Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination

OBJECTIVE

To assess the value of the history and physical examination findings in the diagnosis of symptomatic degenerative lumbar spinal stenosis (LSS).

METHODS

The study was performed in 3 specialty clinics, and included patients with low back pain who were at least age 40. Findings from a standardized history and physical examination were compared with the diagnostic impression of expert attending clinicians. Imaging studies were available in 88% of those with LSS, and the findings further supported the diagnosis of LSS in each case. The sensitivity, specificity, and likelihood ratio associated with each history and physical examination finding were calculated in bivariate analyses, and independent correlates of LSS were identified with multivariate analyses.

RESULTS

Ninety-three patients were evaluated. History findings most strongly associated with the diagnosis of LSS (likelihood ratio > or = 2) were greater age, severe lower-extremity pain, and absence of pain when seated. Physical examination findings most strongly associated with the diagnosis were wide-based gait, abnormal Romberg test result, thigh pain following 30 seconds of lumbar extension, and neuromuscular deficits. Independent correlates of LSS included advanced age (P = 0.0001), absence of pain when seated (P = 0.006), wide-based gait (P = 0.013), and thigh pain following 30 seconds of lumbar extension (P = 0.002).

CONCLUSION

Specific history and physical examination findings are useful in the diagnosis of LSS and should be ascertained routinely in older patients with low back pain.

Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine

A nerve root impingement within a stenotic neuroforamen is a common sequela of cervical degenerative arthritis and herniated nucleus pulposus. Understanding of the effects of cervical position on foraminal size is important in the assessment of pathology and injury, for selection of a provocative maneuver to elicit symptoms and in selecting a position of immobilization for the management of nerve root impingement syndrome. This biomechanical study of human cadaver cervical spines reports the measured variations in the sizes of neuroforamina as a function of cervical positioning. Five fresh frozen adult human cadaver cervical spines (C2-T1) were tested with combinations of flexion-extension and rotational position. Ten pounds of axial load was applied to simulate a normal loading of a cervical spine. The foramina of C5, C6, and C7 were directly measured using a set of finely graded circular probes. Compared to the foraminal diameter at the neutral position, there were statistically significant reductions in the foramen diameter of 10% and 13%, at 20 degrees and 30 degrees of extension respectively (P < 0.01). Conversely, in flexion, there were statistically significant increase of 8% and 10% at 20 degrees and 30 degrees of flexion respectively (P < 0.01). Though there was a reduction in the foraminal size with ipsilateral 20 degrees rotation, and an increase with contralateral 20 degrees rotation, these changes were not significantly different from the mean of the control. Combinations of flexion or extension position with axial rotation did not significantly change the foraminal size compared to the respective sagittal position with no axial rotation.(ABSTRACT TRUNCATED AT 250 WORDS)

Timing of surgical decompression and fixation of acute spinal fractures

A retrospective evaluation of 138 patients requiring operative decompression, reduction and fixation of spinal injuries between January 1986 and April 1989 was conducted. The variables of timing and method of operative intervention, level and classification of fracture, associated injuries, injury severity score (ISS), associated neurologic deficits, length of intensive care unit and hospital stays, and projected costs were analyzed for correlation with postoperative complications (pulmonary, skin, urinary, other). Four subgroups were identified: group IA patients underwent surgery within 72 h of injury and had an ISS of < 18; group IB patients underwent surgery after 72 h and had an ISS of < 18; group IIA patients underwent surgery within 72 h and had an ISS of > or = 18; and group IIB underwent surgery after 72 h and had an ISS of > or = 18. There was no statistically significant difference in the incidence of medical complications in patients comparing groups IA and IB. Group IIB patients had a statistically significant higher rate of morbidity than did group IIA. A separate group of patients with cervical spine injuries with neurologic deficit was analyzed by the same statistical analysis. Irrespective of associated injuries, all had fewer complications if they underwent surgery within 72 h. Morbidity was higher in patients with a neurological deficit compared with neurologically intact patients. Surgical decompression, reduction, and/or fixation of spinal fractures within the first 72 h is indicated in patients with multiple trauma (ISS > or = 18) and cervical injuries with a neurological deficit.

An analysis of baseline data from the PROUD study: an open-label randomised trial of pre-exposure prophylaxis

Background

Pre-exposure prophylaxis (PrEP) has proven biological efficacy to reduce the sexual acquisition of the human immunodeficiency virus (HIV). The PROUD study found that PrEP conferred higher protection than in placebo-controlled trials, reducing HIV incidence by 86 % in a population with seven-fold higher HIV incidence than expected. We present the baseline characteristics of the PROUD study population and place the findings in the context of national sexual health clinic data.

Methods

The PROUD study was designed to explore the real-world effectiveness of PrEP (tenofovir-emtricitabine) by randomising HIV-negative gay and other men who have sex with men (GMSM) to receive open-label PrEP immediately or after a deferral period of 12 months. At enrolment, participants self-completed two baseline questionnaires collecting information on demographics, sexual behaviour and lifestyle in the last 30 and 90 days. These data were compared to data from HIV-negative GMSM attending sexual health clinics in 2013, collated by Public Health England using the genitourinary medicine clinic activity database (GUMCAD).

Results

The median age of participants was 35 (IQR: 29–43). Typically participants were white (81 %), educated at a university level (61 %) and in full-time employment (72 %). Of all participants, 217 (40 %) were born outside the UK. A sexually transmitted infection (STI) was reported to have been diagnosed in the previous 12 months in 330/515 (64 %) and 473/544 (87 %) participants reported ever having being diagnosed with an STI. At enrolment, 47/280 (17 %) participants were diagnosed with an STI. Participants reported a median (IQR) of 10 (5–20) partners in the last 90 days, a median (IQR) of 2 (1–5) were condomless sex acts where the participant was receptive and 2 (1–6) were condomless where the participant was insertive. Post-exposure prophylaxis had been prescribed to 184 (34 %) participants in the past 12 months. The number of STI diagnoses was high compared to those reported in GUMCAD attendees.

Conclusions

The PROUD study population are at substantially higher risk of acquiring HIV infection sexually than the overall population of GMSM attending sexual health clinics in England. These findings contribute to explaining the extraordinary HIV incidence rate during follow-up and demonstrate that, despite broad eligibility criteria, the population interested in PrEP was highly selective.

Trial registration

Current Controlled TrialsISRCTN94465371. Date of registration: 28 February 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1286-4) contains supplementary material, which is available to authorized users.

Acceptability of artificial intelligence (AI)-enabled chatbots, video consultations and live webchats as online platforms for sexual health advice

OBJECTIVES

Sexual and reproductive health (SRH) services are undergoing a digital transformation. This study explored the acceptability of three digital services, (i) video consultations via Skype, (ii) live webchats with a health advisor and (iii) artificial intelligence (AI)-enabled chatbots, as potential platforms for SRH advice.

METHODS

A pencil-and-paper 33-item survey was distributed in three clinics in Hampshire, UK for patients attending SRH services. Logistic regressions were performed to identify the correlates of acceptability.

RESULTS

In total, 257 patients (57% women, 50% aged <25 years) completed the survey. As the first point of contact, 70% preferred face-to-face consultations, 17% telephone consultation, 10% webchats and 3% video consultations. Most would be willing to use video consultations (58%) and webchat facilities (73%) for ongoing care, but only 40% found AI chatbots acceptable. Younger age (<25 years) (OR 2.43, 95% CI 1.35 to 4.38), White ethnicity (OR 2.87, 95% CI 1.30 to 6.34), past sexually transmitted infection (STI) diagnosis (OR 2.05, 95% CI 1.07 to 3.95), self-reported STI symptoms (OR 0.58, 95% CI 0.34 to 0.97), smartphone ownership (OR 16.0, 95% CI 3.64 to 70.5) and the preference for a SRH smartphone application (OR 1.95, 95% CI 1.13 to 3.35) were associated with video consultations, webchats or chatbots acceptability.

CONCLUSIONS

Although video consultations and webchat services appear acceptable, there is currently little support for SRH chatbots. The findings demonstrate a preference for human interaction in SRH services. Policymakers and intervention developers need to ensure that digital transformation is not only cost-effective but also acceptable to users, easily accessible and equitable to all populations using SRH services.

Mutagenic activity of 3 industrial chemicals in a battery of in vitro and in vivo tests

3 chemicals were selected for mutagenicity testing from a priority list, based on production volume and available mutagenicity data. Propargyl alcohol (PA), 2-nitroaniline (2NA), and 5-methyl-1H-benzo-triazole (MBT) were selected for testing using the approach recommended in the Health Protection Branch Genotoxicity Guidelines. The battery of tests included the Salmonella/mammalian microsome mutation assay, the in vitro chromosomal aberration assay, and the bone-marrow micronucleus assay. The results indicate that 2 of the 3 chemicals, PA and 2NA, were clastogenic in vitro. Both PA and 2NA induced chromosomal aberrations in CHO cells in vitro with and without metabolic activation, while none induced reverse mutations detectable with the Salmonella/mammalian microsome assay. Because PA and 2NA were found to be in vitro clastogens, they also were tested in the mouse bone-marrow micronucleus assay. 2NA induced a small increase in micronuclei in males but not females. PA did not induce an increase in micronuclei.

Avascular necrosis of the proximal carpal row. A case report

Avascular necrosis of bone has been described in many sites, including the carpal bones. The case history of a patient with avascular necrosis of the entire proximal row, previously undescribed, is detailed. Numerous contributing factors, including steroid administration, hyperlipidemia, and systemic lupus erythematosus are noted. Occult wrist pain in any patient with known risk factors for avascular necrosis is a warning sign; early bone scan may help prevent late complications.

Barriers and facilitators to engagement with artificial intelligence (AI)-based chatbots for sexual and reproductive health advice: a qualitative analysis

Background The emergence of artificial intelligence (AI) provides opportunities for demand management of sexual and reproductive health services. Conversational agents/chatbots are increasingly common, although little is known about how this technology could aid services. This study aimed to identify barriers and facilitators for engagement with sexual health chatbots to advise service developers and related health professionals. Methods In January-June 2020, we conducted face-to-face, semi-structured and online interviews to explore views on sexual health chatbots. Participants were asked to interact with a chatbot, offering advice on sexually transmitted infections (STIs) and relevant services. Participants were UK-based and recruited via social media. Data were recorded, transcribed verbatim and analysed thematically. Results Forty participants (aged 18-50 years; 64% women, 77% heterosexual, 58% white) took part. Many thought chatbots could aid sex education, providing useful information about STIs and sign-posting to sexual health services in a convenient, anonymous and non-judgemental way. Some compared chatbots to health professionals or Internet search engines and perceived this technology as inferior, offering constrained content and interactivity, limiting disclosure of personal information, trust and perceived accuracy of chatbot responses. Conclusions Despite mixed attitudes towards chatbots, this technology was seen as useful for anonymous sex education but less suitable for matters requiring empathy. Chatbots may increase access to clinical services but their effectiveness and safety need to be established. Future research should identify which chatbots designs and functions lead to optimal engagement with this innovation.

A structural equation model to predict pre-exposure prophylaxis acceptability in men who have sex with men in Leicester, UK

OBJECTIVES

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool for high-risk men who have sex with men (MSM). However, acceptability and uptake have been variable. This study explored the factors that predict PrEP acceptability in MSM in Leicester, where HIV prevalence is double the national average.

METHODS

A total of 191 HIV-negative MSM completed a cross-sectional survey. Participants provided demographic information, and completed measures of HIV knowledge, perceived HIV risk, engagement in sexual risk behaviour, acquisition of a sexually transmitted infection (STI) in the last 12 months, frequency of HIV testing and PrEP acceptability.

RESULTS

Kruskal-Wallis tests showed statistically significant effects of sexual orientation, education level and income, respectively, on HIV knowledge. Gay-identified individuals possessed greater HIV knowledge than bisexuals. Respondents with General Certificate of Secondary Education (GCSE)-level education had significantly less HIV knowledge than those educated to postgraduate level. Respondents with income of < £10 000 possessed significantly less HIV knowledge than higher income groups. Structural equation modelling showed that the relationship between HIV knowledge and PrEP acceptability was mediated by perceived HIV risk, engagement in sexual risk behaviour, acquisition of an STI in the past 12 months and frequency of HIV testing.

CONCLUSIONS

The results reveal socio-economic inequalities in HIV knowledge and HIV testing, and suggest that MSM who have high levels of HIV knowledge and perceived HIV risk and who regularly test for HIV are most likely to endorse PrEP as personally beneficial. HIV knowledge and accurate risk appraisal should be promoted in MSM. The HIV testing context constitutes an ideal context for promoting PrEP to high-risk MSM.

Survey evaluation of the National Patient Safety Agency's Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices

BACKGROUND

Root Cause Analysis (RCA) is a systematic approach to investigations, and is applied in many healthcare settings within comprehensive patient safety systems. The National Patient Safety Agency (NPSA) in England and Wales commissioned a survey evaluation of its national training programme which consisted of 3-day workshops and internet support materials.

METHODS

Anonymous survey of 374 health professionals immediately after they attended the programme (T1), and a further 350 participants 6 months after the programme (T 2), who had attended courses in England and Wales in 2005.

RESULTS

T1 knowledge tests showed a greater understanding of the frameworks and techniques of RCA but with less accuracy in application to scenarios. Personal beliefs about conducting RCAs were consistently positive at both times, but many participants experienced personal barriers to conducting RCA in their current role and trust context, and some felt low confidence in undertaking cascade training of other staff in their trust. There was also low confidence in implementing RCA as standard practice at both times. At T2, 76.7% were confident the outcomes from their RCA had been implemented, but only 12.1% were aware if improvements had been shared outside the local organisation. Barriers to RCA at both times most often concerned time and resources to apply RCA. At T1, there was particular concern for personal development, at T2 greater concern for organisational impediments.

CONCLUSIONS

The RCA programme enhanced knowledge of RCA, and participants valued the programme, but further personal development and organisational support are required to achieve continued improvement in practice and sustained organisational learning.

Attendance of MSM at Genitourinary Medicine services in England: implications for selective HPV vaccination programme (a short communication)

BACKGROUND

Human papillomaviruses (HPV) immunisation programmes for female adolescents in the UK offer relatively little benefit to men who have sex with men (MSM). Targeted HPV vaccination for MSM may reduce the high incidence of HPV-related disease among MSM. We used national data from sexual health clinics to calculate the number of MSM attending these clinics throughout England from 2009 to 2014 and to identify their characteristics, to inform the implementation of a targeted HPV vaccination programme in MSM.

METHODS

We used the Genitourinary Medicine Clinic Activity Dataset (GUMCADv2) to obtain data for men aged 15-70 years who had attended a GUM clinic in England from 2009 to 2014. We analysed both numbers of MSM attending and number of GUM attendances, age at first attendance, ethnicity and geographical area of the clinic in England.

RESULTS

A total of 374 983 MSM attended sexual health services in England between 2009 and 2014. Median age of presentation was 32 years (IQR 25-41) and showed regional geographical variation. Of all men attending sexual health clinics in England, the highest proportion of those identifying as MSM was in London (21%). Excluding visits within 1 month of an initial attendance, 49% of all MSM re-attended within 12 months and 58% within 24 months. MSM aged ≥36 years reattended more frequently than younger MSM. 51% reattended at least twice within 24 months of initial visit.

CONCLUSIONS

The majority of MSM reattend clinic at least once within a 24-month period, potentially facilitating the delivery of a three-dose HPV vaccination programme. This would reduce the burden on sexual health clinics and cost to local authorities due to extra visits if HPV vaccination were to be delivered through these services.

Sexual healthcare professionals' views on the rapid provision of remote services at the beginning of COVID-19 pandemic: A mixed-methods study

Introduction: The COVID-19 pandemic and social distancing measures forced sexual health services to engage with patients remotely. We aimed to understand perceived barriers and facilitators to the provision of digital sexual health services during the first months of the pandemic. Methods: An online survey and qualitative interviews with UK sexual healthcare professionals recruited online and via snowball sampling were conducted in May–July 2020. Results: Amongst 177 respondents (72% female, 86% White, mean age = 46, SD = 9), most utilised telephone and email as their main communication channels; however, their perceived effectiveness varied (94% and 66%, respectively). Most agreed that staff needed additional training (89%), the available technology was not adequate (66%) and health professionals were hesitant to provide online consultations (46%). They had positive attitudes towards digitalisation, improving service quality and cost-effectiveness but were concerned about exacerbating health inequalities. Discussion: The study identifies a need for clear guidelines and training around the use of digital tools as well as a demand for investment in hardware and software required for the provision of remote services. Future research needs to explore the acceptability, safety and effectiveness of various digital tools to narrow health inequalities in sexual health service users.

Reducing new chlamydia infection among young men by promoting correct and consistent condom use: Protocol for a randomised controlled trial. (Preprint)

Background

The health, social, and economic costs of sexually transmitted infections (STIs) represent a major public health concern. Young people are considered one of the groups most at risk for acquiring and transmitting STIs. Correct and consistent condom use has been shown to be the most effective method for reducing STIs; however, condoms are often not used properly. Evidence shows that brief behavior change interventions that focus on skills, communication, and motivation to acquire safe sex practices should be adopted into routine care to reduce STIs. Funding for sexual health services in England has declined dramatically, so novel ways of reducing clinic attendance are being sought. The home-based intervention strategy (HIS-UK) to promote condom use among young men has shown promise in feasibility and pilot studies by demonstrating high acceptability of the intervention in participant and health professional feedback, including aiding men to find condoms they like and feel more confident when using condoms.

Objective

The aim of this study is to determine the effectiveness and cost-effectiveness of HIS-UK when compared to usual condom distribution care among young men.

Methods

The 3 trial arms consisting of “e-HIS” (HIS-UK delivered digitally), “ProHIS” (HIS-UK delivered face-to-face), and control condition (usual National Health Service [NHS] care) will be compared against the following 3 primary outcomes: the extent to which correct and consistent condom use is increased; improvement of condom use experiences (pleasure as well as fit and feel); and decrease in chlamydia test positivity. Eligibility criteria include men aged 16-25 years at risk of STIs through reporting of condom use errors (ie, breakage or slippage) or condomless penile-vaginal or penile-anal intercourse with casual or new sexual partners during the previous 3 months. Prospective participants will be recruited through targeted advertisements and an opportunistic direct approach at selected sexual health and genitourinary medicine services and university-associated health centers and general practitioner practices. Community and educational establishments will be used to further advertise the study and signpost men to recruitment sites. Participants will be randomly allocated to 1 of 3 trial arms. A repeated measures design will assess the parallel arms with baseline and 12 monthly follow-up questionnaires after intervention and 3 chlamydia screening points (baseline, 6, and 12 months).

Results

Recruitment commenced in March 2020. Due to the COVID-19 pandemic, the study was halted and has since reopened for recruitment in Summer 2021. A 30-month recruitment period is planned.

Conclusions

If effective and cost-effective, HIS-UK can be scaled up into routine NHS usual care to reduce both STI transmission in young people and pressure on NHS resources. This intervention may further encourage sexual health services to adopt digital technologies, allowing for them to become more widely available to young people while decreasing health inequalities and fear of stigmatization.

Trial Registration

ISRCTN Registry ISRCTN11400820; https://www.isrctn.com/ISRCTN11400820