Can large surveys conducted on highly selected populations provide valid information on the epidemiology of common health conditions? An analysis of UK Biobank data on musculoskeletal pain

Association between socioeconomic deprivation and bone health status in the UK biobank cohort participants

The effect of deprivation on total bone health status has not been well defined. We examined the relationship between socioeconomic deprivation and poor bone health and falls and we found a significant association. The finding could be beneficial for current public health strategies to minimise disparities in bone health.

PURPOSE

Socioeconomic deprivation is associated with many illnesses including increased fracture incidence in older people. However, the effect of deprivation on total bone health status has not been well defined. To examine the relationship between socioeconomic deprivation and poor bone health and falls, we conducted a cross-sectional study using baseline measures from the United Kingdom (UK) Biobank cohort comprising 502,682 participants aged 40-69 years at recruitment during 2006-2010.

METHOD

We examined four outcomes: 1) low bone mineral density/osteopenia, 2) fall in last year, 3) fracture in the last five years, and 4) fracture from a simple fall in the last five years. To measure socioeconomic deprivation, we used the Townsend index of the participant's residential postcode.

RESULTS

At baseline, 29% of participants had low bone density (T-score of heel < -1 standard deviation), 20% reported a fall in the previous year, and 10% reported a fracture in the previous five years. Among participants experiencing a fracture, 60% reported the cause as a simple fall. In the multivariable logistic regression model after controlling for other covariates, the odds of a fall, fracture in the last five years, fractures from simple fall, and osteopenia were respectively 1.46 times (95% confidence interval [CI] 1.42-1.49), 1.26 times (95% CI 1.22-1.30), 1.31 times (95% CI 1.26-1.36) and 1.16 times (95% CI 1.13-1.19) higher for the most deprived compared with the least deprived quantile.

CONCLUSION

Socioeconomic deprivation was significantly associated with poor bone health and falls. This research could be beneficial to minimise social disparities in bone health.

Serum vitamin D and chronic musculoskeletal pain: a cross-sectional study of 349,221 adults in the UK

Insufficient and deficient vitamin D may be associated with chronic musculoskeletal pain, but study findings are conflicting, and few account for important confounding factors. This cross-sectional study explored the association between serum vitamin D status and chronic musculoskeletal pain in various body sites, adjusting for a wide range and number of potential confounding factors. Data collected at the baseline assessments of 349,221 UK Biobank participants between 2006 and 2010 were analysed. Serum 25-hydroxyvitamin D (25-(OH) D) were measured and categorised as <25.0 nmol/L (severe deficiency), 25.0-49.9 nmol/L (deficiency), 50.0-74.9 nmol/L (insufficiency) and ≥75.0 nmol/L (sufficiency). The outcome was self-reported chronic musculoskeletal pain at any site, neck/shoulder, back, hip, knee, or widespread pain that interfered with usual activities. Potential confounders were identified using Directed Acyclic Graphs, and included sociodemographic, lifestyle, psychological factors, and medical comorbidities. Simple models adjusted for age and sex showed significant associations between suboptimal vitamin D status and chronic pain across all sites (odds ratios [ORs] ranged 1.07-2.85). These associations were weakened or became insignificant after accounting for all confounding factors (ORs ≤1.01) for chronic regional musculoskeletal pain. Severe vitamin D deficiency remained a significant and positive association with chronic widespread pain after adjusting for all confounding factors (OR [95% confidence interval]: 1.26 [1.07, 1.49]). This study suggests that while vitamin D status is not a key independent determinant of chronic regional musculoskeletal pain, severe vitamin D deficiency may be associated with chronic widespread pain. PERSPECTIVES: After counting for various confounders, severe vitamin D deficiency remained significantly associated with increased risk of experiencing chronic widespread pain. Considering the low risk and affordability of vitamin D supplements, their potential use in treating chronic widespread pain in severely vitamin D deficient individuals warrants further exploration.

Mechanisms of pain in aging and age-related conditions: Focus on caregivers

Pain is a complex, subjective experience that can significantly impact quality of life, particularly in aging individuals, by adversely affecting physical and emotional well-being. Whereas acute pain usually serves a protective function, chronic pain is a persistent pathological condition that contributes to functional deficits, cognitive decline, and emotional disturbances in the elderly. Despite substantial progress that has been made in characterizing age-related changes in pain, complete mechanistic details of pain processing mechanisms in the aging patient remain unknown. Pain is particularly under-recognized and under-managed in the elderly, especially among patients with Alzheimer's disease (AD), Alzheimer's disease-related dementias (ADRD), and other age-related conditions. Furthermore, difficulties in assessing pain in patients with AD/ADRD and other age-related conditions may contribute to the familial caregiver burden. The purpose of this article is to discuss the mechanisms and risk factors for chronic pain development and persistence, with a particular focus on age-related changes. Our article also highlights the importance of caregivers working with aging chronic pain patients, and emphasizes the urgent need for increased legislative awareness and improved pain management in these populations to substantially alleviate caregiver burden.

C-Reactive Protein (CRP) is Associated With Chronic Pain Independently of Biopsychosocial Factors

Inflammation is linked with chronic pain but the extent to which this relationship is associated with biopsychosocial factors is not known. We investigated relationships between blood C-reactive protein (CRP) and regional chronic pain conditions adjusting for a large range and number of potential confounders. We performed cross-sectional analyses using the UK Biobank (N = 415,567) comparing CRP in people reporting any of 9 types of regional chronic pain with pain-free controls. Using logistic regression modelling, we explored relationships between CRP and the presence of chronic pain, with demographic, socioeconomic, psychological/lifestyle factors, and medical comorbidities as covariates. CRP was higher in chronic pain at any site compared with controls (Females: median [interquartile range] 1.60 mg/L [2.74] vs 1.17 mg/L [1.87], P < .001; Males: 1.44 mg/L [2.12] vs 1.15 mg/L [1.65], P < .001). In males, associations between CRP and all types of chronic pain were attenuated but remained significant after adjustment for biopsychosocial covariates (OR range 1.08-1.49, P ≤ .001). For females, adjusted associations between CRP and pain remained significant for most chronic pain types (OR range 1.07-1.34, P < .001) except for facial pain (OR 1.04, P = .17) and headache (OR 1.02, P = .07)-although these non-significant findings may reflect reduced sample size. The significant association between CRP and chronic pain after adjustment for key biopsychosocial confounders implicates an independent underlying biological mechanism of inflammation in chronic pain. The presence of yet unknown or unmeasured confounding factors cannot be ruled out. Our findings may inform better-targeted treatments for chronic pain. PERSPECTIVE: Using a large-scale dataset, this article investigates associations between chronic pain conditions and blood C-reactive protein (CRP), to evaluate the confounding effects of a range of biopsychosocial factors. CRP levels were higher in those with chronic pain versus controls after adjusting for confounders-suggesting a possible independent biological mechanism.

Where does it hurt? Small area estimates and inequality in the prevalence of chronic pain

BACKGROUND

Chronic pain affects up to half of UK adults, impacting quality of life and demand on local health services. Whilst local health planning is currently based on subnational prevalence estimates, associations between pain and sociodemographic characteristics suggest that inequalities in the prevalence of chronic and high-impact chronic pain between neighbourhoods within local authorities are likely. We aimed to derive lower super output area (LSOA) estimates of the prevalence of chronic and high-impact chronic pain.

METHODS

Presence of self-reported chronic and high-impact chronic pain were measured in adults aged 35+ in North Staffordshire and modelled using multilevel regression as a function of demographic and geographic predictors. Multilevel model predictions were post-stratified using the North Staffordshire age-sex population structure and LSOA demographic characteristics to estimate the prevalence of chronic and high-impact chronic pain in 298 LSOAs, corrected for ethnic diversity underrepresented in the data. Confidence intervals were generated for high-impact chronic pain using bootstrapping.

RESULTS

Data were analysed from 4162 survey respondents (2358 women, 1804 men). The estimated prevalence of chronic and high-impact chronic pain in North Staffordshire LSOAs ranged from 18.6% to 50.1% and 6.18 [1.71, 16.0]% to 33.09 [13.3, 44.7]%, respectively.

CONCLUSIONS

Prevalence of chronic and high-impact chronic pain in adults aged 35+ varies substantially between neighbourhoods within local authorities. Further insight into small-area level variation will help target resources to improve the management and prevention of chronic and high-impact chronic pain to reduce the impact on individuals, communities, workplaces, services and the economy.

SIGNIFICANCE

Post-stratified multilevel model predictions can produce small-area estimates of pain prevalence and impact. The evidence of substantial variation indicates a need to collect local-level data on pain and its impact to understand health needs and to guide interventions.

Big data, big consortia, and pain: UK Biobank, PAINSTORM, and DOLORisk

Chronic pain (CP) is a common and often debilitating disorder that has major social and economic impacts. A subset of patients develop CP that significantly interferes with their activities of daily living and requires a high level of healthcare support. The challenge for treating physicians is in preventing the onset of refractory CP or effectively managing existing pain. To be able to do this, it is necessary to understand the risk factors, both genetic and environmental, for the onset of CP and response to treatment, as well as the pathogenesis of the disorder, which is highly heterogenous. However, studies of CP, particularly pain with neuropathic characteristics, have been hindered by a lack of consensus on phenotyping and data collection, making comparisons difficult. Furthermore, existing cohorts have suffered from small sample sizes meaning that analyses, especially genome-wide association studies, are insufficiently powered. The key to overcoming these issues is through the creation of large consortia such as DOLORisk and PAINSTORM and biorepositories, such as UK Biobank, where a common approach can be taken to CP phenotyping, which allows harmonisation across different cohorts and in turn increased study power. This review describes the approach that was used for studying neuropathic pain in DOLORisk and how this has informed current projects such as PAINSTORM, the rephenotyping of UK Biobank, and other endeavours. Moreover, an overview is provided of the outputs from these studies and the lessons learnt for future projects.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis

Background

We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care.

Methods

A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated.

Results

Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey.

Conclusion

Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.

A Shared Genetic Signature for Common Chronic Pain Conditions and its Impact on Biopsychosocial Traits

The multiple comorbidities & dimensions of chronic pain present a formidable challenge in disentangling its aetiology. Here, we performed genome-wide association studies of 8 chronic pain types using UK Biobank data (N =4,037-79,089 cases; N = 239,125 controls), followed by bivariate linkage disequilibrium-score regression and latent causal variable analyses to determine (respectively) their genetic correlations and genetic causal proportion (GCP) parameters with 1,492 other complex traits. We report evidence of a shared genetic signature across chronic pain types as their genetic correlations and GCP directions were broadly consistent across an array of biopsychosocial traits. Across 5,942 significant genetic correlations, 570 trait pairs could be explained by a causal association (|GCP| >0.6; 5% false discovery rate), including 82 traits affected by pain while 410 contributed to an increased risk of chronic pain (cf. 78 with a decreased risk) such as certain somatic pathologies (eg, musculoskeletal), psychiatric traits (eg, depression), socioeconomic factors (eg, occupation) and medical comorbidities (eg, cardiovascular disease). This data-driven phenome-wide association analysis has demonstrated a novel and efficient strategy for identifying genetically supported risk & protective traits to enhance the design of interventional trials targeting underlying causal factors and accelerate the development of more effective treatments with broader clinical utility. PERSPECTIVE: Through large-scale phenome-wide association analyses of >1,400 biopsychosocial traits, this article provides evidence for a shared genetic signature across 8 common chronic pain types. It lays the foundation for further translational studies focused on identifying causal genetic variants and pathophysiological pathways to develop novel diagnostic & therapeutic technologies and strategies.

Exploring the Cross-cultural Acceptability of Digital Tools for Pain Self-reporting: Qualitative Study

BACKGROUND

Culture and ethnicity influence how people communicate about their pain. This makes it challenging to develop pain self-report tools that are acceptable across ethnic groups.

OBJECTIVE

We aimed to inform the development of cross-culturally acceptable digital pain self-report tools by better understanding the similarities and differences between ethnic groups in pain experiences and self-reporting needs.

METHODS

Three web-based workshops consisting of a focus group and a user requirement exercise with people who self-identified as being of Black African (n=6), South Asian (n=10), or White British (n=7) ethnicity were conducted.

RESULTS

Across ethnic groups, participants shared similar lived experiences and challenges in communicating their pain to health care professionals. However, there were differences in beliefs about the causes of pain, attitudes toward pain medication, and experiences of how stigma and gender norms influenced pain-reporting behavior. Despite these differences, they agreed on important aspects for pain self-report, but participants from non-White backgrounds had additional language requirements such as culturally appropriate pain terminologies to reduce self-reporting barriers.

CONCLUSIONS

To improve the cross-cultural acceptability and equity of digital pain self-report tools, future developments should address the differences among ethnic groups on pain perceptions and beliefs, factors influencing pain reporting behavior, and language requirements.

Persistent inequalities in consultation incidence and prevalence of low back pain and osteoarthritis in England between 2004 and 2019

Objective

We wanted to determine whether socioeconomic inequalities in primary care consultation rates for two major, disabling musculoskeletal conditions in England narrowed or widened between 2004 and 2019.

Methods

We analysed data from Clinical Practice Research Datalink Aurum, a national general practice electronic health records database, linked to national deprivation ranking of each patient's registered residential postcode. For each year, we estimated the age- and sex-standardized consultation incidence and prevalence for low back pain and OA for the most deprived 10% of neighbourhoods through to the least deprived 10%. We then calculated the slope index of inequality and relative index of inequality overall and by sex, age group and geographical region.

Results

Inequalities in low back pain incidence and prevalence over socioeconomic status widened between 2004 and 2013 and stabilized between 2014 and 2019. Inequalities in OA incidence remained stable over socioeconomic status within the study period, whereas inequalities in OA prevalence widened markedly over socioeconomic status between 2004 and 2019. The widest gap in low back pain incidence and prevalence over socioeconomic status was observed in populations resident in northern English regions and London and in those of working age, peaking at 45-54 years.

Conclusion

We found persistent, and generally increasing, socioeconomic inequalities in the rate of adults presenting to primary care in England with low back pain and OA between 2004 and 2019.

Chronic pain: Evidence from the national child development study

Using data from all those born in a single week in 1958 in Britain we track associations between short pain and chronic pain in mid-life (age 44) and subsequent health, wellbeing and labor market outcomes in later life. We focus on data taken at age 50 in 2008, when the Great Recession hit and then five years later at age 55 in 2013 and again at age 62 in 2021 during the Covid pandemic. We find those suffering both short-term and chronic pain at age 44 continue to report pain and poor general health in their 50s and 60s. However, the associations are much stronger for those with chronic pain. Furthermore, chronic pain at age 44 is associated with a range of poor mental health outcomes, pessimism about the future and joblessness at age 55 whereas short-duration pain at age 44 is not. Pain has strong predictive power for pain later in life: pain in childhood predicts pain in mid-life, even when one controls for pain in early adulthood. Pain appears to reflect other vulnerabilities as we find that chronic pain at age 44 predicts whether or not a respondent has Covid nearly twenty years later.

Associations of Childhood Maltreatment and Genetic Risks With Incident Heart Failure in Later Life

Background We aimed to determine the associations of childhood maltreatment with incident heart failure in later life and explore the potentially modifying effects of genetic risk for heart failure on the associations. Methods and Results This cohort study included adults free of heart failure at baseline enrolled between 2006 and 2010 in the UK Biobank. Childhood maltreatment was retrospectively assessed with the online Childhood Trauma Screener in 2016. Five types of childhood maltreatment (range, 0-5), including physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse, were combined into a total score. A weighted polygenic risk score for heart failure was constructed. Incident all-cause heart failure was prospectively ascertained via hospital inpatient and death records, followed up to May 31, 2021. A total of 153 287 adults (mean [SD] age, 55.9 [7.7] years; 43.6% male) were included. Over a median of 12.2 years (interquartile range, 11.5-12.9 years) of follow-up, 2352 participants had incident heart failure. Childhood maltreatment was associated with a greater risk of incident heart failure in a dose-response manner. One additional type of childhood maltreatment was associated with a 15% increase in the risk of developing heart failure (hazard ratio [HR], 1.15 [95% CI, 1.07-1.23]). There was no statistically significant interaction between genetic risk and childhood maltreatment (P_interaction=0.218). Among participants with high genetic risk, those with 3 to 5 types of childhood maltreatment had a double hazard (HR, 2.00 [95% CI, 1.43-2.80]) of developing heart failure when taking those without any childhood maltreatment as the reference. Conclusions Irrespective of genetic risk for heart failure, childhood maltreatment was associated with an increased risk of incident heart failure in a dose-dependent manner.

Hippocampal volume, FKBP5 genetic risk alleles, and childhood trauma interact to increase vulnerability to chronic multisite musculoskeletal pain

Chronic multisite musculoskeletal pain (CMP) is common and highly morbid. However, vulnerability factors for CMP are poorly understood. Previous studies have independently shown that both small hippocampal brain volume and genetic risk alleles in a key stress system gene, FKBP5, increase vulnerability for chronic pain. However, little is known regarding the relationship between these factors and CMP. Here we tested the hypothesis that both small hippocampal brain volume and FKBP5 genetic risk, assessed using the tagging risk variant, FKBP5rs3800373, increase vulnerability for CMP. We used participant data from 36,822 individuals with available genetic, neuroimaging, and chronic pain data in the UK Biobank study. Although no main effects were observed, the interaction between FKBP5 genetic risk and right hippocampal volume was associated with CMP severity (β = -0.020, p_raw = 0.002, p_adj = 0.01). In secondary analyses, severity of childhood trauma further moderated the relationship between FKBP5 genetic risk, right hippocampal brain volume, and CMP (β = -0.081, p = 0.016). This study provides novel evidence that both FKBP5 genetic risk and childhood trauma moderate the relationship between right hippocampal brain volume and CMP. The data increases our understanding of vulnerability factors for CMP and builds a foundation for further work assessing causal relationships that might drive CMP development.

Genome-wide association studies of low back pain and lumbar spinal disorders using electronic health record data identify a locus associated with lumbar spinal stenosis

ABSTRACT

Identifying genetic risk factors for lumbar spine disorders may lead to knowledge regarding underlying mechanisms and the development of new treatments. We conducted a genome-wide association study involving 100,811 participants with genotypes and longitudinal electronic health record data from the Electronic Medical Records and Genomics Network and Geisinger Health. Cases and controls were defined using validated algorithms and clinical diagnostic codes. Electronic health record-defined phenotypes included low back pain requiring healthcare utilization (LBP-HC), lumbosacral radicular syndrome (LSRS), and lumbar spinal stenosis (LSS). Genome-wide association study used logistic regression with additive genetic effects adjusting for age, sex, site-specific factors, and ancestry (principal components). A fixed-effect inverse-variance weighted meta-analysis was conducted. Genetic variants of genome-wide significance (P < 5 × 10-8) were carried forward for replication in an independent sample from UK Biobank. Phenotype prevalence was 48.8% for LBP-HC, 19.8% for LSRS, and 7.9% for LSS. No variants were significantly associated with LBP-HC. One locus was associated with LSRS (lead variant rs146153280:C>G, odds ratio [OR] = 1.17 for G, P = 2.1 × 10-9), but was not replicated. Another locus on chromosome 2 spanning GFPT1, NFU1, and AAK1 was associated with LSS (lead variant rs13427243:G>A, OR = 1.10 for A, P = 4.3 × 10-8) and replicated in UK Biobank (OR = 1.11, P = 5.4 × 10-5). This was the first genome-wide association study meta-analysis of lumbar spinal disorders using electronic health record data. We identified 2 novel associations with LSRS and LSS; the latter was replicated in an independent sample.

Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review

Background

Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention.

Methods

This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against.

Results

Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome.

Conclusions

Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.

Sex- and age-specific genetic analysis of chronic back pain

ABSTRACT

Sex differences for chronic back pain (cBP) have been reported, with females usually exhibiting greater morbidity, severity, and poorer response to treatment. Genetic factors acting in an age-specific manner have been implicated but never comprehensively explored. We performed sex- and age-stratified genome-wide association study and single nucleotide polymorphism-by-sex interaction analysis for cBP defined as "Back pain for 3+ months" in 202,077 males and 237,754 females of European ancestry from UK Biobank. Two and 7 nonoverlapping genome-wide significant loci were identified for males and females, respectively. A male-specific locus on chromosome 10 near SPOCK2 gene was replicated in 4 independent cohorts. Four loci demonstrated single nucleotide polymorphism-by-sex interaction, although none of them were formally replicated. Single nucleotide polymorphism-explained heritability was higher in females (0.079 vs 0.067, P = 0.006). There was a high, although not complete, genetic correlation between the sexes (r = 0.838 ± 0.041, different from 1 with P = 7.8E-05). Genetic correlation between the sexes for cBP decreased with age (0.858 ± 0.049 in younger people vs 0.544 ± 0.157 in older people; P = 4.3E-05). There was a stronger genetic correlation of cBP with self-reported diagnosis of intervertebral disk degeneration in males than in females (0.889 vs 0.638; P = 3.7E-06). Thus, the genetic component of cBP in the UK Biobank exhibits a mild sex- and age-dependency. This provides an insight into the possible causes of sex- and age-specificity in epidemiology and pathophysiology of cBP and chronic pain at other anatomical sites.

A common variant in CCDC93 protects against myocardial infarction and cardiovascular mortality by regulating endosomal trafficking of low-density lipoprotein receptor

AIMS

Genome-wide association studies have previously identified INSIG2 as a candidate gene for plasma low-density lipoprotein cholesterol (LDL-c). However, we suspect a role for CCDC93 in the same locus because of its involvement in the recycling of the LDL-receptor (LDLR).

METHODS AND RESULTS

Characterization of the INSIG2 locus was followed by studies in over 107 000 individuals from the general population, the Copenhagen General Population Study and the Copenhagen City Heart Study, for associations of genetic variants with plasma lipids levels, with risk of myocardial infarction (MI) and with cardiovascular mortality. CCDC93 was furthermore studied in cells and mice. The lead variant of the INSIG2 locus (rs10490626) is not associated with changes in the expression of nearby genes but is a part of a genetic block, which excludes INSIG2. This block includes a coding variant in CCDC93 p.Pro228Leu, which is in strong linkage disequilibrium with rs10490626 (r2 > 0.96). In the general population, separately and combined, CCDC93 p.Pro228Leu is dose-dependently associated with lower LDL-c (P-trend 2.5 × 10-6 to 8.0 × 10-9), with lower risk of MI (P-trend 0.04-0.002) and lower risk of cardiovascular mortality (P-trend 0.005-0.004). These results were validated for LDL-c, risk of both coronary artery disease and MI in meta-analyses including from 194 000 to >700 000 participants. The variant is shown to increase CCDC93 protein stability, while overexpression of human CCDC93 decreases plasma LDL-c in mice. Conversely, CCDC93 ablation reduces LDL uptake as a result of reduced LDLR levels at the cell membrane.

CONCLUSION

This study provides evidence that a common variant in CCDC93, encoding a protein involved in recycling of the LDLR, is associated with lower LDL-c levels, lower risk of MI and cardiovascular mortality.

Predictors of Mental Health Status among Older United States Adults with Pain

Poor mental health is common among older adults with pain, resulting in high economic burden and impaired quality of life. This retrospective, cross-sectional database study aimed to identify characteristics associated with good mental health status among United States (US) adults aged ≥50 years with self-reported pain in the last four weeks using a weighted sample of 2017 Medical Expenditure Panel Survey data. Hierarchical multivariable logistic regression models were used to identify statistically significant predictors of good (versus poor) perceived mental health status. From a weighted population of 57,074,842 individuals, 85.5% (95% confidence interval (CI) = 84.4%, 86.7%) had good perceived mental health. Good mental health was associated most strongly with physical health status (adjusted odds ratio (AOR) = 9.216, 95% CI = 7.044, 12.058). Employed individuals were 1.7 times more likely to report good mental health versus unemployed (AOR = 1.715, 95% CI = 1.199, 2.452). Individuals who had completed less than high school education (AOR = 0.750, 95% CI = 0.569, 0.987) or who reported having a limitation (AOR = 0.513, 95% CI = 0.384, 0.684) were less likely to report good mental health. These key characteristics can be utilized to predict mental health status, which may be investigated to better manage concurrent pain and poor mental health.

Digital manikins to self-report pain on a smartphone: A systematic review of mobile apps

BACKGROUND

Chronic pain is the leading cause of disability. Improving our understanding of pain occurrence and treatment effectiveness requires robust methods to measure pain at scale. Smartphone-based pain manikins are human-shaped figures to self-report location-specific aspects of pain on people's personal mobile devices.

METHODS

We searched the main app stores to explore the current state of smartphone-based pain manikins and to formulate recommendations to guide their development in the future.

RESULTS

The search yielded 3,938 apps. Twenty-eight incorporated a pain manikin and were included in the analysis. For all apps, it was unclear whether they had been tested and had end-user involvement in the development. Pain intensity and quality could be recorded in 28 and 13 apps, respectively, but this was location specific in only 11 and 4. Most manikins had two or more views (n = 21) and enabled users to shade or select body areas to record pain location (n = 17). Seven apps allowed personalising the manikin appearance. Twelve apps calculated at least one metric to summarise manikin reports quantitatively. Twenty-two apps had an archive of historical manikin reports; only eight offered feedback summarising manikin reports over time.

CONCLUSIONS

Several publically available apps incorporated a manikin for pain reporting, but only few enabled recording of location-specific pain aspects, calculating manikin-derived quantitative scores, or generating summary feedback. For smartphone-based manikins to become adopted more widely, future developments should harness manikins' digital nature and include robust validation studies. Involving end users in the development may increase manikins' acceptability as a tool to self-report pain.

SIGNIFICANCE

This review identified and characterised 28 smartphone apps that included a pain manikin (i.e. pain drawings) as a novel approach to measure pain in large populations. Only few enabled recording of location-specific pain aspects, calculating quantitative scores based on manikin reports, or generating manikin feedback. For smartphone-based manikins to become adopted more widely, future studies should harness the digital nature of manikins, and establish the measurement properties of manikins. Furthermore, we believe that involving end users in the development process will increase acceptability of manikins as a tool for self-reporting pain.

The utilization of buprenorphine in chronic pain

Reclassification of chronic pain as a disease may be helpful because patients with chronic pain require significant treatment and rehabilitation with a clear diagnosis. This can help address critical factors including suffering, quality of life, participation, and with family and social life, which continue to become more important in evaluating the quality of the health care we give our patients today. During the past decade of the opioid epidemic, methadone was the primary treatment for opioid addiction until buprenorphine was approved. Buprenorphine's high-affinity partial agonist properties make it a good alternative to methadone due to lower abuse potential and safer adverse effect profile while maintaining significant efficacy. Expanded out-patient prescribing options have allowed physician and physician extenders such as physician assistants and nurse practitioners to treat these patients that otherwise would have been required to utilize methadone. With unique pharmacological properties, buprenorphine is a safe and effective analgesic for chronic pain. The literature for buprenorphine shows great potential for its utilization in the treatment of chronic pain.

The response-time relationship and covariate effects of acupuncture for chronic pain: A systematic review and model-based longitudinal meta-analysis

BACKGROUND AND OBJECTIVE

Critical clinical questions regarding how soon and how long the analgesic effect will be achieved by acupuncture, as well as who will be responsive to acupuncture, need further address. The aim of the study was to investigate the response-time relationship and covariate effects of acupuncture.

DATABASES AND DATA TREATMENT

PubMed and EMBASE were searched up to December 2018 for randomized controlled trials that involved sham acupuncture, true acupuncture and conventional therapy. We used a model-based longitudinal meta-analysis to characterize the response-time profile of these treatments.

RESULTS

Seventy-seven randomized clinical trials involved chronic shoulder, neck, knee and low back pain were included. The response-time analysis suggested that the treatment duration of acupuncture will be 5 weeks or more to achieve 80% of maximum analgesic effect. Moreover a lower baseline pain intensity and the location of low back pain resulted in a lower pain relief of acupuncture intervention. The absolute maximum analgesic effects of sham acupuncture and conventional therapy were 22.6 and 15.8 points at a 0-100 NRS scale. The absolute effect of true acupuncture was 26.1 points for low back pain (relative effect of 3.5 and 9.4 points to sham and conventional therapy), 34.9 points for other pain body locations (relative effect of 12.3 and 19.1 points to sham and conventional therapy), in patients with a baseline pain intensity of 60 points.

CONCLUSION

The treatment duration of acupuncture will not be less than 5 weeks to achieve 80% maximum analgesic effect. Higher analgesic effect was related to higher baseline pain intensity and pain location of neck, shoulder and knee.

SIGNIFICANCE

Our systematic review and meta-analysis provides the clear evidence for the treatment duration and significant related covariates of acupuncture intervention for chronic pain. These results provide useful suggestion for acupuncture intervention in clinical pain management.

The epidemiology of regular opioid use and its association with mortality: Prospective cohort study of 466 486 UK biobank participants

BACKGROUND

Opioids have, at most, small benefits for non-cancer pain in the medium and long-term but there is good evidence that they cause harm. The current study describes the characteristics and clinical status of people taking regular opioids in Great Britain and determines whether use is associated with mortality risk.

METHODS

An analysis of participants in UK Biobank, a prospective population-based study. At recruitment (2006-10) participants reported medicines which they regularly used in addition to lifestyle and health-related factors. Information was available on deaths until October 2016.

FINDINGS

There were 466 486 participants (54% women) aged 40-69 years and without a prior history of cancer of whom 5.5% were regularly using opioids. Use increased with age-group, was more common in females (6.3% v. 4.6%) and 87% of persons using them reported chronic pain. The highest rates of use (~1 in 9) were in people with low household income, who left school <16 years and lived in areas with high deprivation. Amongst 15,032 people who could not work because of ill-health, 1 in 3 were regularly taking opioids. Regular users reported insomnia (88.7%), a recent major recent life event (57.3%) and were much more likely than non-users to rate their health as poor (RR 5.5, 99% CI (4.9, 6.1)). Those taking weak (4.2% of participants) or strong (1.4%) opioids were more likely to die during follow-up (6.9% and 9.1% respectively v. 3.3% in non-users) an excess which remained after adjustment for demographic, socio-economic, health and lifestyle factors (MRR 1.18 99% CI (1.06, 1.32) and 1.20 99% CI (1.01, 1.43)) respectively.

INTERPRETATION

Regular use of opioids is common in Great Britain, particularly in groups of low socio-economic status. Most users still report chronic pain, poor health generally and are at increased risk of premature death although it is not established that this relationship is causal.

FUNDING

There were no external sources of funding obtained for the current analyses.

The Association Between Alcohol Consumption and Pain Interference in a Nationally Representative Sample: The Moderating Roles of Gender and Alcohol Use Disorder Symptomatology

BACKGROUND

Prior research on alcohol consumption and pain has yielded inconsistent results regarding the directionality of effects for both consumption-to-pain and pain-to-consumption relations. The present study sought to examine directionality of these relations by testing bidirectional longitudinal associations between consumption and pain interference, a crucial aspect of pain that captures pain-related disability and has been regarded as a valuable measure of treatment outcome. In addition, this study explored possible moderation of these bidirectional longitudinal associations by gender and alcohol use disorder (AUD) symptomatology.

METHODS

Analyses included 29,989 current/former drinkers who were interviewed at both waves (2001 and 2004) of the U.S. National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Analyses used self-report data from both waves on past-year average daily volume of alcohol consumed and past-month pain interference (1 item from the Medical Outcomes Study 12-item Short-Form Health Survey [MOS-SF-12]). AUDADIS-IV data from Wave 1 were used to index baseline AUD symptomatology (i.e., symptom count). Cross-lagged panel modeling and multigroup analyses were employed.

RESULTS

Regarding the consumption-to-pain-interference relation, in general, higher baseline alcohol consumption was associated with lower subsequent pain interference at follow-up. However, among men with higher AUD-symptom counts, the opposite pattern emerged, with higher baseline alcohol consumption being significantly related to higher subsequent pain interference at follow-up. Regarding the pain-interference-to-consumption relation, higher baseline pain interference was significantly associated with lower subsequent alcohol consumption at follow-up, and no moderating effects were observed.

CONCLUSIONS

The distinctive patterns of the consumption-to-pain-interference relation observed among men with elevated AUD symptomatology suggest that this relation might be driven by different mechanisms across different groups of individuals. Specifically, the detrimental effect of alcohol on pain interference might emerge at relatively advanced stages of AUD among men, consistent with Koob's Dark Side of Alcohol Addiction theory in human research.

Mental health in UK Biobank - development, implementation and results from an online questionnaire completed by 157 366 participants: a reanalysis

BACKGROUND

UK Biobank is a well-characterised cohort of over 500 000 participants including genetics, environmental data and imaging. An online mental health questionnaire was designed for UK Biobank participants to expand its potential.

AIMS

Describe the development, implementation and results of this questionnaire.

METHOD

An expert working group designed the questionnaire, using established measures where possible, and consulting a patient group. Operational criteria were agreed for defining likely disorder and risk states, including lifetime depression, mania/hypomania, generalised anxiety disorder, unusual experiences and self-harm, and current post-traumatic stress and hazardous/harmful alcohol use.

RESULTS

A total of 157 366 completed online questionnaires were available by August 2017. Participants were aged 45-82 (53% were ≥65 years) and 57% women. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status. Lifetime depression was a common finding, with 24% (37 434) of participants meeting criteria and current hazardous/harmful alcohol use criteria were met by 21% (32 602), whereas other criteria were met by less than 8% of the participants. There was extensive comorbidity among the syndromes. Mental disorders were associated with a high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.

CONCLUSIONS

The UK Biobank questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed because of selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.

"Dr. Google, I am in Pain"-Global Internet Searches Associated with Pain: A Retrospective Analysis of Google Trends Data

We aimed to rank the most common locations of pain among Google users globally and locally and analyze secular and seasonal trends in pain-related searches in the years 2004–2019. We used data generated by Google Trends (GT) to identify and analyze global interest in topics (n = 24) related to locations of pain and how these progressed over time. We analyzed secular trends and time series decomposition to identify seasonal variations. We also calculated the interest in all topics with reference to the relative search volume (RSV) of “Abdominal pain”. Google users were most commonly interested in “Headache” (1.30 [times more frequently than “Abdominal pain”]), “Abdominal pain” (1.00), and “Back pain” (0.84). “Headache” was the most frequent search term in n = 41 countries, while “Abdominal pain” was the most frequent term in n = 27 countries. The interest in all pain-related topics except “Dyspareunia” increased over time. The sharpest increase was observed for “Abdominal pain” (5.67 RSV/year), and “Toothache” (5.52 RSV/year). Most of the topics revealed seasonal variations. Among pain-related topics, “Headache,” “Abdominal pain,” and “Back pain” interested most Google users. GT is a novel tool that allows retrospective investigation of complaints among Internet users.

The prevalence of co-morbidities and their impact on physical activity in people with inflammatory rheumatic diseases compared with the general population: results from the UK Biobank

Objectives

To compare the prevalence and incidence of chronic co-morbidities in people with inflammatory rheumatic and musculoskeletal diseases (iRMDs), and to determine whether the prevalent co-morbidities are associated with physical activity levels in people with iRMDs and in those without iRMDs.

Methods

Participants were recruited to the UK Biobank; a population-based cohort. Data were collected about demographics, physical activity, iRMDs (RA, PsA, AS, SLE) and other chronic conditions, including angina, myocardial infarction, stroke, hypertension, pulmonary disease, diabetes and depression. The standardized prevalence of co-morbidities in people with iRMDs was calculated. Cox regression was used to determine the relationship between the presence of an iRMD and an incident co-morbidity. The relationship between the presence (versus absence) of a (co-)morbidity and physical activity level (low, moderate, high) in people with iRMDs and in those without was assessed using multinomial logistic regression.

Results

A total of 488 991 participants were included. The estimated prevalence of each co-morbidity was increased in participants with an iRMD, compared with in those without, particularly for stroke in participants with SLE (standardized morbidity ratio (95% CI), 4.9 (3.6, 6.6). Compared with people with no iRMD and no morbidity, the odds ratios (95% CI) for moderate physical activity were decreased for: no iRMD and morbidity, 0.87 (0.85, 0.89); iRMD and no co-morbidity, 0.71 (0.64, 0.80); and iRMD and co-morbidity, 0.58 (0.54, 0.63).

Conclusion

Having a (co-)morbidity is associated with reduced physical activity in the general population, and to a greater extent in participants with an iRMD. Optimal management of both iRMDs and co-morbidities may help to reduce their impact on physical activity.

Chronic pain: a review of its epidemiology and associated factors in population-based studies

Chronic pain is a common, complex, and distressing problem that has a profound impact on individuals and society. It frequently presents as a result of a disease or an injury; however, it is not merely an accompanying symptom, but rather a separate condition in its own right, with its own medical definition and taxonomy. Studying the distribution and determinants of chronic pain allows us to understand and manage the problem at the individual and population levels. Targeted and appropriate prevention and management strategies need to take into account the biological, psychological, socio-demographic, and lifestyle determinants and outcomes of pain. We present a narrative review of the current understanding of these factors.

What is the effect of alcohol consumption on the risk of chronic widespread pain? A Mendelian randomisation study using UK Biobank

Studies have shown that moderate alcohol consumption is strongly associated with reduced reporting of chronic widespread pain (CWP). The study designs used, however, are prone to confounding and are not able to establish the direction of causality. The current study overcomes these problems using the Mendelian randomisation design to determine the effect of alcohol consumption on the likelihood of reporting CWP. The UK Biobank recruited 500,000 participants aged between 40 and 69 years. Data collected included questions on chronic pain and alcohol consumption, and biological samples providing genotypic information. Alcohol consumption was categorised as "weekly consumption" or "nonfrequent or infrequent." Participants were classified by genotype according to alleles of the rs1229984 single-nucleotide polymorphism, either "GG" or "AA/AG." Chronic widespread pain was defined as pain all over the body for more than 3 months that interfered with activities. Associations between genotype, CWP, and alcohol consumption were tested by logistic regression. Instrumental variable analysis was used to calculate the causal effect of weekly alcohol consumption on CWP. Persons with "GG" genotype had an increased risk of CWP (odds ratio [OR] 1.17, 99% confidence interval 1.01-1.35) and were more likely to consume alcohol weekly (OR 1.76, 1.70-1.81) compared to those with "AA/AG" genotype. Weekly consumption of alcohol was associated with reduced risk of CWP (OR 0.33, 0.31-0.35), but instrumental variable analysis did not show a causal effect of alcohol consumption on reducing CWP (OR 1.29, 0.96-1.74). An interpretation of observational population studies as showing a protective effect of alcohol on CWP is not supported.

Queixas musculoesqueléticas no ombro: características dos usuários e dos atendimentos na atenção primária

RESUMO A dor no ombro representa a terceira principal queixa musculoesquelética da população. Afeta fatores físicos, psicológicos e econômicos do indivíduo. A atenção primária à saúde é essencial para a eficácia do cuidado dos pacientes acometidos. Este estudo é observacional transversal e obteve um perfil dos usuários e das consultas médicas com relato de dor no ombro durante um ano na atenção primária do município de Ribeirão Preto (SP). Foram analisados em prontuários os registros das consultas médicas agendadas e sem agendamento prévio. Nestes registros foram coletados dados dos pacientes que apresentaram queixas de dor musculoesquelética no ombro (dados sociodemográficos e características das consultas), que foram analisados de forma descritiva e pelos testes qui-quadrado de Pearson, razão de chance e regressão logística múltipla. A frequência de consultas médicas por queixa de dor no ombro foi de 9,2%. O perfil dos indivíduos que se queixaram de dor no ombro se caracterizava por mulheres, com idade avançada, casadas, alfabetizadas e que apresentavam alguma ocupação. As consultas em sua maioria tiveram retornos agendados, oferecimento de orientações terapêuticas e poucos encaminhamentos.

Evaluation of uptake and effect on patient-reported outcomes of a clinician and patient co-led chronic musculoskeletal pain self-management programme provided by the UK National Health Service

In the United Kingdom, chronic pain affects approximately 28 million adults, creating significant healthcare and socio-economic costs. The aim was to establish whether a programme designed to use best evidence of content and delivery will be used by patients with significant musculoskeletal pain problems. Of 528 patients recruited, 376 participated in a 7-week-long group-based self-management programme (SMP) co-delivered by clinical and lay tutors. Of these, 308 patients (mean age, 53 years; 69% females, 94% White) completed at least five SMP sessions. Six months after pre-course assessment, participants reported significantly improved patient activation and health status, lower depression and anxiety scores, decreased pain severity and interference, and improved self-management skills. There were no improvements in health state and pain self-efficacy. Uptake rate was 71% and completion 82%. The results should be of value to commissioners of pathways of care for the large numbers of patients attending the English NHS for chronic musculoskeletal pain.

Mental health in UK Biobank: development, implementation and results from an online questionnaire completed by 157 366 participants

BACKGROUND

UK Biobank is a well-characterised cohort of over 500 000 participants that offers unique opportunities to investigate multiple diseases and risk factors.

AIMS

An online mental health questionnaire completed by UK Biobank participants was expected to expand the potential for research into mental disorders.

METHOD

An expert working group designed the questionnaire, using established measures where possible, and consulting with a patient group regarding acceptability. Case definitions were defined using operational criteria for lifetime depression, mania, anxiety disorder, psychotic-like experiences and self-harm, as well as current post-traumatic stress and alcohol use disorders.

RESULTS

157 366 completed online questionnaires were available by August 2017. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status than the general population across a range of indicators. Thirty-five per cent (55 750) of participants had at least one defined syndrome, of which lifetime depression was the most common at 24% (37 434). There was extensive comorbidity among the syndromes. Mental disorders were associated with high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.

CONCLUSIONS

The questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed owing to selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.

DECLARATION OF INTEREST

G.B. received grants from the National Institute for Health Research during the study; and support from Illumina Ltd. and the European Commission outside the submitted work. B.C. received grants from the Scottish Executive Chief Scientist Office and from The Dr Mortimer and Theresa Sackler Foundation during the study. C.S. received grants from the Medical Research Council and Wellcome Trust during the study, and is the Chief Scientist for UK Biobank. M.H. received grants from the Innovative Medicines Initiative via the RADAR-CNS programme and personal fees as an expert witness outside the submitted work.

Comparison of Sociodemographic and Health-Related Characteristics of UK Biobank Participants With Those of the General Population

The UK Biobank cohort is a population-based cohort of 500,000 participants recruited in the United Kingdom (UK) between 2006 and 2010. Approximately 9.2 million individuals aged 40–69 years who lived within 25 miles (40 km) of one of 22 assessment centers in England, Wales, and Scotland were invited to enter the cohort, and 5.5% participated in the baseline assessment. The representativeness of the UK Biobank cohort was investigated by comparing demographic characteristics between nonresponders and responders. Sociodemographic, physical, lifestyle, and health-related characteristics of the cohort were compared with nationally representative data sources. UK Biobank participants were more likely to be older, to be female, and to live in less socioeconomically deprived areas than nonparticipants. Compared with the general population, participants were less likely to be obese, to smoke, and to drink alcohol on a daily basis and had fewer self-reported health conditions. At age 70–74 years, rates of all-cause mortality and total cancer incidence were 46.2% and 11.8% lower, respectively, in men and 55.5% and 18.1% lower, respectively, in women than in the general population of the same age. UK Biobank is not representative of the sampling population; there is evidence of a “healthy volunteer” selection bias. Nonetheless, valid assessment of exposure-disease relationships may be widely generalizable and does not require participants to be representative of the population at large.

Understanding cultural influences on back pain and back pain research

Low back pain is highly prevalent and places a considerable burden on individuals, their families and communities. This back pain burden is unequally distributed around the world and within populations. Clinicians and researchers addressing back pain should be aware of the cultural, social and political context of back pain patients and how this context can influence pain perception, disability and health care use. Culture, which influences the beliefs and behaviour of individuals within a social group, could be considered an important contributor to the unequal distribution of back pain. However, there is paucity of high-quality research exploring the influence of culture on the experience and management of back pain. Further development and testing of specific tools, assessment methods and communication strategies are needed to improve our understanding of how cultural practices, values and identifications affect those dealing with back pain.

Persons with chronic widespread pain experience excess mortality: longitudinal results from UK Biobank and meta-analysis

Objective

It is uncertain whether persons with chronic widespread pain (CWP) experience premature mortality. Using the largest study conducted, we determine whether such a relationship exists, estimate its magnitude and establish what factors mediate any relationship.

Methods

UK Biobank, a cohort study of 0.5 million people aged 40–69 years, recruited throughout Great Britain in 2006–2010. Participants reporting ‘pain all over the body’ for >3 months were compared with persons without chronic pain. Information on death (with cause) was available until mid-2015. We incorporated these results in a meta-analysis with other published reports to calculate a pooled estimate of excess risk.

Results

7130 participants reported CWP and they experienced excess mortality (mortality risk ratio 2.43, 95%CI 2.17 to 2.72). Specific causes of death in excess were cancer (1.73adjusted age and sex, 95% CI 1.46 to 2.05), cardiovascular (3.24adjusted age and sex, 95% CI 2.55 to 4.11), respiratory (5.66adjusted age and sex, 95% CI 4.00 to 8.03) and other disease-related causes (4.04adjusted age and sex, 95% CI 3.05 to 5.34). Excess risk was substantially reduced after adjustment for low levels of physical activity, high body mass index, poor quality diet and smoking. In meta-analysis, all studies showed significant excess all-cause (combined estimate 1.59 (95% CI 1.05 to 2.42)), cardiovascular and cancer mortality.

Conclusions

Evidence is now clear that persons with CWP experience excess mortality. UK Biobank results considerably reduce uncertainty around the magnitude of excess risk and are consistent with the excess being explained by adverse lifestyle factors, which could be targeted in the management of such patients.

Biobanks and Their Clinical Application and Informatics Challenges

Biobanks are one of the most important biomedical research resources and contribute to the development of biomarker detection, molecular diagnosis, translational medicine, and multidisciplinary disease research, as well as studies of interactions between genetic and environmental or lifestyle factors. Aiming for the wide clinical application of biobanks, biobanking efforts have recently switched from a focus on accumulating samples to both formalizing and sustaining collections in light of the rapid progress in the fields of personalized medicine and bioinformatics analysis. With the emergence of novel molecular diagnostic technologies, although the bioinformatics platform of biobanks ensures reliable bioinformatics analysis of patient samples, there are a series of challenges facing biobanks in terms of the overall harmonization of policies, integrated processes, and local informatics solutions across the network. Further, there is a controversy regarding the increased role of ethical boards, governance, and accreditation bodies in ensuring that collected samples have sufficient informatics capabilities to be used in biobanks. In this volume, we present a selection of current issues on the inevitable challenges of the clinical application of biobanks in informatics.

Physiotherapy for patients with shoulder pain in primary care: a descriptive study of diagnostic- and therapeutic management

BACKGROUND

Shoulder pain is one of the three main musculoskeletal complaints and more than 50% of the patients have symptoms longer than 6 months. Until now, limited data exist about the content of physiotherapy for patients with shoulder pain in primary care.

OBJECTIVE

Describe current physiotherapeutic diagnostic- and therapeutic management, including the use of diagnostic ultrasound, in patients with shoulder pain in primary care.

DESIGN AND SETTING

A prospective cohort study in primary care physiotherapy with a 12 week follow-up.

METHODS

Descriptive data from physiotherapists was collected, such as: the diagnostic hypotheses after patient history and physical examination, the use of specific tests and diagnostic ultrasound, the interventions used and possible changes in treatment plan.

RESULTS

Subacromial impingement syndrome was the most common hypothesis after patient history (48%) as well as physical examination (39%). Diagnostic ultrasound was used in 31% and of these patients the clinical diagnosis changed in 29%. Various interventions were used in all clinical diagnoses. After 12 weeks 41% of patients still received physiotherapy treatment.

CONCLUSIONS

Patients with shoulder pain in physiotherapy practice frequently show signs of subacromial impingement syndrome. The interventions used by the physiotherapists were generally in line with the guideline for subacromial impingement syndrome however a small proportion of physiotherapists used massage and tape/bracing techniques. A large proportion of patients were still receiving treatment after 12 weeks when no improvement was observed. If treatment for patients with subacromial impingement shows no benefit patients should be referred back to the general practitioner or orthopedic surgeon. Conclusions from this study might be slightly biased because of the selection of physiotherapists.

Intrathecal drug delivery systems for the management of chronic non-cancer pain: protocol for a systematic review of economic evaluations

INTRODUCTION

Intrathecal drug delivery (ITDD) systems are an option for the management of patients with chronic non-cancer pain, cancer pain and spasticity. Concerns over their invasiveness and high initial costs have led National Health Service (NHS) England to decommission ITDD for patients with chronic non-cancer pain. However, the extent to which this decision is in line with existing economic evidence is unclear. To address this question, we will carry out a systematic review to identify and evaluate the existing evidence on the cost-effectiveness of ITDD for chronic non-cancer pain.

METHODS AND ANALYSIS

A high-sensitivity search strategy will be employed in Cochrane Library, MEDLINE, EMBASE, Web of Science, NHS EED, DARE and HTA. Database searches will be complemented by additional searching techniques. Screening of the results will be performed by 2 reviewers independently using predetermined inclusion and exclusion criteria. Full and partial economic evaluations will be included. Data extraction will be carried out using a form created for the purposes of this review. Quality assessment of all included studies will be performed using recommended checklists.

ETHICS AND DISSEMINATION

Ethical approval is not required as primary data will not be collected. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42016035266.