THU0486 2019 FRENCH GUIDELINES AND CARE PATHWAY ABOUT LOW BACK PAIN MANAGEMENT IN ADULTS

Background:

Low back pain (LBP) is a frequent, disabling symptom, for which the risk of chronicity is increased by heterogeneous care. Developing and implementing recommendations is likely to improve LBP management.

Objectives:

To develop French guidelines and care pathway on the management of LBP, coordinated by the French National Authority for Health (FNAH) and based on previous international guidelines in addition to update literature.

Methods:

A compilation report was constituted on the basis of a systematic review of guidelines between January 2013 and December 2018, and systematic reviews and meta-analysis in the field of LBP between January 2015 and December 2018. This report summarized the state-of-the-art for each predefined area of the guideline. A panel of experts including patients’ representatives and 19 health professionals involved in LBP management was constituted to elaborate the guideline based on the compilation report. A care pathway was constituted to identify the trajectory and the different steps followed by a patient with LBP. Then, the compilation report and the preliminary guidelines were submitted to 24 academic institutions and stakeholders for feedback. Based on the preliminary guideline and the responses of academic institutions and stakeholders, the final recommendations were drawn up by the expert panel. The guideline was finally submitted to an independent committee of the FNAH for final validation. For each area of the guidelines, agreement between experts of the working group was evaluated through the RAND/UCLA method.

Results:

The initial literature search identified 572 references of recent international guidelines or systematic reviews about LBP. After selection, the compilation report included 101 references. The compilation report was submitted to the expert group during 3 different meetings to reach a consensus on different topics. Thirty-one preliminary recommendations and a care pathway (divided in two parts to facilitate its use and readability) were drafted and submitted to academic institutions and stakeholders. Having considered their comments, final recommendations and care pathway were written. The final guideline was validated by the FNAH. Then, the consensus of the expert panel was assessed about all the final guidelines separately: 32 recommendations (including the care pathway) were evaluated as appropriate; none were evaluated uncertain or inappropriate. Strong approval was obtained for 27 of them (including the care pathway) and weak for 5 of them.

Conclusion:

This new LBP guideline was based on recent scientific evidence. It introduced several concepts, including the need to identify low back pain at risk of chronicity, in order to provide quicker intensive management if necessary. This guideline should be updated in 5 years’ time, in order to keep it in line with ongoing scientific evidence.

Disclosure of Interests: :

Florian Bailly Consultant of: Consultation fees from Lilly and Grünenthal laboratories, Anne Priscille Trouvin Speakers bureau: Speaker for menarini, recordati, pfizer, astellas, Sandrine Bercier: None declared, Sabrina Dadoun: None declared, Jean Philippe Deneuville: None declared, Rogatien Faguer: None declared, Jean Baptiste Fassier: None declared, Michèle Koleck: None declared, Louis Lassalle: None declared, Thomas Le Vraux: None declared, Brigitte Liesse: None declared, Karine Petitprez: None declared, Aline Ramond: None declared, Jean François Renard: None declared, Alexandra Roren: None declared, Sylvie Rozenberg Consultant of: Pfizer, Catherine Sebire: None declared, Gilles Viudes: None declared, François Rannou Grant/research support from: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier, Fondation Arthritis

, Consultant of: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier

, Speakers bureau: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne

, Audrey Petit: None declared

Description of low back pain attendances in French ED

Background

Low back pain (LBP) is one of the leading contributors to disease burden worldwide [1]. In 2018, French health care insurance launched a population awareness campaign in order to promote effective behaviour change in France. Because LBP acute episodes often lead to emergency visits, Santé publique France, the French Public Health Agency and the Federation of Observatories for Emergency Medecine, performed a pre-campaign situational analysis of LBP in the French emergency department (ED) involved in the OSCOUR® network.

Methods

The OSCOUR network is part of the French syndromic surveillance system SurSaUD® [2] coordinated by Santé publique France since 2004. In 2017, the system collects daily individual data from about 700 ED representing 92% of the French ED attendances. Those data contain demographic, administrative and medical information including discharge diagnosis coded according ICD-10. ED attendances with a diagnosis related to LBP were analyzed from 2014 to 2017. Temporal distribution of LBP attendances, hospitalizations after discharge and stay duration in ED services were also analyzed.

Results

From 2014 to 2017, 504 ED were included in the analysis and LBP represented 1.12% (N = 481,291) of ED all visits. This proportion remained stable over the period. 60% of LBP attendances concerned 18 to 50 years old adults and almost 10% were hospitalized after discharge. This proportion increased with age to reach 43% for the 85 years old and more. LBP attendances were more frequent on Monday. Median stay duration were almost 3 hours but increased with age and for hospitalized patients.

Conclusions

The broad coverage of the ED OSCOUR® network on the whole territory and the strong partnership between epidemiologists and clinicians enable Santé publique France to produce reliable results which are also consistent with ED physician’s perception. Finally those results can be used as a reference contributing to evaluate potential benefits of this campaign.

Key messages

This description of low back pain ED attendances is consistent with emergency physicians perception on field and can be used as a reference to evaluate potential benefits of the prevention campaign. The national coverage of the ED OSCOUR® network and the strong partnership with emergency physicians enable Santé publique France to produce relevant description on the main causes of ED attendances.

Monitoring measles outbreaks using emergency department data in France

Background

Measles’ outbreaks still occur in industrialised countries and reactive monitoring of the disease is needed. In France, measles’ monitoring is based on a mandatory notification (MN).

Methods

In France, for each emergency department (ED) visit, an Electronic ED Abstract (EEDA) is transmitted to the OSCOUR® network included in national Syndromic Surveillance System. EEDA include the diagnosis at discharge using International Classification of Disease (ICD-10). This study aims to evaluate the correlation between the number of measles MN and the number of ED visits related to measles and to calculate the positive predictive value (PPV) of diagnosis at discharge of measles in ED. The study period covered the third wave of the 2008-2011 French outbreak. From 2010 to 2011, we analyzed EEDA transmitted from 32/53 ED of the PACA region and regional measles MN. Using weekly aggregated data, the correlation between the number of measles cases given by both MN and ED sources was assessed (Pearson coefficient). In the 4 ED (2 pediatric) of the teaching hospital of Marseille, electronic medical files coded as measles were reviewed to evaluate the PPV of the diagnosis coded according to the national MN case definition (gold standard).

Results

2,949 MN were transmitted and 1,306/1.3 million visits in ED were coded as measles. The peak of the outbreak was reported the same week by EEDA and MN. The correlation between EEDA and MN was strong (0.91; p < 0.001). Hospitalization rate was 20.7% and 21.0% according to EEDA and MN (p = 0.81). Among 363 medical files coded as measles in the 4 ED, 14 cases (3.9%) did not fulfilled the national case definition (PPV: 96.1 [IC95%: 94.2-98.1]), 86 (23.7%) fulfilled criteria for “clinical case” and 263 (72.5%) for “confirmed case".

Conclusions

Most of the time, ED visits coded as measles fulfilled diagnosis criteria. Our results suggested that EEDA (better reactivity) could be complementary to MN (better completeness) to monitor measles.

Key messages

Most of the time, ED visits coded as measles fulfilled diagnosis criteria: PPV of coded medical diagnosis in ED for measles is high. Reactivity of ED data monitoring could usefully complete mandatory notification for measles surveillance.

Maternal periconceptional undernutrition in Merinos d'Arles sheep: 1. Effects on pregnancy and reproduction results of dams and offspring growth performances

Maternal undernutrition during gestation can condition offspring adult health, with the periconceptional period pointed out as a key period. The aim of this study was to evaluate the effects of maternal periconceptional undernutrition on pregnancy and offspring growth performance in sheep. 52 Merinos d'Arles ewes were fed to requirements (control group, C), whereas 64 ewes received 50% of their dietary needs from -15 to +30 days post-conception (restricted group, R). Thereafter, both groups were fed according to needs. Maternal body weight (BW), body condition score (BCS) and Non Esterified Fatty Acids (NEFA), progesterone, leptin and cortisol plasma concentrations were monitored weekly during the restriction period and the following month, then monthly until weaning. Lambs were weighed weekly until weaning at 22 kg BW, then monthly. Plasma leptin was monitored monthly in lambs. The BW, BCS, and leptin concentrations were significantly decreased, whereas NEFA and cortisol concentrations were increased in R dams. Maximum progesterone concentration was higher in R ewes that had a high (10-25%) vs. low (0-10%) BW loss during restriction (27.9 ± 2.59 vs. 20.8 ± 2.00 ng/mL, P < 0.05). Overall, gestation was significantly longer in the R group (151.0 ± 0.3 vs. 149.4 ± 0.4 days, P < 0.001). There was no difference between groups for pregnancy rates, prolificacy, birth weight and lamb mortality, but the proportion of male lambs was significantly higher in the R group, only for singletons (16/26 vs. 9/26, P < 0.05). Lamb growth was not significantly modified by treatment. Leptin concentrations at birth were significantly lower in R vs. C males (6.15 ± 0.13 ng/mL vs. 7.42 ± 0.36 ng/mL, P < 0.05), whereas in females, leptin concentrations were significantly higher in R vs. C lambs at 4 mo of age (7.31 ± 0.27 ng/mL vs. 6.41 ± 0.29 ng/mL, P < 0.05). These results indicate that maternal periconceptional undernutrition in a hardy breed does not significantly affect lamb birth weight and growth rates, in contrast to previous reports in other breeds, suggesting that caution must be taken when extrapolating programming data between breeds and breeding conditions.

Laboratory and field-based tests of deltamethrin insecticides against adult Culicoides biting midges

Bluetongue virus (BTV) is an economically important arbovirus of ruminants transmitted by Culicoides biting midges. Vector control using residual spraying or application to livestock is recommended by many authorities to reduce BTV transmission; however, the impact of these measures in terms of both inflicting mortality on Culicoides and subsequently upon BTV transmission is unclear. This study consisted of a standardized World Health Organization laboratory assay to determine the susceptibility of European Culicoides species to deltamethrin and a field trial based upon allowing individuals of a laboratory strain of Culicoides nubeculosus Meigen to feed upon sheep treated with Butox 7.5 pour-on (a deltamethrin-based topical formulation). Susceptibility in the laboratory trial was higher in colony C. nubeculosus (24-h LC90 = 0.00106%), than in field populations of Culicoides obsoletus Meigen (24-h LC90 = 0.00203%) or Culicoides imicola Kieffer (24-h LC90 = 0.00773%). In the field, the pour-on formulation was tested with a total of 816 C. nubeculosus specimens fed upon on the thigh of treated sheep. The study revealed a maximum mortality rate of 49% at 4 d postapplication, and duration of lethal effect was predicted to be as short as 10 d, despite testing being carried out with a highly susceptible strain. The reasons for this low efficacy are discussed with reference both to the potential for lack of spread of the active ingredient on the host and feeding patterns of the major potential vector species on the sheep host. Practical implications for vector control strategies during BTV incursions are also detailed.

241 EFFECT OF MATERNAL PERICONCEPTIONAL UNDERNUTRITION ON MALE OFFSPRING PHYSIOLOGY AND TESTICULAR DEVELOPMENT

Epidemiological studies in humans, as well as animal models, have shown that maternal environment at critical periods of fetal development can condition offspring adult health. Previous studies have shown effects of maternal undernutrition during early to mid gestation on Sertoli cell proliferation and seminiferous tubule diameter in male lambs of 10 months of age. Delayed follicular maturation and meiosis in female fetuses have been reported after maternal undernutrition from mating. The aim of this project was to evaluate the long-term effects of maternal periconceptional undernutrition on offspring physiology and reproductive function. Postnatal development of male offspring is presented here. Fifty-two control females of Merinos d’Arles breed (R100) were fed a normal diet adapted to their needs, and 64 restricted females (R50) received 50% of their dietary needs from 15 days before until 30 days after synchronized breeding. Thereafter, both groups were fed to meet their nutritional requirements. Males were weighed at birth and every week. Blood samples were collected monthly to monitor plasma leptin and cortisol concentrations. Organ weights were recorded at commercial slaughter (35 kg) and histological analysis was performed on testicles and adrenals. Data were analysed by ANOVA or Student’s test. Twenty-two live R100 and 34 live R50 male lambs were obtained. Gestation was significantly longer in the restricted group (P < 0.01). Growth rate, live weight, and age at slaughter were not significantly different between groups. Plasma leptin concentrations were significantly lower at birth (P < 0.001) and tended to be higher at 4 months of age (P = 0.09) in R50. There was a significant interaction between group, age, and litter size for basal cortisol concentrations: in singletons (n = 15 R50 and n = 8 R100), cortisol was significantly lower in R50 at 3 months of age (P < 0.05) and tended to be higher at 4 months whereas in twins (n = 17 R50 and n = 10 R100), cortisol was significantly lower at birth (P < 0.05) but not thereafter (triplets were not considered here because of low numbers). There was no statistical difference for carcass, testicle, or kidney weight. In contrast, carcass to live weight ratio and perirenal fat to live weight ratio were increased in all R50 (P < 0.05). Adrenal to live weight ratio tended to be increased in R50 lambs (P = 0.06). Histological examination revealed no statistical difference between groups for adrenal corticomedullary ratio, zona glomerulosa to medulla ratio, and zona fasciculata to medulla ratio. There was no significant difference for the analysis of testicular tissue (diameter and surface of seminiferous tubules). The expression of genes involved in testicular differentiation (SRY, 3β-HSD, OCT3/4, VASA, stra8, SOX9) is currently being studied by quantitative PCR and will be presented. These results confirm the effects of periconceptional undernutrition on metabolic function but so far, no effect has been demonstrated on testicular histology. Litter size seems to play an important role, because effects were different between singletons and twins.