UK Back pain Exercise And Manipulation (UK BEAM) trial--national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578]

BACKGROUND

Low back pain has major health and social implications. Although there have been many randomised controlled trials of manipulation and exercise for the management of low back pain, the role of these two treatments in its routine management remains unclear. A previous trial comparing private chiropractic treatment with National Health Service (NHS) outpatient treatment, which found a benefit from chiropractic treatment, has been criticised because it did not take treatment location into account. There are data to suggest that general exercise programmes may have beneficial effects on low back pain. The UK Medical Research Council (MRC) has funded this major trial of physical treatments for back pain, based in primary care. It aims to establish if, when added to best care in general practice, a defined package of spinal manipulation and a defined programme of exercise classes (Back to Fitness) improve participant-assessed outcomes. Additionally the trial compares outcomes between participants receiving the spinal manipulation in NHS premises and in private premises.

DESIGN

Randomised controlled trial using a 3 x 2 factorial design.

METHODS

We sought to randomise 1350 participants with simple low back pain of at least one month's duration. These came from 14 locations across the UK, each with a cluster of 10-15 general practices that were members of the MRC General Practice Research Framework (GPRF). All practices were trained in the active management of low back pain. Participants were randomised to this form of general practice care only, or this general practice care plus manipulation, or this general practice care plus exercise, or this general practice care plus manipulation followed by exercise. Those randomised to manipulation were further randomised to receive treatment in either NHS or private premises. Follow up was by postal questionnaire one, three and 12 months after randomisation. The primary analysis will consider the main treatment effects before interactions between the two treatment packages. Economic analysis will estimate the cost per unit of health utility gained by adding either or both of the treatment packages to general practice care.

Lessons learned from raltitrexed--quality assurance, patient education and intensive supportive drugs to optimise tolerability

Although recent trials have raised concerns about the toxicity of raltitrexed monotherapy in patients with advanced colorectal cancer (aCRC), similar concerns have also been raised with other chemotherapy regimens in aCRC. The lessons learnt form our previous experiences with raltitrexed are, therefore, still important as they offer practical guidances to optimise tolerability of chemotherapy for CRC in general. The aims of the study were to report the low-toxicity profile in 58 patients receiving raltitrexed when a rigorous patient information and education strategy was implemented together with an intensive supportive adjuvant drugs regimen from the start. After a discussion with the consultant, all patients received a further consultation with a specialist nurse, a series of bespoke information tools, including an information video and written guidelines on how to avoid, prevent and deal promptly with the side-effects of raltitrexed. They all received intravenous adjuvant ondansetron and dexamethasone, then oral domperidone, ranitidine and nystatin from cycle one. The dose intensity was 98% over 307 cycles. Toxicity associated with raltitrexed comprised grade 1/2 diarrhoea (31.6% of treatment cycles), nausea (12.4%) and vomiting (8.4%), with no grade 3/4 events; grade 1/2 alopecia (17.9%); grade 1 (only) stomatitis (2.3%) and grade 1/2/3 lethargy (70.3%, only 2.3% grade 3), anaemia (14.3%, only 0.3% grade 3) and neutropenia (3.3%, only 0.3% grade 3). There were no treatment-related deaths. The low toxicity, despite high-dose intensity, suggests that intensive supportive education and drugs should have a role in the future design of regimens containing raltitrexed and other chemotherapy regimens for colorectal carcinoma.

[MRI of the ear]

The purpose of this review article is to describe the normal anatomy, the specific imaging techniques and the applications of MR imaging to temporal bone pathologies. Though the evaluation of the ear is mainly based upon CT, MR imaging is essential in the work-up of tumors and inflammatory diseases, such as epidermoids, cholesterol granulomas, paragangliomas and transtegmental masses. MR Imaging is mandatory in the evaluation of the internal acoustic canal and the cerebellopontine angle. Finally, MR imaging plays an important role in the detection of recurrent cholesteatoma after middle ear surgery, and in the work-up of the labyrinthic cavities before cochlear implantation.

Development of a fluorescent probe for the study of nucleosome assembly and dynamics

To develop a probe for use in real-time dynamic studies of nucleosomes, core histones (from Drosophila) were conjugated to a DNA-intercalating dye, thiazole orange, by a reaction targeting Cys 110 of histone H3. In the absence of DNA, the conjugated histones are only very weakly fluorescent. However, upon reconstitution into nucleosomes by standard salt dialysis procedures, the probe fluoresces strongly, reflecting its ability to intercalate into the nucleosomal DNA. The probe is also sensitive to the nature of the DNA-histone interaction. Nucleosomes reconstituted by stepwise salt dialysis give a fluorescence signal quite different from that of the species formed when DNA and histones are simply mixed in low salt. In addition, changing either the DNA length or the type of sequence (nucleosome positioning sequences versus random DNA of the same size) used in the reconstitution alters the resulting fluorescence yield. The results are all consistent with the conclusion that a more rigid, less flexible nucleosome structure results in less fluorescence than a looser structure, presumably due to structural constraints on dye intercalation. This probe should be well suited to analyzing nucleosome dynamics and to following factor-mediated assembly and remodeling of nucleosomes in real time, particularly at the single-molecule level.

Effects of chronic low back pain, age and gender on vertical spinal creep

This study investigated the effect of chronic low back pain, age, gender, and time of measurement on the magnitude of vertical spinal creep (VSC) and its recovery. A mixed design, involving three independent variables (chronic low back pain, age, and gender) and one repeated variable (time), was used. One hundred and six subjects of both genders, with and without chronic low back pain, aged between 20 and 60 years, participated in the study. The measurement of VSC and its recovery was performed using a seated stadiometer that allowed continuous measurement of VSC without changing the subject's posture over 25 min. Unloaded VSC was measured during the initial 5 min, followed by 10 min with an additional load of 15% of the subject's body weight and then for a further 10 min after the removal of the load. Subjects were grouped into one of eight categories according to the presence of chronic low back pain, age (20-39 years or 40-60 years) and gender. Repeated measures analysis of variance was computed. A significant increase in VSC with time of measurement was observed (p<0.001). No significant main effects for chronic low back pain, age, or gender were found at any time during the 25-min VSC testing protocol. Significant interactions were found between age and gender during the loaded (p=0.02) and unloaded (p=0.02) phases. A significant interaction was found between chronic low back pain and gender at the end of the unloaded phase (p=0.04). These findings suggest a combined influence of chronic low back pain, age, and gender on VSC and its recovery and that the dominance of each variable changed with the time of the measurement. Thus, subjects who differ in the presence of chronic low back pain, age, and gender should not be combined for statistical analysis of VSC and its recovery.

Acute myelogenous leukemia complicated by acute necrotizing ulcerative gingivitis due to Aspergillus terreus

Infections caused by Aspergillus terreus are rare but have been associated with a poor outcome in immunocompromised patients due to frequent resistance to conventional antifungal therapy. This report describes a case of a woman who developed acute necrotizing ulcerative gingivitis (ANUG) due to A. terreus during induction chemotherapy for acute myelogenous leukemia. She initially failed to respond to treatment with amphotericin B but the infection resolved following the introduction of oral itraconazole. Opportunistic infections caused by A. terreus are an emerging problem and can be associated with a high mortality rate. Early microbiological diagnosis is critical since resistance to amphotericin B is likely and itraconazole appears to be an effective treatment for this infection.

Successful pregnancy after hysteroscopic metroplasty

Congenital anomalies of the uterus have been estimated to affect 0.06-10% of women. Uterine septae account for approximately 80% to 90% of these anomalies and is also associated with the poorest reproductive outcome. Pregnancy loss in patients with a septate uterus has been reported to be as high as 90% after other causes for miscarriages have been excluded. We present here the first experience in Jamaica, of a successful pregnancy outcome after hysteroscopic metroplasty in a woman with a septate uterus and three previous miscarriages.

A modified Kleihauer technique for the quantification of foetomaternal haemorrhage

The Kleihauer technique, based on acid elution of maternal red cells, is the mostly widely used technique in the UK to screen for, and estimate the volume of, foetomaternal haemorrhage (FMH) and for determining the need for additional doses of anti-D immunoglobulin to prevent maternal alloimmunization. However, technicians often report difficulties in identifying and accurately counting maternal red cells in the blood film, leading to imprecision in the calculated FMH. In this report, we describe a simple modification of the standard Kleihauer technique, based on performing acid elution of only half of the film. Compared to the standard method, the modified technique showed improved accuracy and reduced interobserver variability across a range of simulated FMH volumes. There was a high degree of correlation between the new technique and FMH estimated by flow cytometry (r2 = 0.916, P < 0.001). Technicians found the new technique easy to incorporate into routine practice in a busy teaching hospital laboratory and were impressed by the relative ease of counting maternal ghost cells. The modified technique has been used routinely in our laboratory for 3 years, during which time our performance in the UK National External Quality Assurance Scheme for FMH has been uniformly satisfactory.

Lower prevalence of pre-morbid neurological illness in African-Caribbean than White psychotic patients in England

BACKGROUND

It has been suggested that the increased incidence of psychosis in African-Caribbeans living in England may be due to illnesses in which social stress plays an important aetiological role. If this is the case, the prevalence of factors associated with psychosis that predate illness onset such as obstetric complications, pre-morbid neurological illness and poor childhood social adjustment may be expected to be lower in African-Caribbean than Whites psychotic patients.

METHOD

Details of obstetric complications, pre-morbid neurological illness, and pre-morbid social adjustment were obtained for 337 psychotic patients by patient interview, interviews of mothers and chart review. The proportions of patients with each 'risk factor' in the African-Caribbean (N = 103) and White (N = 184) groups were compared using regression analysis; age, sex, social class, diagnosis and referral status were possible explanatory variables.

RESULTS

African-Caribbean patients were less likely to have suffered a pre-morbid neurological disorder than their White counterparts (odds ratio 0.19, 95% CI 0.06-0.61). There was no significant difference in pre-morbid social adjustment or obstetric complications between the two groups, though fewer obstetric complications were reported in the African-Caribbean group (21.5%) than the White group (30.9%).

CONCLUSIONS

African-Caribbean patients with psychosis have experienced less pre-morbid neurological illness.

Partially matched related donor peripheral blood progenitor cell transplantation in paediatric patients adding fludarabine and anti-lymphocyte gamma-globulin

Twenty-one paediatric patients (11 males and 10 females) received a CD34-selected partially matched related donor transplant for malignant (16 cases) and non-malignant conditions (five cases). The average cell dose was 11.13 x 10(6)/kg. Fifteen of 16 patients with malignant conditions and one with non-malignant disease received total body irradiation plus cyclophosphamide. Three of 5 patients with non-malignant conditions and one with leukaemia, received busulphan plus cyclophosphamide. One patient with Fanconi anaemia received 100 mg/kg of cyclophosphamide. Fludarabine (25 mg/m(2)/day for 5 days) was administered prior to all these regimens. Additionally, anti-lymphocyte gamma-globulin (12.5 mg/kg/day) was administered from day -2 to day +2. Three (15%) patients failed to achieve complete chimaerism (CC). These patients received a second cell infusion. Two of them achieved CC. In the third patient, the percentage of donor cells was increased. The likelihood for engraftment was not related to the cell dose received. Acute graft-versus-host disease (GVHD) occurred in nine patients but only one developed GVHD >grade II. Eight patients developed active viral infections, which resolved after treatment. Patients receiving cell doses higher than our average had a significantly faster CD3 and CD4 cell recovery and experienced a lower incidence of viral infections. After 480 +/- 255 days of median follow-up, 16/21 patients are alive and well and have CC. Three patients died of leukaemic relapse and a fourth from progression of his disease (adreno-leuko-dystrophy). We conclude that partially matched related donors are a feasible source of haemopoietic progenitor cells for transplantation for patients without matched familial or unrelated donors.

A review of intensity modulated radiation therapy: incorporating a report on the seventh education workshop of the ACPSEM--ACT/NSW branch. Australasian College of Physical Scientists and Engineers in Medicine

Intensity modulated radiation therapy (IMRT) is an evolving treatment technique that has become a clinical treatment option in several radiotherapy centres around the world. In August 2001 the ACT/NSW branch of the ACPSEM held its seventh education workshop, the subject was IMRT. This review considers the current use of IMRT and reports on the proceedings of the workshop. The workshop provided some of the theory behind IMRT, discussion of the practical issues associated with IMRT, and also involved presentations from Australian centres that had clinically implemented IMRT. The main topics of discussion were patient selection, plan assessment, multi-disciplinary approach, quality assurance and delivery of IMRT. Key points that were emphasised were the need for a balanced multi-disciplinary approach to IMRT, in both the establishment and maintenance of an IMRT program; the importance of the accuracy of the final dose distribution as compared to the minor in-field fluctuations of individual beams; and that IMRT is an emerging treatment technique, undergoing continuing development and refinement.

Design of high essential amino acid proteins: two design strategies for improving protease resistance of the nutritious MB-1 protein

Protein design is currently used for the creation of new proteins with desirable traits. In our lab, we focus on the synthesis of proteins with high essential amino acid content having potential applications in animal nutrition. One of the limitations we face in this endeavour is achieving stable proteins despite a highly biased amino acid content. We report here the synthesis and characterisation of two mutants derived from our MB-1 designer protein. The first mutant contains a disulphide bridge designed to cross-link remote segments of the polypeptide chain. The second one is a Tyr62-Trp mutant, where position 62 is buried in the core of the protein. Both mutants were found to be largely helical as per design, and based on thermal denaturation experiments, were substantially more stable than the MB-1 parent molecule. Enhancement of conformational stability in MB-1Trp translated into an impressive improvement of its ability to resist proteolytic degradation. Furthermore, digestion experiments intended to model degradation of proteins in a cow's rumen revealed that MB-1Trp's resistance to degradation compared to that of cytochrome c. Design strategies used for these mutants are discussed with regards to their applicability in creating efficient nutritional proteins.

The point-of-referral barrier--a factor in the success of telehealth

A feasibility study was carried out to test the hypothesis that, for an effective telehealth service, a full-time coordinator is required to act as a single point of contact for consultation requests. By shifting the responsibility for telepaediatrics from the referrer to the provider, the telehealth process becomes equally (or more) attractive as the conventional alternative. Preliminary results showed that, within six months, telepaediatric activity increased to an average of 8 h per month. Not only did certain health services become more accessible to children and their families in remote areas of Queensland, but significant savings were also made. At least 12 patient transfers were avoided to and from the tertiary facility, with an estimated minimum saving of $18,000 to the health-care provider.

Reliability of the vertical spinal creep response measured in sitting (asymptomatic and low-back pain subjects)

Vertical spinal creep (or change in stature) has been used as an index of spinal loading, yet reliability of the testing protocol has not been fully examined. This study investigated the reliability of a vertical spinal creep response in 10 asymptomatic and five low-back pain subjects. Each subject performed the 25-min testing protocol, which consisted of three phases (5-min preload, 10-min loaded and 10-min unloaded), at the same time on two separate days. Good reliabilities in vertical spinal creep response between two days of testing were demonstrated for both asymptomatic and low-back pain subjects.