Effectiveness and cost-effectiveness of a web-based cardiac rehabilitation programme for people with chronic stable angina: protocol for the ACTIVATE (Angina Controlled Trial Investigating the Value of the 'Activate your heart' Therapeutic E-intervention) randomised controlled trial

INTRODUCTION

Chronic stable angina is common and disabling. Cardiac rehabilitation is routinely offered to people following myocardial infarction or revascularisation procedures and has the potential to help people with chronic stable angina. However, there is insufficient evidence of effectiveness and cost-effectiveness for its routine use in this patient group. The objectives of this study are to compare the effectiveness and cost-effectiveness of the 'Activate Your Heart' cardiac rehabilitation programme for people with chronic stable angina compared with usual care.

METHODS AND ANALYSIS

ACTIVATE is a multicentre, parallel-group, two-arm, superiority, pragmatic randomised controlled trial, with recruitment from primary and secondary care centres in England and Wales and a target sample size of 518 (1:1 allocation; allocation sequence by minimisation programme with built-in random element). The study uses secure web-based allocation concealment. The two treatments will be optimal usual care (control) and optimal usual care plus the 'Activate Your Heart' web-based cardiac rehabilitation programme (intervention). Outcome assessment and statistical analysis will be performed blinded; participants will be unblinded. Outcomes will be measured at baseline and at 6 and 12 months' follow-up. Primary outcome will be the UK version of Seattle Angina Questionnaire (SAQ-UK), physical limitations domain at 12 months' follow-up. Secondary outcomes will be the remaining two domains of SAQ-UK, dyspnoea, anxiety and depression, health utility, self-efficacy, physical activity and the incremental shuttle walk test. All safety events will be recorded, and serious adverse events assessed to determine whether they are related to the intervention and expected. Concurrent economic evaluation will be cost-utility analysis from health service perspective. An embedded process evaluation will determine the mechanisms and processes that explain the implementation and impacts of the cardiac rehabilitation programme.

ETHICS AND DISSEMINATION

North of Scotland National Health Service Research Ethics Committee approval, reference 21/NS/0115. Participants will provide written informed consent. Results will be disseminated by peer-reviewed publication.

TRIAL REGISTRATION NUMBER

ISRCTN10054455.

Antihypertensive treatment in people of very old age with frailty: time for a paradigm shift?

The optimal management of hypertension in individuals aged 80 years or older with frailty remains uncertain due to multiple gaps in evidence. Complex health issues, polypharmacy, and limited physiological reserve make responding to antihypertensive treatments unpredictable. Patients in this age group may have limited life expectancy, so their quality of life should be prioritized when making treatment decisions. Further research is needed to identify which patients would benefit from more relaxed blood pressure targets and which antihypertensive medications are preferable or should be avoided. A paradigm shift is required in attitudes towards treatment, placing equal emphasis on deprescribing and prescribing when optimizing care. This review discusses the current evidence on managing hypertension in individuals aged 80 years or older with frailty, but further research is essential to address the gaps in knowledge and improve the care of this population.

Barriers to and facilitators of physical activity in adults living with and beyond cancer, with special emphasis on head and neck cancer: a systematic review of qualitative and mixed methods studies

PURPOSE

Physical activity can improve health outcomes for cancer patients; however, only 30% of patients are physically active. This review explored barriers to and facilitators of physical activity promotion and participation in patients living with and beyond cancer. Secondary aims were to (1) explore similarities and differences in barriers and facilitators experienced in head and neck cancer versus other cancers, and (2) identify how many studies considered the influence of socioeconomic characteristics on physical activity behaviour.

METHODS

CINAHL Plus, MEDLINE, PsycINFO, Scopus and Cochrane (CDSR) were searched for qualitative and mixed methods evidence. Quality assessment was conducted using the Mixed Methods Appraisal Tool and a Critical Appraisal Skills Programme Tool. Thematic synthesis and frequency of reporting were conducted, and results were structured using the Capability-Opportunity-Motivation-Behaviour model and Theoretical Domains Framework.

RESULTS

Thirty qualitative and six mixed methods studies were included. Socioeconomic characteristics were not frequently assessed across the included studies. Barriers included side effects and comorbidities (physical capability; skills) and lack of knowledge (psychological capability; knowledge). Having a dry mouth or throat and choking concerns were reported in head and neck cancer, but not across other cancers. Facilitators included improving education (psychological capability; knowledge) on the benefits and safety of physical activity.

CONCLUSION

Educating patients and healthcare professionals on the benefits and safety of physical activity may facilitate promotion, uptakeand adherence. Head and neck cancer patients experienced barriers not cited across other cancers, and research exploring physical activity promotion in this patient group is required to improve physical activity engagement.

Effects of different exercise types on quality of life for patients with atrial fibrillation: a systematic review and meta-analysis

AIM

To investigate the effectiveness of exercise and the most effective types of exercise for patients with atrial fibrillation (AF) to improve health-related quality of life (HRQoL) and exercise capacity, and reduce AF burden, AF recurrence and adverse events.

METHODS AND RESULTS

Systematic search in PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL Plus, and SPORTDiscus for randomized controlled trials (RCTs) and nonrandomized pre-post intervention studies investigating the effect of different types of exercise on AF patients. After exclusion, 12 studies (11 RCTs, 1 prepost) with a total of 670 participants were included. Exercise interventions consisted of aerobic exercise, aerobic interval training (AIT), Qigong, yoga, and exercise-based cardiac rehabilitation (CR). There were significant positive effects of exercise on general health {mean difference [MD] = 6.42 [95% confidence interval (CI): 2.90, 9.93]; P = 0.0003; I2 = 17%} and vitality [MD = 6.18 (95% CI: 1.94, 10.41); P = 0.004; I2 = 19%)] sub-scales of the Short Form 36-item questionnaire (SF-36). Qigong resulted in a significant improvement in the 6-min walk test [MD = 105.00m (95% CI: 19.53, 190.47)]. Exercise-based CR and AIT were associated with a significant increment in V̇O2peak, and AIT significantly reduced AF burden. Adverse events were few and one intervention-related serious adverse event was reported for exercise-based CR.

CONCLUSION

Exercise led to improvements in HRQoL, exercise capacity, and reduced AF burden. The available exercise interventions for AF patients are few and heterogeneous. Future studies are needed for all types of exercise intervention in this patient group to (co-)develop an optimized exercise training intervention for AF patients.

STIMULATE-ICP-CAREINEQUAL (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways) study protocol: Defining usual care and examining inequalities in Long Covid support

INTRODUCTION

Individuals with Long Covid represent a new and growing patient population. In England, fewer than 90 Long Covid clinics deliver assessment and treatment informed by NICE guidelines. However, a paucity of clinical trials or longitudinal cohort studies means that the epidemiology, clinical trajectory, healthcare utilisation and effectiveness of current Long Covid care are poorly documented, and that neither evidence-based treatments nor rehabilitation strategies exist. In addition, and in part due to pre-pandemic health inequalities, access to referral and care varies, and patient experience of the Long Covid care pathways can be poor. In a mixed methods study, we therefore aim to: (1) describe the usual healthcare, outcomes and resource utilisation of individuals with Long Covid; (2) assess the extent of inequalities in access to Long Covid care, and specifically to understand Long Covid patients' experiences of stigma and discrimination.

METHODS AND ANALYSIS

A mixed methods study will address our aims. Qualitative data collection from patients and health professionals will be achieved through surveys, interviews and focus group discussions, to understand their experience and document the function of clinics. A patient cohort study will provide an understanding of outcomes and costs of care. Accessible data will be further analysed to understand the nature of Long Covid, and the care received.

ETHICS AND DISSEMINATION

Ethical approval was obtained from South Central-Berkshire Research Ethics Committee (reference 303958). The dissemination plan will be decided by the patient and public involvement and engagement (PPIE) group members and study Co-Is, but will target 1) policy makers, and those responsible for commissioning and delivering Long Covid services, 2) patients and the public, and 3) academics.

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background

As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain.

Objectives

To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention.

Data sources

Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews.

Design

Realist evidence synthesis and co-design for primary care service innovation.

Setting

Primary care in Wales and England.

Participants

Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers.

Methods

The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation.

Results

Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change.

Limitations

Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts.

Conclusions

We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

Future work

A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial.

Study registration

This study is registered as PROSPERO CRD42018103027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

Development of an intervention to expedite cancer diagnosis through primary care: a protocol

BACKGROUND

GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms.

AIM

This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes.

DESIGN & SETTING

Non-experimental mixed-method study with GPs and primary care practice teams from Wales.

METHOD

Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial.

RESULTS

The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis.

CONCLUSION

This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.

Mixed methods process evaluation of an enhanced community-based rehabilitation intervention for elderly patients with hip fracture

OBJECTIVES

To describe the implementation of an enhanced rehabilitation programme for elderly hip fracture patients with mental capacity, in a randomised feasibility study compared with usual rehabilitation. To compare processes between the two and to collect the views of patients, carers and therapy staff about trial participation.

DESIGN

Mixed methods process evaluation in a randomised feasibility study.

SETTING

Patient participants were recruited on orthopaedic and rehabilitation wards; the intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Sixty-one older adults (aged ≥65 years) recovering from surgical treatment (replacement arthroplasty or internal fixation) following hip fracture, who were living independently prior to fracture and had mental capacity and 31 of their carers.

INTERVENTIONS

Usual care (control) or usual care plus an enhanced rehabilitation package (intervention). The enhanced rehabilitation consisted of a patient-held information workbook, goal-setting diary and up to six additional therapy sessions.

PROCESS EVALUATION COMPONENTS

Recruitment of sites and rehabilitation teams, response of rehabilitation teams, recruitment and reach in patient and carer participants, intervention delivery, delivery to individuals, response of individual patients to the enhanced intervention or usual rehabilitation, response of carer participants, unintended consequences and testing intervention theory and context.

RESULTS

Usual rehabilitation care was very variable. The enhanced rehabilitation group received a mean of five additional therapy sessions. All of the returned goal-setting diaries had inputs from the therapy team, and half had written comments by the patients and carers. Focus group themes: variation of usual care and its impact on delivering the intervention; the importance of goal setting; the role of the therapist in providing reassurance about safe physical activities; and acceptability of the extra therapy sessions.

CONCLUSIONS

Lessons learnt for a future definitive RCT include how to enhance recruitment and improve training materials, the workbook, delivery of the extra therapy sessions and recording of usual rehabilitation care.

TRIAL REGISTRATION NUMBER

ISRCTN22464643; Post- results.

Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC)

BACKGROUND

Adalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early.

METHODS

A pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months' duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase.

RESULTS

The internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants.

CONCLUSIONS

Improved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN14569274 . Registered on 15 December 2014.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Hip fracture in the elderly multidisciplinary rehabilitation (FEMuR) feasibility study: testing the use of routinely collected data for future health economic evaluations

Background

Health economic evaluations rely on the accurate measurement of health service resource use in order to calculate costs. These are usually measured with patient completed questionnaires using instruments such as the Client Service Receipt Inventory (CSRI). These rely on participants' recall and can be burdensome to complete. Health service activity data are routinely captured by electronic databases.The aim was to test methods for obtaining these data and compare with those data collected using the CSRI, within a feasibility study of an enhanced rehabilitation intervention following hip fracture (Fracture in the Elderly Multidisciplinary Rehabilitation: FEMuR).

Methods

Primary care activity including prescribing data was obtained from the Secure Anonymised Information Linkage (SAIL) Databank and secondary care activity (Emergency Department attendances, out-patient visits and in-patient days) directly from Betsi Cadwaladr University Health Board (BCUHB), North Wales, UK. These data were compared with patient responses from the CSRI using descriptive statistics and the intraclass correlation coefficient (ICC).

Results

It was possible to compare health service resource use data for 49 out of 61 participants in the FEMuR study. For emergency department (ED) attendances, records matched in 23 (47%) cases, 21 (43%) over-reported on electronic records compared with CSRI and five participants (10%) under-reported, with an overall ICC of 0.42. For out-patient episodes, records matched in only six cases, 28 participants over-reported on electronic records compared with CSRI and 15 (12%) under-reported, with an overall ICC of only 0.27. For in-patient days, records matched exactly in only five cases (10%), but if an error margin of 7 days was allowed, then agreement rose to 39 (66%) cases, and the overall ICC for all data was 0.88.It was only possible to compare prescribing data for 12 participants. For prescribing data, the SAIL data reported 117 out of 118 items (99%) and the CSRI only 89 (79%) items.

Conclusions

The use of routinely collected data has the potential to improve the efficiency of trials and other studies. Although the methodology to make the data available has been demonstrated, the data obtained was incomplete and the validity of using this method remains to be demonstrated.

Trial registration

Trial registration: ISRCTN22464643 Registered 21 July 2014.

Impact of health challenges on pig growth performance, carcass characteristics, and net returns under commercial conditions

Understanding how disease affects commercial production is imperative for pig producers to quantify its full impact on pig performance, carcass quality, and net returns. The objective of this experiment was to assess the productivity and economic importance of naturally occurring health challenges (HC) under commercial conditions. Three 1,000 pig grow-finish facilities received 936 pigs each. The experimental period started approximately 34 d post placement at an average start BW of 13.1 ± 0.2 kg. Barns were characterized based on the relative HC, determined by diagnostic assessments as the main characterization tool, along with other health indicators. Barns were characterized as low challenge health (LCh), moderate challenge health (MCh), and high challenge health (HCh). All barns tested positive for porcine reproductive and respiratory syndrome virus infection prior to the start of the experiment. Additionally, the MCh and HCh barns experienced influenza type A virus of swine. Similar to commercial production conditions, the disease challenge was not imposed but rather occurred naturally. Reduced ADG, ADFI, and G:F were observed with an increased HC (P < 0.001). Similarly, mortality was increased when the HC increased (P < 0.001). Decreased ADG increased days to achieve harvest BW, by 10 and 15 d in the MCh and HCh treatments compared with LCh, respectively (P < 0.001). No differences were observed for percent lean, loin depth, or fat depth (P > 0.10). The economic impact of the HC was assessed by applying these growth performance data to two economic models encompassing the two main marketing methods used by U.S. pig producers: fixed-weight and fixed-time. Financial losses attributed to the variation in disease severity that occurred in the present study ranged from $8.49 and $26.10 U.S. dollars (USD)/pig marketed using a fixed-market weight model, or between $11.02 and $29.82 USD/pig using a fixed-time model, depending on feed costs and market hog prices. In conclusion, increasing severity of HC under commercial conditions reduced ADG by 8% and 14% and resulted in mortality as high as 19.9%. Losses of $8.49 to $29.82/pig marketed underscore the potential magnitude of the economic impact of mixed etiology concurrent diseases in pork production.

Subcutaneous Injection of Adalimumab Trial compared with Control (SCIATiC): a randomised controlled trial of adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica

BACKGROUND

Biological treatments such as adalimumab (Humira^®; AbbVie Ltd, Maidenhead, UK) are antibodies targeting tumour necrosis factor alpha, released from ruptured intervertebral discs, which might be useful in sciatica. Recent systematic reviews concluded that they might be effective, but that a definitive randomised controlled trial was needed. Usual care in the NHS typically includes a physiotherapy intervention.

OBJECTIVES

To test whether or not injections of adalimumab plus physiotherapy are more clinically effective and cost-effective than injections of saline plus physiotherapy for patients with sciatica.

DESIGN

Pragmatic, parallel-group, randomised controlled trial with blinded participants and clinicians, and an outcome assessment and statistical analysis with concurrent economic evaluation and internal pilot.

SETTING

Participants were referred from primary care and musculoskeletal services to outpatient physiotherapy clinics.

PARTICIPANTS

Adults with persistent symptoms of sciatica of 1-6 months' duration and with moderate to high levels of disability. Eligibility was assessed by research physiotherapists according to clinical criteria for diagnosing sciatica.

INTERVENTIONS

After a second eligibility check, trial participants were randomised to receive two doses of adalimumab (80 mg and then 40 mg 2 weeks later) or saline injections. Both groups were referred for a course of physiotherapy.

MAIN OUTCOME MEASURES

Outcomes were measured at the start, and after 6 weeks' and 6 months' follow-up. The main outcome measure was the Oswestry Disability Index (ODI). Other outcomes: leg pain version of the Roland-Morris Disability Questionnaire, Sciatica Bothersomeness Index, EuroQol-5 Dimensions, 5-level version, Hospital Anxiety and Depression Scale, resource use, risk of persistent disabling pain, pain trajectory based on a single question, Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia and adverse effects.

SAMPLE SIZE

To detect an effect size of 0.4 with 90% power, a 5% significance level for a two-tailed t-test and 80% retention rate, 332 participants would have needed to be recruited.

ANALYSIS PLAN

The primary effectiveness analysis would have been linear mixed models for repeated measures to measure the effects of time and group allocation. An internal pilot study would have involved the first 50 participants recruited across all centres. The primary economic analysis would have been a cost-utility analysis.

RESULTS

The internal pilot study was discontinued as a result of low recruitment after eight participants were recruited from two out of six sites. One site withdrew from the study before recruitment started, one site did not complete contract negotiations and two sites signed contracts shortly before trial closure. In the two sites that did recruit participants, recruitment was slow. This was partly because of operational issues, but also because of a low rate of uptake from potential participants.

LIMITATIONS

Although large numbers of invitations were sent to potential participants, identified by retrospective searches of general practitioner (GP) records, there was a low rate of uptake. Two sites planned to recruit participants during GP consultations but opened too late to recruit any participants.

CONCLUSION

The main failure was attributable to problems with contracts. Because of this we were not able to complete the internal pilot or to test all of the different methods for primary care recruitment we had planned. A trial of biological therapy in patients with sciatica still needs to be done, but would require a clearer contracting process, qualitative research to ensure that patients would be willing to participate, and simpler recruitment methods.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14569274.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 60. See the NIHR Journals Library website for further project information.

Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups

OBJECTIVES

To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture.

DESIGN

Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams.

SETTING

North Wales.

PARTICIPANTS

Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13).

RESULTS

The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring.

CONCLUSIONS

A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III).

TRIAL REGISTRATION NUMBER

ISRCTN22464643, Pre-results.

Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR): a phase II randomised feasibility study of a multidisciplinary rehabilitation package following hip fracture

OBJECTIVE

To conduct a rigorous feasibility study for a future definitive parallel-group randomised controlled trial (RCT) and economic evaluation of an enhanced rehabilitation package for hip fracture.

SETTING

Recruitment from 3 acute hospitals in North Wales. Intervention delivery in the community.

PARTICIPANTS

Older adults (aged ≥65) who received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by clinical team) and received rehabilitation in the North Wales area.

INTERVENTION

Remote randomisation to usual care (control) or usual care+enhanced rehabilitation package (intervention), including six additional home-based physiotherapy sessions delivered by a physiotherapist or technical instructor, novel information workbook and goal-setting diary.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary: Barthel Activities of Daily Living (BADL). Secondary measures included Nottingham Extended Activities of Daily Living scale (NEADL), EQ-5D, ICECAP capability, a suite of self-efficacy, psychosocial and service-use measures and costs. Outcome measures were assessed at baseline and 3-month follow-up by blinded researchers.

RESULTS

62 participants were recruited, 61 randomised (control 32; intervention 29) and 49 (79%) completed 3-month follow-up. Minimal differences occurred between the 2 groups for most outcomes, including BADL (adjusted mean difference 0.5). The intervention group showed a medium-sized improvement in the NEADL relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d 0.63), and a trend for greater improvement in self-efficacy and mental health, but with small effect sizes. The mean cost of delivering the intervention was £231 per patient. There was a small relative improvement in quality-adjusted life year in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

The trial methods were feasible in terms of eligibility, recruitment and retention. The effectiveness and cost-effectiveness of the rehabilitation package should be tested in a phase III RCT.

TRIAL REGISTRATION NUMBER

ISRCTN22464643; Results.

Health professionals' perspectives on exercise referral and physical activity promotion in primary care: Findings from a process evaluation of the National Exercise Referral Scheme in Wales

BACKGROUND AND OBJECTIVES

Referring clinicians' experiences of exercise referral schemes (ERS) can provide valuable insights into their uptake. However, most qualitative studies focus on patient views only. This paper explores health professionals' perceptions of their role in promoting physical activity and experiences of a National Exercise Referral Scheme (NERS) in Wales.

DESIGN

Qualitative semi-structured group interviews.

SETTING

General practice premises.

METHODS

Nine semi-structured group interviews involving 46 health professionals were conducted on general practice premises in six local health board areas. Purposive sampling taking into account area deprivation, practice size and referral rates was employed. Interviews were transcribed verbatim and analysed using the Framework method of thematic analysis.

RESULTS

Health professionals described physical activity promotion as important, although many thought it was outside of their expertise and remit, and less important than other health promotion activities such as smoking cessation. Professionals linked decisions on whether to advise physical activity to patients to their own physical activity levels and to subjective judgements of patient motivation. While some described ERS as a holistic alternative to medication, with potential social benefits, others expressed concerns regarding their limited reach and potential to exacerbate inequalities. Barriers to referral included geographic isolation and uncertainties about patient selection criteria, medico-legal responsibilities and a lack of feedback about patient progress.

CONCLUSION

Clinicians' concerns about expertise, priority setting and time constraints should be addressed to enhance physical activity promotion in primary care. Further research is needed to fully understand decision making relating to provision of physical activity advice and use of ERS.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR): study protocol for a phase II randomised feasibility study of a multidisciplinary rehabilitation package following hip fracture [ISRCTN22464643]

BACKGROUND

Proximal femoral fracture is a common, major health problem in old age resulting in loss of functional independence and a high-cost burden on society, with estimated health and social care costs of £2.3 billion per year in the UK. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of effectiveness is lacking. Usual rehabilitation care is delivered by a multi-disciplinary team in the hospital and in the community. An 'enhanced rehabilitation' intervention has been developed consisting of a workbook, goal-setting diary and extra therapy sessions, designed to improve self-efficacy and increase the amount and quality of the practice of physical exercise and activities of daily living.

METHODS/DESIGN

This paper describes the design of a phase II study comprising an anonymous cohort of all proximal femoral fracture patients admitted to the three acute hospitals in Betsi Cadwaladr University Health Board over a 6-month period with a randomised feasibility study comparing the enhanced rehabilitation intervention with usual care. These will assess the feasibility of a future definitive randomised controlled trial and concurrent economic evaluation in terms of recruitment, retention, outcome measure completion, compliance with the intervention and fidelity of delivery, health service use data, willingness to be randomised and effect size for a future sample size calculation. Focus groups will provide qualitative data to contribute to the assessment of the acceptability of the intervention amongst patients, carers and rehabilitation professionals and the feasibility of delivering the planned intervention. The primary outcome measure is function assessed by the Barthel Index. Secondary outcomes measure the ability to perform activities of daily living, anxiety and depression, potential mediators of outcomes such as hip pain, self-efficacy and fear of falling, health utility, health service use, objectively assessed physical function and adverse events. Participants' preference for rehabilitation services will be assessed in a discrete choice experiment.

DISCUSSION

Phase II studies are an opportunity to not only assess the feasibility of trial methods but also to compare different methods of outcome measurement and novel methods of obtaining health service use data from routinely collected patient information.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643, UKCRN16677.

Generic and Subtribal relationShipS in neotropical cymbidieae (orchidaceae) baSed on matK/ycf1 plaStid data

Relationships among all subtribes of Neotropical Cymbidieae (Orchidaceae) were estimated using combined matK/ycf1 plastid sequence data for 289 taxa. The matrix was analyzed using RAxML. Bootstrap (BS) analyses yield 100% BS support for all subtribes except Stanhopeinae (87%). Generic relationships within subtribes are highly resolved and are generally congruent with those presented in previous studies and as summarized in Genera Orchidacearum. Relationships among subtribes are largely unresolved. The Szlachetko generic classification of Maxillariinae is not supported. A new combination is made for Maxillaria cacaoensis J.T.Atwood in Camaridium.

Function of glandular secretions in fragrance collection by male euglossine bees (Apidae: Euglossini)

MaleEulaema cingulata (Fabricius) (Apidae: Euglossini) possess large cephalic labial glands that secrete a mixture of lipids. In the process of fragrance collection, males secrete the labial gland lipids onto the substrate. The mixture of lipids and fragrances is then taken up by the front tarsal brushes and transferred to the hind tibial organs. The labial gland secretions apparently serve as a nonpolar solvent and carrier that increases the efficiency of fragrance collection.

A systematic review and meta-analysis of biological treatments targeting tumour necrosis factor α for sciatica

PURPOSE

Systematic review comparing biological agents, targeting tumour necrosis factor α, for sciatica with placebo and alternative interventions.

METHODS

We searched 21 electronic databases and bibliographies of included studies. We included randomised controlled trials (RCTs), non-RCTs and controlled observational studies of adults who had sciatica treated by biological agents compared with placebo or alternative interventions.

RESULTS

We pooled the results of six studies (five RCTs and one non-RCT) in meta-analyses. Compared with placebo biological agents had: better global effects in the short-term odds ratio (OR) 2.0 (95 % CI 0.7-6.0), medium-term OR 2.7 (95 % CI 1.0-7.1) and long-term OR 2.3 [95 % CI 0.5 to 9.7); improved leg pain intensity in the short-term weighted mean difference (WMD) -13.6 (95 % CI -26.8 to -0.4), medium-term WMD -7.0 (95 % CI -15.4 to 1.5), but not long-term WMD 0.2 (95 % CI -20.3 to 20.8); improved Oswestry Disability Index (ODI) in the short-term WMD -5.2 (95 % CI -14.1 to 3.7), medium-term WMD -8.2 (95 % CI -14.4 to -2.0), and long-term WMD -5.0 (95 % CI -11.8 to 1.8). There was heterogeneity in the leg pain intensity and ODI results and improvements were no longer statistically significant when studies were restricted to RCTs. There was a reduction in the need for discectomy, which was not statistically significant, and no difference in the number of adverse effects.

CONCLUSIONS

There was insufficient evidence to recommend these agents when treating sciatica, but sufficient evidence to suggest that larger RCTs are needed.

The Hip and Knee Book: developing an active management booklet for hip and knee osteoarthritis

BACKGROUND

The pain and disability of hip and knee osteoarthritis can be improved by exercise, but the best method of encouraging this is not known.

AIM

To develop an evidence-based booklet for patients with hip or knee osteoarthritis, offering information and advice on maintaining activity.

DESIGN OF STUDY

Systematic review of reviews and guidelines, then focus groups.

SETTING

Four general practices in North East Wales.

METHOD

Evidence-based messages were developed from a systematic review, synthesised into patient-centred messages, and then incorporated into a narrative. A draft booklet was examined by three focus groups to improve the phrasing of its messages and discuss its usefulness. The final draft was examined in a fourth focus group.

RESULTS

Six evidence-based guidelines and 54 systematic reviews were identified. The focus groups found the draft booklet to be informative and easy to read. They reported a lack of clarity about the cause of osteoarthritis and were surprised that the pain could improve. The value of exercise and weight loss beliefs was accepted and reinforced, but there was a perceived contradiction about heavy physical work being causative, while moderate exercise was beneficial. There was a fear of dependency on analgesia and misinterpretation of the message on hyaluranon injections. The information on joint replacement empowered patients to discuss referral with their GP. The text was revised to accommodate these issues.

CONCLUSION

The booklet was readable, credible, and useful to end-users. A randomised controlled trial is planned, to test whether the booklet influences beliefs about osteoarthritis and exercise.

Activity Increase Despite Arthritis (AIDA): design of a Phase II randomised controlled trial evaluating an active management booklet for hip and knee osteoarthritis [ISRCTN24554946]

BACKGROUND

Hip and knee osteoarthritis is a common cause of pain and disability, which can be improved by exercise interventions. However, regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement. The best method of encouraging increased activity in this patient group is not known. A booklet has been developed for patients with hip or knee osteoarthritis. It focuses on changing disadvantageous beliefs and encouraging increased physical activity.

METHODS/DESIGN

This paper describes the design of a Phase II randomised controlled trial (RCT) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs, and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour. A computerised search of four general medical practice patients' record databases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months. A random sample of 120 will be invited to participate in the RCT comparing the new booklet with a control booklet, and we expect 100 to return final questionnaires. This trial will assess the feasibility of recruitment and randomisation, the suitability of the control intervention and outcome measurement tools, and will provide an estimate of effect size. Outcomes will include beliefs about hip and knee pain, beliefs about exercise, fear avoidance, level of physical activity, health status and health service costs. They will be measured at baseline, one month and three months.

DISCUSSION

We discuss the merits of testing effectiveness in a phase II trial, in terms of intermediate outcome measures, whilst testing the processes for a larger definitive trial. We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24554946.

Nurse-led vs. conventional physician-led follow-up for patients with cancer: systematic review

AIM

This paper is a report of a systematic review of the effectiveness and cost-effectiveness of nurse-led follow-up for patients with cancer.

BACKGROUND

As cancer survivorship increases, conventional follow-up puts a major burden on outpatient services. Nurse-led follow-up is a promising alternative. Data sources. Searches were conducted covering a period from inception to February 2007 of 19 electronic databases, seven online trial registries, five conference proceedings reference lists of previous reviews and included studies.

REVIEW METHODS

Standard systematic review methodology was used. Comparative studies and economic evaluations of nurse-led vs. physician-led follow-up were eligible. Studies comparing different types of nurse-led follow-up were excluded. Any cancer was considered; any outcome measure included.

RESULTS

Four randomised controlled trials were identified, two including cost analyses. There were no statistically significant differences in survival, recurrence or psychological morbidity. One study showed better HRQL measures for nurse-led follow-up, but one showed no difference, two showed a statistically significant difference for patient satisfaction, but two did not. Patients with lung cancer were more satisfied with nurse-led telephone follow-up and more were able to die at home. Patients with breast cancer thought patient-initiated follow-up convenient, but found conventional follow-up more reassuring. One study showed the cost of nurse-led follow-up to be less than that of physician-led follow-up, but no statistical comparison was made.

CONCLUSION

Patients appeared satisfied with nurse-led follow-up. Patient-initiated or telephone follow-up could be practical alternatives to conventional care. However, well-conducted research is needed before equivalence to physician-led follow-up can be assured in terms of survival, recurrence, patient well-being and cost-effectiveness.

Response to dietary digestible energy concentration in growing pigs fed cereal grain-based diets

Understanding how energy is utilized by the pig, and how the pig responds to changes in dietary energy concentration, is essential information in determining the optimal concentration of dietary energy under farm conditions, which are often highly diverse. The objective of these experiments was to determine how changes in dietary DE concentration, achieved through graded changes in diet composition, would affect the performance and carcass composition of growing pigs. In Exp. 1, which was conducted in a research facility, 300 pigs (31.1 +/- 2.6 kg) were assigned to diets containing 3.09, 3.24, 3.34, 3.42, or 3.57 Mcal of DE/kg. Experiment 2, which was conducted at a commercial swine farm, involved 720 pigs (36.8 +/- 5.9 kg) assigned to diets containing 3.12, 3.30, or 3.43 Mcal of DE/kg. Increased DE concentration was attained by using more wheat, soybean meal, and fat and less barley; true ileal lysine was adjusted as DE increased, and minimal AA:lysine ratios were maintained. In Exp. 1, ADG improved linearly as the energy content of the diet increased (P = 0.03). Feed intake decreased (P < 0.001) and feed efficiency and daily caloric intake improved (P = 0.005) with increased DE content. Variability in growth was not affected by treatment. Carcass index and LM thickness were not affected by increasing dietary DE content; backfat thickness, however, was increased (P < 0.001). In Exp. 2, overall ADG was unaffected by dietary energy content, although an improvement in growth was observed until the pigs reached approximately 80 kg of BW. Overall feed intake decreased with increasing energy content (P = 0.01), although this was not observed during the initial 6 wk of the experiment. Carcass index, lean yield, and backfat were not affected by increasing dietary energy content, whereas LM thickness tended to increase (P = 0.08). The value per pig was unaffected by increasing dietary energy content in both experiments, and returns above feed costs were reduced. Increasing the energy density of the diet for growing pigs through incremental changes in dietary composition had a variable impact on overall growth performance and carcass quality. Increasing the dietary DE had no effect on variations in BW at the time of marketing.

A survey of local health promotion initiatives for older people in Wales

Background

As the demographic profile of the UK changes, policy makers and practitioners have to respond to health challenges presented by a progressively ageing population. The health promotion plan for older people, aged over 50 years, in Wales included eight key areas: physical activity, healthy eating, home safety and warmth, emotional health, health protection, smoking, alcohol and sexual health. The aim of this study was to describe the extent, content and regional variation of existing health promotion initiatives for older people in Wales, provided by statutory, voluntary and private sector agencies.

Method

A questionnaire was sent to senior health promotion specialists employed in the 22 local authority areas in Wales to ascertain details of all projects promoting health and wellbeing in the eight key areas where the priority population was aged over 50, or the majority of users were older people. Additional information was sought from project leads and websites.

Results

Eighteen questionnaires were returned; not all were fully completed. Four areas did not return a questionnaire. Additional information was obtained from internet searches but this mainly concerned national initiatives rather than local projects. In all, 120 projects were included, 11 were throughout Wales. Best provision was for physical activity, with 3 national and 42 local initiatives, but local provision was patchy. Healthy eating, and home safety and warmth had far fewer initiatives, as did health protection, which comprised two national immunisation campaigns. Smoking and alcohol misuse were poorly provided for, and there was no provision for older people's sexual health. Evaluation arrangements were poorly described. Half of those who responded identified unmet training needs.

Conclusion

The reasons for patchy provision of services were not clear. Increased efforts to improve the coverage of interventions known to be effective should be made. Rigorous evaluation of projects is needed to ascertain the most effective and appropriate interventions, especially for alcohol misuse and sexual health. These conclusions are relevant to the other countries of the United Kingdom (UK), and more widely across Europe.

Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials

BACKGROUND

The most important risk factors for back and neck pain are psychosocial. Nevertheless, systematic reviews of spinal manipulation have concentrated on pain and spine related disability, and ignored psychological outcomes.

OBJECTIVE

To assess whether spinal manipulation was effective in improving psychological outcome.

DESIGN

Systematic review of randomised controlled trials (RCTs).

METHODS

RCTs were identified by searching Medline, CINAHL, Embase, CENTRAL, AMED, PsycINFO until November 2005. Trials reporting psychological outcomes including the mental health components of generic outcomes were extracted, and combined where appropriate in meta-analyses.

RESULTS

One hundred and twenty nine RCTs of spinal manipulation were identified; 12 had adequately reported psychological outcomes. Six trials with a verbal intervention comparator were combined in a meta-analysis, and found a mean benefit from spinal manipulation equivalent to 0.34 of the population standard deviation (S.D.) [95% confidence interval (CI) 0.23-0.45] at 1-5 months; 0.27 of the S.D. [95% CI 0.14-0.40] at 6-12 months. Eight trials with a physical treatment comparator were combined in a meta-analysis and found a mean benefit of 0.13 of the S.D. [95% CI 0.01-0.24] in favour of manipulation at 1-5 months; 0.11 of the S.D. [95% CI -0.02 to 0.25] at 6-12 months.

CONCLUSIONS

There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.

Dietary B vitamin needs of strains of pigs with high and moderate lean growth12

Ten sets of 5 littermate pigs from each of 2 genetic strains were utilized to determine the impact of the dietary concentration of 5 B vitamins (riboflavin, niacin, pantothenic acid, cobalamin, and folacin) on growth from 9 to 28 kg of BW in pigs with high or moderate capacity for lean growth. All pigs (penned individually) were reared via a segregated, early weaning scheme, so that the lean growth potential of each strain could be expressed. The basal diet provided the 5 test vitamins at concentrations of total and estimated bioavailability equivalent to a minimum of 100 and 70%, respectively, of their estimated requirements (NRC, 1998) for 5- to 10-kg pigs. At a BW of 9 +/- 0.9 kg, pigs within each litter were allotted to the basal diet supplemented with sources of the 5 test vitamins equivalent to an additional 0, 100, 200, 300, or 400% (bioavailable) of the NRC requirements. Pigs from the high lean strain consumed less feed (P < 0.05) and gained BW faster (P < 0.02) and more efficiently (P < 0.01) than pigs of the moderate lean strain. In both lean strains, the rate and efficiency of growth were improved (P < 0.01) as dietary B vitamin concentrations were increased. However, the dietary B vitamin concentrations needed to optimize G:F were greater (P < 0.03) in the high (>470% of NRC, 1998) vs. moderate (270%) lean strain. Based on these data, the dietary needs for 1 or more of the 5 B vitamins are greater than current NRC (1998) estimates, particularly in pigs expressing a high rate of lean tissue growth. The greater need for these vitamins is not associated with greater dietary energy intake or body energy accretion rate but is potentially due to shifts in the predominant metabolic pathways.

Why should we exercise when our knees hurt? A qualitative study of primary care patients with osteoarthritis of the knee

BACKGROUND

Osteoarthritis (OA) of the knee is common and disabling. Exercise is effective in reducing pain and disability, but long-term adherence to exercise regimens is disappointing, and motivation to exercise in those with OA knee is poorly understood.

OBJECTIVES

To examine the views of primary care patients with OA knee towards exercise, explore factors that determine the acceptability and motivation to exercise, and to identify barriers that limit its use.

METHOD

Semi-structured interviews were conducted with 22 primary care patients with OA knee, six of whom also participated in a focus group for triangulation. Transcripts were coded into categories and themes to develop a conceptual framework and typology of exercise behaviour.

RESULTS

Exercise behaviour depended upon physical capacity to exercise; exercise beliefs and other factors such as enjoyment, social support, priority setting and context. Four types of patients were identified: 'long-term sedentary' who had never exercised; 'long-term active' who continued to exercise; 'exercise retired' who used to exercise, but had stopped because of their symptoms, and because they believed that exercise was damaging their joints; and 'exercise converted' who recently started to exercise, and preferred a gym because of the supervision and social support they received there.

CONCLUSIONS

Several physical, cognitive and contextual factors, and a typology of exercise behaviour were identified that could be addressed in primary care consultations. The importance of gyms and GP referral schemes for people who are exercising for the first time, and the high level of patient satisfaction associated with these were highlighted.

Should your GP be an osteopath? Patients' views of an osteopathy clinic based in primary care

BACKGROUND

Spinal pain is a common reason for consulting general practitioners (GPs), and complementary therapists such as osteopaths and chiropractors. Patients express greater satisfaction with the care from chiropractors and osteopaths, because they are perceived as having more empathy, diagnostic skill and effective treatment, but their attitude to a GP providing an osteopathy service is unknown.

AIM

To explore patients' views of receiving osteopathy in contrast with usual GP care, to provide insight into the psychological benefit of treatment, and to explore their views on how such a service should be provided and funded.

DESIGN OF STUDY

Qualitative study using semi-structured interviews preceded by short questionnaires.

SETTING

Primary care osteopathy clinic treating patients from Llanfairfechan Health Centre, which also accepted referrals from neighbouring practices in North West Wales in a randomised controlled trial.

METHOD

Short questionnaires followed by semi-structured interviews with 20 participants. The interview transcripts were analysed by open coding into categories, axial coding to define the categories' properties and selective coding for the final thematic account.

RESULTS

Traditional GP skills were valued, but GP care for spinal pain was perceived as limited and ineffective. Osteopathy was attractive because it did not involve drugs, but it had short-term painful side effects, and some found it frightening. Physical benefits included increased mobility and reduced pain; psychological benefits included removal of fear and improved understanding. Provision of osteopathy by a GP was welcomed, so long as the GP was properly qualified, and had sufficient time.

CONCLUSION

A GP run osteopathy clinic provided additional physical and psychological benefit. GP consultation might be improved by adopting some features from the osteopathic consultation.

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial

BACKGROUND

Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended.

OBJECTIVE

Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain.

METHODS

A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping.

RESULTS

Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios.

CONCLUSION

A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.

Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care

BACKGROUND

Spinal pain is common and frequently disabling. Management guidelines have encouraged referral from primary care for spinal manipulation. However, the evidence base for these recommendations is weak. More pragmatic trials and economic evaluations have been recommended.

OBJECTIVES

Our aim was to assess the effectiveness and health care costs of a practice-based osteopathy clinic for subacute spinal pain.

METHODS

A pragmatic randomized controlled trial was carried out in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. A total of 201 patients with neck or back pain of 2-12 weeks duration were allocated at random between usual GP care and an additional three sessions of osteopathic spinal manipulation. The primary outcome measure was the Extended Aberdeen Spine Pain Scale (EASPS). Secondary measures included SF-12, EuroQol and Short-form McGill Pain Questionnaire. Health care costs were estimated from the records of referring GPs.

RESULTS

Outcomes improved more in the osteopathy group than the usual care group. At 2 months, this improvement was significantly greater in EASPS [95% confidence interval (CI) 0.7-9.8] and SF-12 mental score (95% CI 2.7-10.7). At 6 months, this difference was no longer significant for EASPS (95% CI -1.5 to 10.4), but remained significant for SF-12 mental score (95% CI 1.0-9.9). Mean health care costs attributed to spinal pain were significantly greater by 65 UK pounds in the osteopathy group (95% CI 32-155 UK pounds). Though osteopathy also cost 22 UK pounds more in mean total health care cost, this was not significant (95% CI - 159 to 142 UK pounds).

CONCLUSION

A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes, at little extra cost. Rigorous multicentre studies are now needed to assess the generalizability of this approach.

Extending the Aberdeen Back Pain Scale to include the whole spine: a set of outcome measures for the neck, upper and lower back

Many therapists treat the spine as a 'functional unit', but suitable condition-specific outcome measures for the whole spine are not available. One of the most rigorously tested measures for back pain related health status is the Aberdeen Back Pain Scale, but it is only suitable for the lower back. The Aberdeen Back Pain Scale was extended to create a set of interlocking outcome measures for the neck, upper and lower back. Questions in these extended outcome measures had to fulfil a series of psychometric criteria before being accepted into the final questionnaires. This involved response frequency, item-total correlation and principal component analysis. The final questionnaires were tested for reliability, criterion and construct validity, responsiveness and acceptability, on patients attending a primary care musculoskeletal clinic. One question was discarded from all three sets of questionnaires and a further question was removed from the neck questionnaire. Baseline scores approximated to normal distributions. Although not completely reproducible, they were internally consistent, so showed evidence of reliability. They were highly correlated with the SF-12 and their mean scores changed according to whether their health status, measured by a transition question, improved, stayed the same or worsened. Modified standardised response means showed large changes when health status improved and moderate-sized changes when health status worsened. Patients made few adverse comments about the questionnaires and found them acceptable. The Extended Aberdeen Spine Pain Scales for neck, upper and lower back pain, showed evidence of reliability, validity, responsiveness and acceptability. They can be used for single regions of the spine or combined as clinically necessary. They are particularly recommended for primary care patients.

Generic circumscription and relationships in the tribe Melanthieae (Liliales, Melanthiaceae), with emphasis on Zigadenus: evidence from ITS and trnL-F sequence data

The circumscription and relationships of genera within the tribe Melanthieae (29 representative taxa) were evaluated using parsimony analyses of ITS (nuclear ribosomal) and trnL-F (plastid) DNA sequence data, alone and in combination. Proposed new generic circumscriptions, strongly supported by the tree statistics and topologies in all analyses, are correlated with potential morphological synapomorphies at the proper level of universality. Based on the molecular cladograms, Stenanthium is biphyletic, and the traditional Zigadenus s.l. (sensu lato) is polyphyletic. Amianthium and Schoenocaulon are distinct entities; the Veratrum complex is conservatively treated as one large monophyletic genus (including Melanthium). Although some generic relationships are not highly resolved, the analyses provide strong support for Zigadenus glaberrimus as sister to the rest of the tribe, and Amianthium muscitoxicum as closely related to Veratrum s.l. As a result of these analyses, seven genera (some with novel circumscription) are recognized within the tribe Melanthieae: Amianthium, Anticlea, Schoenocaulon, Stenanthium, Toxicoscordion, Veratrum, and Zigadenus.

Subtribal and generic relationships of Maxillarieae (Orchidaceae) with emphasis on Stanhopeinae: combined molecular evidence

The monophyly of and phylogenetic relationships within the orchid tribe Maxillarieae Pfitzer were evaluated using parsimony analyses of combined nuclear ribosomal and plastid DNA sequence data of ITS 1 and 2, matK, and the trnL intron and the trnL-F intergene spacer. Each of the separate analyses produced highly congruent but weakly supported patterns (by the bootstrap), so these were combined in a single analysis. Analysis of 90 ingroup taxa (representing ∼35% of currently recognized genera) and four outgroup taxa produced resolved and highly supported cladograms. Based on the cladograms, we recognize six subtribes: Eriopsidinae, Oncidiinae (including Pachyphyllinae, Ornithocephalinae, and Telipogoninae), Stanhopeinae, Coeliopsidinae, Maxillariinae (including Lycastinae and Bifrenariinae), and Zygopetalinae (including Cryptarrheninae, Dichaeinae, Huntleyinae, and Warreinae). Stanhopeinae were sampled most intensively; their generic relationships were highly resolved in the analysis and largely agree with currently accepted generic concepts based on morphology. Coeliopsidinae (Coeliopsis, Lycomormium, Peristeria) are sister to Stanhopeinae. Correlations are drawn among phylogeny, pollination mechanisms, and life history traits.

Phylogeny of sulfate-reducing bacteria(1)

Sulfate-reducing bacteria (SRB) are a diverse group of prokaryotes that may be divided into four groups based on rRNA sequence analysis: Gram-negative mesophilic SRB; Gram-positive spore forming SRB; thermophilic bacterial SRB; and thermophilic archaeal SRB. In this review, we have assembled representative 16S rRNA sequences reported to date for SRB and have constructed phylogenetic trees from these sequences. Physiological characteristics particular to each of these groups are discussed, as is the availability of tested group-specific phylogenetic probes and PCR primers directed toward individual groups.

Phylogenetic Analysis of Pasteuria penetrans by 16S rRNA Gene Cloning and Sequencing

Pasteuria penetrans is an endospore-forming bacterial parasite of Meloidogyne spp. This organism is among the most promising agents for the biological control of root-knot nematodes. In order to establish the phylogenetic position of this species relative to other endospore-forming bacteria, the 16S ribosomal genes from two isolates of P. penetrans, P-20, which preferentially infects M. arenaria race 1, and P-100, which preferentially infects M. incognita and M. javanica, were PCR-amplified from a purified endospore extraction. Universal primers for the 16S rRNA gene were used to amplify DNA which was cloned, and a nucleotide sequence was obtained for 92% of the gene (1,390 base pairs) encoding the 16S rDNA from each isolate. Comparison of both isolates showed identical sequences that were compared to 16S rDNA sequences of 30 other endospore-forming bacteria obtained from GenBank. Parsimony analyses indicated that P. penetrans is a species within a clade that includes Alicyclobacillus acidocaldarius, A. cycloheptanicus, Sulfobacillus sp., Bacillus tusciae, B. schlegelii, and P. ramosa. Its closest neighbor is P. ramosa, a parasite of Daphnia spp. (water fleas). This study provided a genomic basis for the relationship of species assigned to the genus Pasteuria, and for comparison of species that are parasites of different phytopathogenic nematodes.

Creating an educational videotape

Staff development and patient education coordinators are challenged to lead efforts to provide resources for patient education. One option to provide cost-effective, quality education is the use of videotapes. In this article, the authors identify six advantages of video instruction and detail the steps to create an educational videotape.

Effect of lean growth genotype and dietary amino acid regimen on the lactational performance of sows

The effect of dietary amino acid regimen and genetic capacity for lean tissue growth on the lactational performance of sows was determined in primiparous sows with a high (350 to 390 g/d) or low (240 to 280 g/d) genetic capacity for lean tissue growth from 18 to 110 kg of body weight. During lactation, sows were offered daily 6.5 kg of one of four fortified corn-soybean meal diets containing .58, .77, .96, and 1.15% lysine (L). Litters were standardized to 14 pigs within 8 h after birth. On d 2 of lactation, the high lean growth (LG) sows possessed more proteinaceous tissues and protein and less fat tissue and lipid. During lactation (d 2 to 28 postpartum), high LG sows consumed more feed, mobilized more body protein, and lost less body lipid. Milk, milk energy, and milk lysine yields (pooled across dietary regimens) were similar between genotypes. As daily dietary lysine intakes increased from 27 to 62 g and total digestible lysine supplies (from diet and mobilized tissues) increased from 39 to 68 g, daily yields of milk, milk energy, and milk lysine increased, but the magnitude of the response differed (P < .05) between genotypes, evidently because of differences in the ability of the high and low LG sows to mobilize energy from body tissue. Based on these data, the lactational capacities of high and low LG sows nursing 12 to 14 pigs are similar when similar supplies of lysine and energy are available from dietary intake and mobilized body tissue stores. When supplies of ME do not limit milk synthesis, daily digestible lysine intakes of at least 54 g (> or = 66 g from a corn-soy diet) are needed by these sows nursing litters of 12 to 14 pigs to support milk synthesis and minimize maternal protein losses. This is equivalent to a total digestible lysine need of 4.3 to 4.6 g/kg of milk produced. When ME provided by the diet is less than that needed to fuel maximum milk synthesis, however, the dietary amino acid needs of genetically lean sows may be reduced because of their inability to mobilize sufficient body fat stores.

Effect of chronic immune system activation on the rate, efficiency, and composition of growth and lysine needs of pigs fed from 6 to 27 kg

The influence of a low and a high level chronic immune system (IS) activation on growth and dietary nutrient needs of pigs was evaluated. All pigs were of a single genetic strain and geographical site of origin, and the low and high IS pigs were created by physically isolating pigs from or continuously exposing pigs to major vectors of environmental antigen transmission. In each IS group, four littermate barrows in each of six litters were allotted at 25 +/- 2 d of age to one of four dietary amino acid regimens (.60, .90, 1.20, or 1.50% dietary lysine. Dietary lysine concentrations were achieved by altering the ratio of corn to soybean meal resulting in lysine being the first-limiting amino acid in each diet. Pigs were individually penned in facilities maintained at 25.6 +/- 2 degrees C and allowed to freely consume feed from 6.2 to 26.5 kg BW. On the basis of the differences in serological antibody titers, lymphocyte CD4+:CD8+ ratios, and serum alpha-1-acylglycoprotein concentrations, low and high levels of IS activation were established and maintained during the study. Minimizing the degree of chronic IS activation resulted in greater feed intakes (P < .09), body weight and protein gains (P < .01), gain:feed ratios (P < .01), and body leanness (protein:lipid, P < .01). The level of IS activation did not influence the partial efficiency of energy utilization for body protein and lipid accretion. To allow their greater capacity for body growth and protein accretion to be expressed, the low IS pigs required greater dietary lysine concentrations and daily lysine intakes than high IS pigs.

Effect of chronic immune system activation on body nitrogen retention, partial efficiency of lysine utilization, and lysine needs of pigs

The influence of a low and high level of chronic immune system (IS) activation on body nitrogen retention, partial efficiency of dietary lysine utilization, and lysine needs of pigs at three body weights was determined. All pigs were of a single genetic strain and geographical site of origin, and the low and high IS pigs were created by physically isolating pigs from or continuously exposing pigs to major vectors of antigen transmission. In each IS group, four littermate barrows in each of six litters were allotted at 25 d of age to one of four dietary amino acid regimens (.60, .90, 1.20, or 1.50% dietary lysine). Pigs were individually penned and allowed to freely consume feed from 6.2 to 26.5 kg BW. Nitrogen balance during 4-d periods was determined for each pig at BW of 10, 17.5, and 25 kg. Minimizing the level of chronic IS activation resulted in 4.7 to 7.7 g/d greater body nitrogen retention, 147 to 201 g/d greater BW gain, and 101 to 147 g more gain per kilogram of feed in pigs at the three BW. Dietary lysine intakes needed to maximize each of these criteria at BW of 10, 17.5, and 25 kg were a minimum of 2, 2, and 3 g/d greater in the low vs high IS pigs. However, the partial efficiency of lysine utilization for body nitrogen retention was similar between IS groups. On the basis of these data, the greater dietary lysine needs of the low IS pigs are due to their greater biological capacity for body nitrogen accretion and not to differences in their efficiency of dietary lysine utilization.

Effect of level of chronic immune system activation on the growth and dietary lysine needs of pigs fed from 6 to 112 kg

The effect of a low and a high level of chronic immune system (IS) activation on the rate, efficiency, and composition of body growth and dietary lysine needs of pigs fed from 6 to 112 kg body weight was evaluated. All pigs were of a single genetic strain and geographical site of origin, and the low and high IS pigs were created by physically isolating pigs from and continually exposing pigs to major vectors of environmental antigen transmission. In each IS group, five littermate barrows from each of seven litters were individually penned and randomly allotted to one of five dietary amino acid regimens (.6, .9, 1.20, 1.50, and 1.80% lysine from 6 to 27 kg BW and .45, .60, .75, .90, and 1.05% lysine from 27 to 112 kg BW). Dietary lysine concentrations were achieved by altering the ratio of corn to soybean meal in the diets, and diets were formulated such that lysine was the first-limiting amino acid. Low IS pigs possessed lower (P < .01) T lymphocyte CD4+:CD8+ ratios and serum alpha-1-acylglycoprotein concentrations. Low IS pigs also consumed more (P < .01) feed, gained body weight faster (P < .01), required less (P < .01) feed per unit of gain, and at 112 kg BW produced bodies with more (P < .12) muscle and less (P < .10) fatty tissue and offal than high IS pigs. To allow their elevated capacities for proteinaceous tissue to be expressed, low IS pigs required .15 to .30 percentage units greater dietary lysine concentrations and 2 to 5 g higher daily lysine intakes at each 14-kg BW increment from 6 to 112 kg BW.