Evidence-based classification of low back pain in the general population: one-year data collected with SMS Track

BACKGROUND

It was previously assumed that low back pain (LBP) is a disorder that can be classified as acute, subacute and chronic. Lately, the opinion seems to have veered towards a concept of it being a more recurrent or cyclic condition. Interestingly, a recent review of the literature indicated that LBP in the general population is a rather stable condition, characterized as either being present or absent. However, only one of the reviewed studies had used frequent data collection, which would be necessary when studying detailed course patterns over time. It was the purpose of this study to see, if it was possible to identify whether LBP, when present, is rather episodic or chronic/persistent. Further, we wanted to see if it was possible to describe any specific course profiles of LBP in the general population.

METHODS

In all, 293 49/50-yr old Danes, who previously participated in a population-based study on LBP were invited to respond to 26 fortnightly text-messages over one year, each time asking them the number of days they had been bothered by LBP in the past two weeks. The course patterns for these individuals were identified through manual analysis, by observing the interplay between non-episodes and episodes of LBP. A non-episode of LBP was defined as a period of at least one month without LBP as proposed by de Vet et al. A fortnight with at least one day of pain was defined as a pain fortnight (FN). At least one pain FN surrounded by a non-episode on each side was defined as an episode of LBP. After some preliminary observations of the spread of data, episodes were further classified as brief (consisting of only one pain FN) or longer (if there were at least 2 pain FNs in a row). An episode of at least 6 pain FNs in a row (i.e. 3 months) was defined as a long-lasting episode.

RESULTS

In all, 261 study subjects were included in the analyses, for which 7 distinct LBP subsets could be identified. These could be grouped into three major clusters; those mainly without LBP (35%), those with episodic LBP (30%) and those with persistent LBP (35%). There was a positive association between number of episodes and their duration.

CONCLUSION

In this study population, consisting of 50-yr old persons from the general population, LBP, when present, could be classified as either 'episodic' or 'mainly persistent'. About one third was mainly LBP-free throughout the year of study. More information is needed in relation to their relative proportions in various populations and the clinical relevance of these subgroups.

The impact of early life exposure to Plasmodium falciparum on the development of naturally acquired immunity to malaria in young Malawian children

Background

Antibodies targeting malaria blood-stage antigens are important targets of naturally acquired immunity, and may act as valuable biomarkers of malaria exposure.

Methods

Six-hundred and one young Malawian children from a randomized trial of prenatal nutrient supplementation with iron and folic acid or pre- and postnatal multiple micronutrients or lipid-based nutrient supplements were followed up weekly at home and febrile episodes were investigated for malaria from birth to 18 months of age. Antibodies were measured for 601 children against merozoite surface proteins (MSP1 19kD, MSP2), erythrocyte binding antigen 175 (EBA175), reticulocyte binding protein homologue 2 (Rh2A9), schizont extract and variant surface antigens expressed by Plasmodium falciparum-infected erythrocytes (IE) at 18 months of age. The antibody measurement data was related to concurrent malaria infection and to documented episodes of clinical malaria.

Results

At 18 months of age, antibodies were significantly higher among parasitaemic than aparasitaemic children. Antibody levels against MSP1 19kD, MSP2, schizont extract, and IE variant surface antigens were significantly higher in children who had documented episodes of malaria than in children who did not. Antibody levels did not differ between children with single or multiple malaria episodes before 18 months, nor between children who had malaria before 6 months of age or between 6 and 18 months.

Conclusions

Antibodies to merozoite and IE surface antigens increased following infection in early childhood, but neither age at first infection nor number of malaria episodes substantially affected antibody acquisition. These findings have implications for malaria surveillance during early childhood in the context of elimination.

Trials registration Clinical Trials Registration: NCT01239693 (Date of registration: 11-10-2010). URL: http://www.ilins.org

Episode-based payment: evaluating the impact on chronic conditions

BACKGROUND

Policy makers are interested in aggregating fee-for-service reimbursement into episode-based bundle payments, hoping it will lead to greater efficiency in the provision of care. The focus of bundled payment initiatives has been upon surgical or discrete procedures. Relatively little is known about calculating and implementing episode-based payments for chronic conditions.

OBJECTIVE

Compare the differences in two different episode-creation algorithms for two common chronic conditions: diabetes and coronary artery disease (CAD).

STUDY DESIGN

We conducted a retrospective evaluation using enrollees with continuous coverage in a self-funded plan from 2003 to 2006, meeting Healthcare Effectiveness Data and Information Set (HEDIS) criteria for diabetes or CAD. For each condition, an annual episode-based payment was assessed using two algorithms: Episode Treatment Groups (ETGs) and the Prometheus model.

PRINCIPAL FINDINGS

We began with 1,580 diabetes patients with a 4-year total payment mean of $67,280. ETGs identified 1,447 (92%) as having diabetes with 4-year episode-based mean payments of $12,731; while the Prometheus model identified 1,512 (96%) as having diabetes, but included only 1,195 of them in the Prometheus model with mean diabetes payments of $23,250. Beginning with 1,644 CAD patients with a 4-year total payment mean of $65,661, ETGs identified 983 patients (60%) with a 4-year episode-based mean of $24,362. The Prometheus model identified 1,135 (69%) as CAD patients with 948 CAD patients having a mean of $26,536.

CONCLUSIONS

The two episode-based methods identify different patients with these two chronic conditions. In addition, there are significant differences in the episode-based payment estimates for diabetes, but similar estimates for CAD. Implementing episode-based payments for chronic conditions is challenging, and thoughtful discussions are needed to determine appropriate payments.

Size-resolved aerosol trace elements at a rural mountainous site in Northern China: importance of regional transport

This paper presents an intensive field measurement campaign carried out at the rural mountainous site of Xinglong (960 m a.s.l.) in Northern China during Sep. 3-20 2008. Size-segregated samples were collected daily and analyzed for 25 trace elements (TEs). The majority of the TEs showed comparable concentrations in fine (<2.1 μm) and coarse particles (2.1-9 μm). In addition, elements like K, Mn, Cu, Se, Mo, Ag, Cd, Tl and Pb were accumulated in fine mode whereas Al, Co and Sb were concentrated in a coarse mode. For most of the TEs, their enrichment factor (EF) increased with decreasing particle size from large (>9 μm) to coarse, and to fine, signifying influences by anthropogenic emissions. The observed concentrations of heavy metals in fine particles, with EF values higher than 100, were significantly higher than the historical data recorded in the 1980s and 1990s, reflecting the increasing emissions in the target area. One pronounced event occurred on Sep. 14 when all of the TEs showed a peak, which was associated with regional emissions from both southeast (SE) and southwest (SW) indicated by backward trajectory analysis. This is further supported by the measurements in upwind sites where the concentrations of TEs were several times higher than those in Xinglong, suggesting potential source regions. Episodes of heavy metals were generally characterized by significant enhancements of fine mode and air mass trajectories from SE or SW alone. Taking this finding and factor analysis results together, the metallic episodes were attributable to the long-range transport of regional plumes from coal consumption and nonferrous metal smelting. With the rapid urbanization and industrialization in Northern China, the increasing emissions of TEs will place a great strain on human health and the environment in the downwind regions, thus long-term and multi-site observation with high time resolution are necessary.

Neck pain patterns and subgrouping based on weekly SMS-derived trajectories

BACKGROUND

Neck and low back pain represent dynamic conditions that change over time, often with an initial improvement after the onset of a new episode, followed by flare-ups or variations in intensity. Pain trajectories were previously defined based on longitudinal studies of temporal patterns and pain intensity of individuals with low back pain. In this study, we aimed to 1) investigate if the defined patterns and subgroups for low back pain were applicable to neck pain patients in chiropractic practice, 2) explore the robustness of the defined patterns, and 3) investigate if patients within the various patterns differ concerning characteristics and clinical findings.

METHODS

Prospective cohort study including 1208 neck pain patients from chiropractic practice. Patients responded to weekly SMS-questions about pain intensity and frequency over 43 weeks. We categorized individual responses into four main patterns based on number of days with pain and variations in pain intensity, and subdivided each into four subgroups based on pain intensity, resulting in 16 trajectory subgroups. We compared baseline characteristics and clinical findings between patterns and between Persistent fluctuating and Episodic subgroups.

RESULTS

All but two patients could be classified into one of the 16 subgroups, with 94% in the Persistent fluctuating or Episodic patterns. In the largest subgroup, "Mild Persistent fluctuating" (25%), mean (SD) pain intensity was 3.4 (0.6) and mean days with pain 130. Patients grouped as "Moderate Episodic" (24%) reported a mean pain intensity of 2.7 (0.6) and 39 days with pain. Eight of the 16 subgroups each contained less than 1% of the cohort. Patients in the Persistent fluctuating pattern scored higher than the other patterns in terms of reduced function and psychosocial factors.

CONCLUSIONS

The same subgroups seem to fit neck and low back pain patients, with pain that typically persists and varies in intensity or is episodic. Patients in a Persistent fluctuating pattern are more bothered by their pain than those in other patterns. The low back pain definitions can be used on patients with neck pain, but with the majority of patients classified into 8 subgroups, there seems to be a redundancy in the original model.

Health Risk Impacts of Exposure to Airborne Metals and Benzo(a)Pyrene during Episodes of High PM10 Concentrations in Poland

OBJECTIVE

To check whether health risk impacts of exposure to airborne metals and Benzo(a) Pyrene during episodes of high PM10 concentrations lead to an increased number of lung cancer cases in Poland.

METHODS

In this work, we gathered data from 2002 to 2014 concerning the ambient concentrations of PM10 and PM10-bound carcinogenic Benzo(a)pyrene [B(a)P] and As, Cd, Pb, and Ni. With the use of the criterion of the exceedance in the daily PM10 mass concentration on at least 50% of all the analyzed stations, the PM10 maxima's were selected. Lung cancer occurrences in periods with and without the episodes were further compared.

RESULTS

During a 12-year period, 348 large-scale smog episodes occurred in Poland. A total of 307 of these episodes occurred in the winter season, which is characterized by increased emissions from residential heating. The occurrence of episodes significantly (P < 0.05) increased the concentrations of PM10-bound carcinogenic As, Cd, Pb, Ni, and B(a)P. During these events, a significant increase in the overall health risk from those PM10-related compounds was also observed. The highest probability of lung cancer occurrences was found in cities, and the smallest probability was found in the remaining areas outside the cities and agglomerations.

CONCLUSION

The link between PM pollution and cancer risk in Poland is a serious public health threat that needs further investigation.

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study

BACKGROUND

Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up.

METHODS

Up to 550 adults of working age (18-65 years) seen for LBP in primary care complete up to 36 "Scheduled" surveys over 1-year follow-up, and also complete unscheduled "Flare Window" surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1-4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1-4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers.

DISCUSSION

FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04828330 , registered April 2, 2021.

Shifts in task absorption during decision-making episodes

In today's rapidly evolving technological landscape, this study investigates the impact of new technology on organizational work dynamics. By integrating the Job Demands-Resources theory and the Episodic Process Model, we examine the cognitive mechanisms that influence task performance during decision-making episodes. Our research focuses on episodic job demands and resources, emphasizing the mediating role of task absorption in the relationship between these factors and task performance. Our findings reveal that episodic job resources positively affect task absorption and performance, while job demands moderate the relationship between job resources and task absorption. Employing the Beer Distribution Game alongside neuroscience-based eye-tracking techniques, we analyze visual attention dynamics during decision-making episodes, providing novel insights into the interplay between task absorption and task performance. Theoretically, our study highlights the significance of task absorption in understanding how episodic job resources impact decision-making performance. Practically, our results advocate for the implementation of decision-making-focused skills development through physiological measures such as neurofeedback training programs. This research underscores the importance of individual time management in enhancing task performance, contributing to a nuanced understanding of job resources, job demands, and task absorption in the context of technological transformation.

Characterizing managing physicians by claims sequences in episodes of care

Value-based healthcare in the US is a payment structure that ties reimbursement to quality rather than volume alone. One model of value-based care is the Tennessee Division of TennCare's Episodes of Care program, which groups common health conditions into episodes using specified time windows, medical code sets and quality metrics as defined in each episode's Detailed Business Requirements [1,2]. Tennessee's program assigns responsibility for an episode to a managing physician, presenting a unique opportunity to study physician variability in cost and quality within these structured episodes. This paper proposes a pipeline for analysis demonstrated using a cohort of 599 Outpatient and Non-Acute Inpatient Cholecystectomy episodes managed by BlueCross BlueShield of Tennessee in 2016. We sorted episode claims by date of service, then calculated the pairwise Levenshtein distance between all episodes. Next, we adjusted the resulting matrix by cost dissimilarity and performed agglomerative clustering. We then examined the lowest and highest average episode cost clusters for patterns in cost and quality. Our results indicate that the facility type where the surgery takes place is important: outpatient ambulatory care center for the lowest cost cluster, and hospital operating room for the highest cost cluster. Average patient risk scores were higher in the highest cost cluster than the lowest cost cluster. Readmission rate (a quality metric tied to managing physician performance) was low for the whole cohort. Lastly, we explain how our analytical pipeline can be generalized and extended to domains beyond Episodes of Care.

The Association Between Vitamin D Level and PFAPA Syndrome: A Systematic Review

Periodic Fever, Aphthous Ulcers, Pharyngitis and Adenitis (PFAPA) Syndrome's etiology is not well understood. The objective of this study is to explore the association between vitamin D level and PFAPA syndrome. A systematic review of all publications addressing the association between vitamin D level and PFAPA syndrome prior to May 2019 was conducted. Data were collected from online medical databases namely, PubMed, Ovid Medline, Embase, Cochrane Library, Google Scholar, and Scopus. The review adhered to the PRISMA statement and was performed in 3 main phases; an initial screening review of abstracts was performed, followed by a detailed review of full articles based on inclusion and exclusion criteria, and lastly a final review to extract data from selected articles. 3 prospective review-based and one case report articles were included with a total of 281 patients, 98 of whom were cases of PFAPA, while 183 were controls. Vitamin D levels were deficient in 27% of PFAPA group as compared with the control. Vitamin D supplementation was given as an initial treatment in 25/98 of the patients. Only 1 patient received it as a second treatment. After vitamin D supplementation, a marked reduction of the number of febrile episodes and modification of the mean duration were recognized. There may be an association between Vitamin D deficiency and a higher frequency of PFAPA episodes. Vitamin D supplementation in children with PFAPA may reduce the frequency of episodes and help manage the condition.

An Analysis of Failures Leading to Fire Accidents in Hospitals; with Specific Reference to India

Fire can be especially dangerous when it occurs in hospitals because many patients in any typical hospital are not physically fit enough to quickly respond to emergency measures, especially evacuation calls. The present paper reports an in-depth assessment of the factors which have led to major fire accidents in Indian hospitals. The study reveals that several building safety codes, acts and guidelines are available, not only to prevent accidental fires but also to minimize harm when such fires do take place. However, observance of the stipulations is very lax, and seems to be exercised more in breach than in compliance. The study reveals that hospitals have zones like the intensive care units which are not only more prone to accidents than other zones but can also cause greater loss of lives due to the presence of critically ill patients, or persons who are extremely vulnerable (for instance newborn babies). Special codes and practices need to be framed for such zones. The study has also identified and catalogued a series of measures which must be implemented in future to prevent accidental fires in hospitals. The study is with reference to accidents that have occurred in India from 2010 to the present but is representative of the situation prevailing in most developing countries.

Episode detection based on personalized intensity of care thresholds: a schizophrenia case study

BACKGROUND

Schizophrenia Spectrum Disorder (SSD) is characterized by its chronic, episodic nature. The clear definition of such episodes is essential for various clinical and research purposes. Most current definitions of episodes in SSD are based on either hospitalizations or on symptom scales. Both have drawbacks; symptom scales are measured infrequently, while hospitalization rates are often affected by policy. This study presents an approach for defining episodes in healthcare data that does not suffer such drawbacks.

METHODS

Healthcare use of 13,155 SSD patients in the Northern Netherlands with up to 12 years of follow-up was available. Patient-level structural changes in the trend of healthcare use costs were determined using Exponentially Weighted Moving Average (EWMA) control charts. Control charts restart with updated parameters after a detected structural change. Episodes were defined using these structural changes. The resulting episodes were validated by investigating their association with the Global Assessment of Functioning (GAF) scale.

RESULTS

The mean number of episodes was 0.61 (sd: 0.60) per patient per year. For the sub-group without hospitalizations this was 0.51 (sd: 0.71). Average episode duration of the sub-group (147 days, sd: 309.4) was similar to that of the full sample (150 days, sd: 305.5). A significant inverse association was identified between GAF scores and the episode-state indicator.

CONCLUSIONS

The repeated application of EWMA control charts based on healthcare-intensity is a feasible and promising tool for quantifying patient-level healthcare episodes. The validation using GAF scores indicates that our episode indicator is associated with lower levels of global functioning. Results for individuals without hospitalizations indicate that the method is robust with regard to changes in healthcare policy.