Diagnostic clinical prediction rules for categorising low back pain: A systematic review

BACKGROUND

Low back pain (LBP) is a common complex condition, where specific diagnoses are hard to identify. Diagnostic clinical prediction rules (CPRs) are known to improve clinical decision-making. A review of LBP diagnostic-CPRs by Haskins et al. (2015) identified six diagnostic-CPRs in derivation phases of development, with one tool ready for implementation. Recent progress on these tools is unknown. Therefore, this review aimed to investigate developments in LBP diagnostic-CPRs and evaluate their readiness for implementation.

METHODS

A systematic review was performed on five databases (Medline, Amed, Cochrane Library, PsycInfo, and CINAHL) combined with hand-searching and citation-tracking to identify eligible studies. Study and tool quality were appraised for risk of bias (Quality Assessment of Diagnostic Accuracy Studies-2), methodological quality (checklist using accepted CPR methodological standards), and CPR tool appraisal (GRade and ASsess Predictive).

RESULTS

Of 5021 studies screened, 11 diagnostic-CPRs were identified. Of the six previously known, three have been externally validated but not yet undergone impact analysis. Five new tools have been identified since Haskin et al. (2015); all are still in derivation stages. The most validated diagnostic-CPRs include the Lumbar-Spinal-Stenosis-Self-Administered-Self-Reported-History-Questionnaire and Diagnosis-Support-Tool-to-Identify-Lumbar-Spinal-Stenosis, and the StEP-tool which differentiates radicular from axial-LBP.

CONCLUSIONS

This updated review of LBP diagnostic CPRs found five new tools, all in the early stages of development. Three previously known tools have now been externally validated but should be used with caution until impact evaluation studies are undertaken. Future funding should focus on externally validating and assessing the impact of existing CPRs on clinical decision-making.

Study of the measurement and predictive validity of the Functional Movement Screen

Objective

The aim of the study was to evaluate the reported measurement capabilities and predictive validity of the Functional Movement Screen (FMS) for injury.

Methods

This was a prospective observational longitudinal study of 24 male footballers from a single team in England, alongside analysis of an existing database over one season (September 2015–May 2016). A preseason FMS was carried out with scores recorded by an experienced assessor and derived, retrospectively, from the three-dimensional movement data that were simultaneously captured. The assessor scores were compared with the photogrammetric system to determine measurement validity, and predictive validity was quantified by assessing sensitivity and specificity (cut-off score of 14).

Results

The real-time assessor score matched the photogrammetric score awarded for one of the participants, was higher than the photogrammetric system for 22 participants and was lower than the photogrammetric system in 1 participant. There was no discernible relationship between FMS scores and the competencies required to be met as per the rules articulated for the allocation of a score. A higher number of total injuries were associated with higher FMS scores, whether determined through real-time assessment or codification of kinematic variables. Additionally, neither method of score determination was able to prospectively identify players at risk of serious injury.

Conclusion

The FMS does not demonstrate the properties essential to be considered as a measurement scale and has neither measurement nor predictive validity. A possible reason for these observations could be the complexity in the instructions associated with the scale. Further work on eliminating redundancies and improving the measurement properties is recommended.

Feasibility study of a take-home array-based functional electrical stimulation system with automated setup for current functional electrical stimulation users with foot-drop

OBJECTIVE

To investigate the feasibility of unsupervised community use of an array-based automated setup functional electrical stimulator for current foot-drop functional electrical stimulation (FES) users.

DESIGN

Feasibility study.

SETTING

Gait laboratory and community use.

PARTICIPANTS

Participants (N=7) with diagnosis of unilateral foot-drop of central neurologic origin (>6mo) who were regular users of a foot-drop FES system (>3mo).

INTERVENTION

Array-based automated setup FES system for foot-drop (ShefStim).

MAIN OUTCOME MEASURES

Logged usage, logged automated setup times for the array-based automated setup FES system and diary recording of problems experienced, all collected in the community environment. Walking speed, ankle angles at initial contact, foot clearance during swing, and the Quebec User Evaluation of Satisfaction with Assistive Technology version 2.0 (QUEST version 2.0) questionnaire, all collected in the gait laboratory.

RESULTS

All participants were able to use the array-based automated setup FES system. Total setup time took longer than participants' own FES systems, and automated setup time was longer than in a previous study of a similar system. Some problems were experienced, but overall, participants were as satisfied with this system as their own FES system. The increase in walking speed (N=7) relative to no stimulation was comparable between both systems, and appropriate ankle angles at initial contact (N=7) and foot clearance during swing (n=5) were greater with the array-based automated setup FES system.

CONCLUSIONS

This study demonstrates that an array-based automated setup FES system for foot-drop can be successfully used unsupervised. Despite setup's taking longer and some problems, users are satisfied with the system and it would appear as effective, if not better, at addressing the foot-drop impairment. Further product development of this unique system, followed by a larger-scale and longer-term study, is required before firm conclusions about its efficacy can be reached.

A whole water catchment approach to investigating the origin and distribution of Cryptosporidium species

AIMS

Investigating the distribution and origin of Cryptosporidium species in a water catchment affected by destocking and restocking of livestock as a result of a foot and mouth disease epidemic.

METHODS AND RESULTS

Surface water, livestock and wildlife samples were screened for Cryptosporidium and oocysts characterised by sequencing SSU rRNA and COWP loci, and fragment analysis of ML1, ML2 and GP60 microsatellite loci. Oocyst concentrations in water samples (0-20.29 per 10 l) were related to rainfall events, amount of rainfall and topography. There was no detectable impact from catchment restocking. Cryptosporidium spp. found in water were indicative of livestock (Cryptosporidium andersoni and Cryptosporidium parvum) and wildlife (novel genotypes) sources. However, C. andersoni was not found in any animals sampled. Calf infections were age related; C. parvum was significantly more common in younger animals (<4 weeks old). Older calves shared Cryptosporidium bovis, Cryptosporidium ryanae and C. parvum. Wildlife shed C. parvum, Cryptosporidium ubiquitum, muskrat genotype II and deer genotype.

CONCLUSIONS

Several factors affect the occurrence of Cryptosporidium within a catchment. In addition to farmed and wild animal hosts, topography and rainfall patterns are particularly important.

SIGNIFICANCE AND IMPACT OF THE STUDY

These factors must be considered when undertaking risk-based water safety plans.

Sonographic evaluation of the subclavian artery during thoracic outlet syndrome shoulder manoeuvres

Clinical tests for vascular thoracic outlet syndrome (vTOS) generally incorporate shoulder horizontal flexion/extension (HF/HE), abduction (ABD) and external rotation (ER). The effect of these clinical tests on blood flow characteristics and the most effective arm positions for detecting arterial compromise are, however, unknown. The aims of this study are to establish normative vascular responses in the subclavian artery (i.e. arterial diameter [D] and peak systolic blood flow velocity [PSV]) to various arm positions, and determine the incidence of abnormal physiological responses. Ten male and twenty-one female (mean age: 25 yr) healthy volunteers were rigorously screened prior to testing. With the subject seated the arm was passively supported in a randomised series of 12 standardised shoulder positions incorporating varying degrees of HF/HE, ABD and ER. Doppler ultrasound insonated the subclavian artery D (mm) and PSV (cms(-1)) in each position. Data comparisons were made using ANOVAs with bonferroni adjustment for multiple comparisons. Alpha level was set at p=0.01. Significant decreases (p=0.008) in PSV were recorded from 120 degrees , 90 degrees and 45 degrees ABD (92+/-10, 89+/-11 and 88+/-14 cm s(-1), respectively) to 180 degrees ABD (mean+/-95% CI: 52+/-16 cm s(-1)). Similarly, post-hoc comparisons revealed a significant decrease (p=0.008) in PSV from 120 degrees ABD (94+/-14 cm s(-1)) to 120 degrees ABD with 30 degrees HE and 90 degrees ER (69+/-12 cm s(-1)). Complete lack of blood flow was demonstrated by six subjects and two subjects at end of range ABD and combined end of range ER and HE, respectively. The heterogenous response of asymptomatic individuals with no past history of TOS symptoms raises uncertainty of the validity of positive test responses from extreme arm positions. Clinical decisions based on false positive outcomes have serious implications for mistreatment such as inappropriate surgical intervention; therefore it is imperative that clinical decision is not based on test outcomes alone. Further research is required to determine the cause of heterogenous responses in asymptomatics and discover means to improve test specificity.

Estimation of diffuse and point source microbial pollution in the ribble catchment discharging to bathing waters in the north west of England

Achieving compliance with the mandatory standards of the 1976 Bathing Water Directive (76/160/EEC) is required at all U.K. identified bathing waters. In recent years, the Fylde coast has been an area of significant investments in 'point source' control, which have not proven, in isolation, to satisfactorily achieve compliance with the mandatory, let alone the guide, levels of water quality in the Directive. The potential impact of riverine sources of pollution was first confirmed after a study in 1997. The completion of sewerage system enhancements offered the potential for the study of faecal indicator delivery from upstream sources comprising both point sources and diffuse agricultural sources. A research project to define these elements commenced in 2001. Initially, a desk study reported here, estimated the principal infrastructure contributions within the Ribble catchment. A second phase of this investigation has involved acquisition of empirical water quality and hydrological data from the catchment during the 2002 bathing season. These data have been used further to calibrate the 'budgets' and 'delivery' modelling and these data are still being analysed. This paper reports the initial desk study approach to faecal indicator budget estimation using available data from the sewerage infrastructure and catchment sources of faecal indicators.

The Ergonomics Society--the Society Lectures 1999: the Ergonomics Society: 50 years of growth

Developments in the Society are outlined since the early history was described by Edholm and Murrell. Major changes in the Society's operation and the context in which these changes took place are given. The changes in research directions, growth in educational facilities for professional education and the ever widening areas for the application of ergonomics are discussed. The consequences of these developments for the expansion of a recognition of the contribution of ergonomics, and the position of professionals in the international scene are touched upon.

FMLP-induced enzyme release from neutrophils: a role for intracellular calcium

The ability of the chemotactic peptide N-formylmethionyl-leucyl-phenylalanine (FMLP) to stimulate beta-glucuronidase release and 45Ca2+ release from rabbit neutrophils was studied. FMLP stimulated enzyme release from cytochalasin B-treated cells either in the presence or the absence of extracellular calcium. Depletion of cell calcium, by exposure to either ethyleneglycol-bis(beta-aminoethylether)-N,N'-tetraacetic acid or the calcium ionophore A23187, blocked the ability of FMLP to stimulate enzyme release and 45Ca2+ release in the absence of extracellular calcium. The ability of A23187 to lower the 45Ca2+ content of neutrophils, to block FMLP-stimulated 45Ca2+ release, and to inhibit FMLP-stimulated enzyme release in the absence of calcium was dose dependent over the same concentration range (10(-8) to 10(-6) M A23187) for all three actions. In contrast, FMLP stimulated enzyme release from A23187-treated cells, provided that extracellular calcium was present. This secretory response was normal as judged by cell ultrastructure and FMLP dose-response relationships. It is concluded that A23187 depletes a pool of intracellular calcium usually released by FMLP and that release of calcium from this pool is necessary for initiation of enzyme secretion in the absence of extracellular calcium.

Acute and chronic drug abuse emergencies in Metropolitan Toronto

From 3,548 drug overdose or abuse cases presenting at 21 Metropolitan Toronto hospitals' Emergency departments, data concerning demographic and medical characteristics, investigative and management procedures, drug analysis services, and disposition of patients were collected. Of the 3,548 cases, 2,723 (77%) were acute overdose and 816 (23%) were drug abuse. Drug overdose was more common than drug abuse for both sexes, but was more characteristic of females. The drugs most frequently alleged ingested were benzodiazepines (34%), ethanol (32%), salicylates (16%), and barbiturates (14%). The frequency with which particular classes of drugs are alleged in overdose corresponds closely to the frequency of prescribing these drugs in Ontario.

Alcohol use by patients admitted to hospital emergency rooms for treatment of drug overdose and misuse

Persons admitted to hospital emergency rooms for treatment of drug misuse with concomitant alcohol use were generally found to be heavy drinkers.

Adverse biochemical and clinical consequences of furosemide administration

Nurse monitors collected clinical and laboratory data from 204 hospitalized patients receiving furosemide (122 men and 82 women; mean age 69.6 years). Biochemical abnormalities and clinical problems definitely or probably induced by any drug occurred in 70.6% and 49.0% respectively of the patients, and were attributed to furosemide in 81.3% and 13.0% respectively of these patients. The most important clinical events were dehydration and hypotension. Furosemide-induced hypochloremia, hypokalemia and hyponatremia occurred in 35.8%, 25.0% and 24.5% of the patients respectively. Most of the biochemical changes were slight, and only 3.9% of the patients had a furosemide-induced decrease in the serum potassium concentration to less than 3.0 mmol/L. Surprisingly, 24.5% of the patients also manifested drug-induced hyperkalemia. Administration potassium supplements or spironolactone, or both, concurrently with furosemide was responsible in most cases for the development of hyperkalemia. The occurrence of drug-induced adverse effects after 2 weeks of hospitalization was significantly associated (P less than 0.05) with subsequent prolongation of hospitalization. The high frequency of drug-induced events warrants careful monitoring of all patients receiving furosemide in spite of the low frequency of serious toxic effects produced by the drug.