracetam, zonisamide, or lamotrigine for newly diagnosed focal epilepsy: an open-label, non-inferiority, multicentre, phase 4, randomised controlled trial

Background: Levetiracetam and zonisamide are licensed as monotherapy for patients with focal epilepsy, but there is uncertainty as to whether they should be recommended as first-line treatments because of insufficient evidence of clinical effectiveness and cost-effectiveness. We aimed to assess the long-term clinical effectiveness and cost-effectiveness of levetiracetam and zonisamide compared with lamotrigine in people with newly diagnosed focal epilepsy. Methods: This randomised, open-label, controlled trial compared levetiracetam and zonisamide with lamotrigine as first-line treatment for patients with newly diagnosed focal epilepsy. Adult and paediatric neurology services across the UK recruited participants aged 5 years or older (with no upper age limit) with two or more unprovoked focal seizures. Participants were randomly allocated (1:1:1) using a minimisation programme with a random element utilising factor to receive lamotrigine, levetiracetam, or zonisamide. Participants and investigators were not masked and were aware of treatment allocation. SANAD II was designed to assess non-inferiority of both levetiracetam and zonisamide to lamotrigine for the primary outcome of time to 12-month remission. Anti-seizure medications were taken orally and for participants aged 12 years or older the initial advised maintenance doses were lamotrigine 50 mg (morning) and 100 mg (evening), levetiracetam 500 mg twice per day, and zonisamide 100 mg twice per day. For children aged between 5 and 12 years the initial daily maintenance doses advised were lamotrigine 1·5 mg/kg twice per day, levetiracetam 20 mg/kg twice per day, and zonisamide 2·5 mg/kg twice per day. All participants were included in the intention-to-treat (ITT) analysis. The per-protocol (PP) analysis excluded participants with major protocol deviations and those who were subsequently diagnosed as not having epilepsy. Safety analysis included all participants who received one dose of any study drug. The non-inferiority limit was a hazard ratio (HR) of 1·329, which equates to an absolute difference of 10%. A HR greater than 1 indicated that an event was more likely on lamotrigine. The trial is registered with the ISRCTN registry, 30294119 (EudraCt number: 2012-001884-64). Findings: 990 participants were recruited between May 2, 2013, and June 20, 2017, and followed up for a further 2 years. Patients were randomly assigned to receive lamotrigine (n=330), levetiracetam (n=332), or zonisamide (n=328). The ITT analysis included all participants and the PP analysis included 324 participants randomly assigned to lamotrigine, 320 participants randomly assigned to levetiracetam, and 315 participants randomly assigned to zonisamide. Levetiracetam did not meet the criteria for non-inferiority in the ITT analysis of time to 12-month remission versus lamotrigine (HR 1·18; 97·5% CI 0·95–1·47) but zonisamide did meet the criteria for non-inferiority in the ITT analysis versus lamotrigine (1·03; 0·83–1·28). The PP analysis showed that 12-month remission was superior with lamotrigine than both levetiracetam (HR 1·32 [97·5% CI 1·05 to 1·66]) and zonisamide (HR 1·37 [1·08–1·73]). There were 37 deaths during the trial. Adverse reactions were reported by 108 (33%) participants who started lamotrigine, 144 (44%) participants who started levetiracetam, and 146 (45%) participants who started zonisamide. Lamotrigine was superior in the cost-utility analysis, with a higher net health benefit of 1·403 QALYs (97·5% central range 1·319–1·458) compared with 1·222 (1·110–1·283) for levetiracetam and 1·232 (1·112, 1·307) for zonisamide at a cost-effectiveness threshold of £20 000 per QALY. Cost-effectiveness was based on differences between treatment groups in costs and QALYs. Interpretation: These findings do not support the use of levetiracetam or zonisamide as first-line treatments for patients with focal epilepsy. Lamotrigine should remain a first-line treatment for patients with focal epilepsy and should be the standard treatment in future trials. Funding: National Institute for Health Research Health Technology Assessment programme

The SANAD II study of the effectiveness and cost-effectiveness of valproate versus levetiracetam for newly diagnosed generalised and unclassifiable epilepsy: an open-label, non-inferiority, multicentre, phase 4, randomised controlled trial

Background: Valproate is a first-line treatment for patients with newly diagnosed idiopathic generalised or difficult to classify epilepsy, but not for women of child-bearing potential because of teratogenicity. Levetiracetam is increasingly prescribed for these patient populations despite scarcity of evidence of clinical effectiveness or cost-effectiveness. We aimed to compare the long-term clinical effectiveness and cost-effectiveness of levetiracetam compared with valproate in participants with newly diagnosed generalised or unclassifiable epilepsy. Methods: We did an open-label, randomised controlled trial to compare levetiracetam with valproate as first-line treatment for patients with generalised or unclassified epilepsy. Adult and paediatric neurology services (69 centres overall) across the UK recruited participants aged 5 years or older (with no upper age limit) with two or more unprovoked generalised or unclassifiable seizures. Participants were randomly allocated (1:1) to receive either levetiracetam or valproate, using a minimisation programme with a random element utilising factors. Participants and investigators were aware of treatment allocation. For participants aged 12 years or older, the initial advised maintenance doses were 500 mg twice per day for levetiracetam and valproate, and for children aged 5–12 years, the initial daily maintenance doses advised were 25 mg/kg for valproate and 40 mg/kg for levetiracetam. All drugs were administered orally. SANAD II was designed to assess the non-inferiority of levetiracetam compared with valproate for the primary outcome time to 12-month remission. The non-inferiority limit was a hazard ratio (HR) of 1·314, which equates to an absolute difference of 10%. A HR greater than 1 indicated that an event was more likely on valproate. All participants were included in the intention-to-treat (ITT) analysis. Per-protocol (PP) analyses excluded participants with major protocol deviations and those who were subsequently diagnosed as not having epilepsy. Safety analyses included all participants who received one dose of any study drug. This trial is registered with the ISRCTN registry, 30294119 (EudraCt number: 2012-001884-64). Findings: 520 participants were recruited between April 30, 2013, and Aug 2, 2016, and followed up for a further 2 years. 260 participants were randomly allocated to receive levetiracetam and 260 participants to receive valproate. The ITT analysis included all participants and the PP analysis included 255 participants randomly allocated to valproate and 254 randomly allocated to levetiracetam. Median age of participants was 13·9 years (range 5·0–94·4), 65% were male and 35% were female, 397 participants had generalised epilepsy, and 123 unclassified epilepsy. Levetiracetam did not meet the criteria for non-inferiority in the ITT analysis of time to 12-month remission (HR 1·19 [95% CI 0·96–1·47]); non-inferiority margin 1·314. The PP analysis showed that the 12-month remission was superior with valproate than with levetiracetam. There were two deaths, one in each group, that were unrelated to trial treatments. Adverse reactions were reported by 96 (37%) participants randomly assigned to valproate and 107 (42%) participants randomly assigned to levetiracetam. Levetiracetam was dominated by valproate in the cost-utility analysis, with a negative incremental net health benefit of −0·040 (95% central range −0·175 to 0·037) and a probability of 0·17 of being cost-effectiveness at a threshold of £20 000 per quality-adjusted life-year. Cost-effectiveness was based on differences between treatment groups in costs and quality-adjusted life-years. Interpretation: Compared with valproate, levetiracetam was found to be neither clinically effective nor cost-effective. For girls and women of child-bearing potential, these results inform discussions about benefit and harm of avoiding valproate. Funding: National Institute for Health Research Health Technology Assessment Programme

How to fall slower than gravity: and other everyday (and not so everyday) uses of mathematics and physical reasoning

An engaging collection of intriguing problems that shows you how to think like a mathematical physicist Paul Nahin is a master at explaining odd phenomena through straightforward mathematics. In this collection of twenty-six intriguing problems, he explores how mathematical physicists think. Always entertaining, the problems range from ancient catapult conundrums to the puzzling physics of a very peculiar kind of glass called NASTYGLASS―and from dodging trucks to why raindrops fall slower than the rate of gravity. The questions raised may seem impossible to answer at first and may require an unexpected twist in reasoning, but sometimes their solutions are surprisingly simple. Nahin’s goal, however, is always to guide readers―who will need only to have studied advanced high school math and physics―in expanding their mathematical thinking to make sense of the curiosities of the physical world. The problems are in the first part of the book and the solutions are in the second, so that readers may challenge themselves to solve the questions on their own before looking at the explanations. The problems show how mathematics―including algebra, trigonometry, geometry, and calculus―can be united with physical laws to solve both real and theoretical problems. Historical anecdotes woven throughout the book bring alive the circumstances and people involved in some amazing discoveries and achievements, and the book also includes a new analysis of how the Enola Gay escaped the atomic blast from the bomb it dropped on Hiroshima. More than a puzzle book, this work will immerse you in the delights of scientific history while honing your math skills

Time machine tales: the science fiction adventures and philosophical puzzles of time travel

This book contains a broad overview of time travel in science fiction, along with a detailed examination of the philosophical implications of time travel. The emphasis of this book is now on the philosophical and on science fiction, rather than on physics, as in the author's earlier books on the subject. In that spirit there are, for example, no Tech Notes filled with algebra, integrals, and differential equations, as there are in the first and second editions of TIME MACHINES. Writing about time travel is, today, a respectable business. It hasn’t always been so. After all, time travel, prima facie, appears to violate a fundamental law of nature; every effect has a cause, with the cause occurring before the effect. Time travel to the past, however, seems to allow, indeed to demand, backwards causation, with an effect (the time traveler emerging into the past as he exits from his time machine) occurring before its cause (the time traveler pushing the start button on his machine’s control panel to start his trip backward through time). Time Machine Tales includes new discussions of the advances by physicists and philosophers that have appeared since the publication of TIME MACHINES in 1999, examples of which are the chapters on time travel paradoxes. Those chapters have been brought up-to-date with the latest philosophical thinking on the paradoxes. Paul Nahin is THE authority on the intricate physics of time travel, paradoxes and all. He makes the field as clear as it can be. — Gregory Benford, author of Timescape

An imaginary tale: the story of [the square root of] -1

Today complex numbers have such widespread practical use--from electrical engineering to aeronautics--that few people would expect the story behind their derivation to be filled with adventure and enigma. In An Imaginary Tale, Paul Nahin tells the 2000-year-old history of one of mathematics' most elusive numbers, the square root of minus one, also known as i. He recreates the baffling mathematical problems that conjured it up, and the colorful characters who tried to solve them.In 1878, when two brothers stole a mathematical papyrus from the ancient Egyptian burial site in the Valley of King

Chases and escapes: the mathematics of pursuit and evasion

We all played tag when we were kids. What most of us don't realize is that this simple chase game is in fact an application of pursuit theory, and that the same principles of games like tag, dodgeball, and hide-and-seek are also at play in military strategy, high-seas chases by the Coast Guard, and even romantic pursuits. In Chases and Escapes, Paul Nahin gives us the first complete history of this fascinating area of mathematics, from its classical analytical beginnings to the present day. Drawing on game theory, geometry, linear algebra, target-tracking algorithms, and muc

When least is best: how mathematicians discovered many clever ways to make things as small (or as large) as possible

What is the best way to photograph a speeding bullet? Why does light move through glass in the least amount of time possible? How can lost hikers find their way out of a forest? What will rainbows look like in the future? Why do soap bubbles have a shape that gives them the least area? By combining the mathematical history of extrema with contemporary examples, Paul J. Nahin answers these intriguing questions and more in this engaging and witty volume. He shows how life often works at the extremes--with values becoming as small (or as large) as possible--and how mathematicians over the centur

In praise of simple physics: the science and mathematics behind everyday questions

Physics can explain many of the things that we commonly encounter. It can tell us why the night is dark, what causes the tides, and even how best to catch a baseball. With In Praise of Simple Physics, popular math and science writer Paul Nahin presents a plethora of situations that explore the science and math behind the wonders of everyday life. Roaming through a diverse range of puzzles, he illustrates how physics shows us ways to wring more energy from renewable sources, to measure the gravity in our car garages, to figure out which of three light switches in the basement controls the light bulb in the attic, and much, much more. How fast can you travel from London to Paris? How do scientists calculate the energy of an atomic bomb explosion? How do you kick a football so it stays in the air and goes a long way downfield? Nahin begins with simpler problems and progresses to more challenging questions, and his entertaining, accessible, and scientifically and mathematically informed explanations are all punctuated by his trademark humor. Readers are presumed to have some background in beginning differential and integral calculus. Whether you simply have a personal interest in physics' influence in the world or you're an engineering and science student who wants to gain more physics know-how, this book has an intriguing scenario for you