The impact of gender on asthma in the daily clinical practice

Objectives: It is up-to-date to consider the potential gender impact on a disease. There are few data about gender difference in asthma. Therefore, the present cross-sectional study tested this hypothesis in a real-life setting to investigate possible difference between genders.

Methods: This study was cross-sectional, considering 554 consecutive outpatients suspected of asthma, who were referred for a first specialist visit. Clinical and functional parameters were evaluated.

Results: Females with asthma could have a worse perception of asthma control, assessed by asthma control test (ACT), and more anxiety than asthmatic males. However, there was no difference regarding asthma control grading, asthma severity, and asthma medication use between genders; the differences in lung function were without clinical relevance.

Conclusions: In the daily clinical practice, it is relevant to consider gender in the management of asthma.     

The creation of the diagnostic accuracy quality scale (DAQS)

Background:

The utility of a dedicated clinical test is dependent on the diagnostic accuracy values and the quality of the study in which the test was examined. Scales allow a summative scoring of bias within a study. At present, there are no scales advocated to measure the bias of diagnostic accuracy studies.

Objective:

The objective of this study was to create a new diagnostic accuracy quality scale (DAQS) that provides a quantitative summary of the methodological quality of studies evaluating clinical tests and measures.

Design:

The study used a four-round Delphi survey designed to create, revise, and develop consensus for a quality scale.

Methods:

The four-round Delphi involved a work team and a respondent group of experts. An initial round among the work team created a working document, which was then modified and revised, with opportunities to create new items threaded in the second round. Rounds III and IV involved voting on the importance of each of the proposed items and consensus development from the respondent group. Consensus for the selection of an item required a 75% approval for the importance of that item.

Results:

Sixteen individuals with a variety of research/professional backgrounds made up the respondent group. Modification and revision of the initial work team instrument created a scale with 21 items that reflected potential areas of methodological bias.

Limitations:

The new scale needs validation through weighted assessment. In addition, there was a large proportion of physical therapist/researchers on the work team and the respondent group.

Conclusions:

Systematic reviews allow summation of evidence for clinical tests and scales are essential to critique the quality of the articles included in the review. The DAQS may serve this role for diagnostic accuracy studies.     

A double-blind placebo-controlled clinical investigation into pain reduction effect of placing the pain spot outside the intersection area of the two currents of interferential therapy compared to traditional method

Background: Interferential therapy (IFT) is applied to intersect in the painful area but no confirmed effect with this method. Experimentally, the highest voltage of IFT is induced outside the intersection of the two currents. Placing the painful area outside the intersection point (external application) would reveal a better effect.

Objectives: To examine the effect of external application in pain compared to traditional method.

Design: A double-blind placebo-controlled clinical investigation.

Setting: A public hospital.

Participants: 168 LBP subjects.

Interventions: Assignment: (1) external IFT, (2) placebo external IFT, (3) traditional IFT and (4) placebo traditional IFT. Groups 1 and 3 received 20 min of IFT at 100 Hz and groups 2 and 4 received sham IFT.

Main outcome measures: Before and after IFT session, pain severity (VAS), pressure threshold (PPT), pain distribution and ROM were assessed.

Results: IFT changed all outcomes similarly. VAS and ROM improved statistically, P < 0.03. A trend of better VAS reduced with active IFTs.

Conclusions: No therapeutic difference between the two methods.     

Pain pattern classification and directional preference for patients with neck pain

Objectives:

Pain Pattern Classification (PPC) and Directional Preference (DP) have been shown to be predictive of health care outcomes and serve to guide orthopedic clinical decision making. We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes.

Methods:

Clinical outcome measures including pain intensity and disability were completed at first examination and follow-up by 335 patients. A Pearson’s chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used to determine differences in rates for the continuous variables. A Tukey’s range test was used to determine differences in follow-up pain intensity and disability for neck pain dual-classification schemes.

Results:

The prevalence of DP was 82.4%. The prevalence of CEN, Non-CEN, and Non-Classifiable (NC) was 15.2%, 42.1%, and 25.1%, respectively. The prevalence of DP was lowest for patients with sub-acute symptoms and who were <45 years old. Patients classified as DP CEN had, on average 2.62 NDI units less than patients classified as Non-DP. Patients classified as DP CEN had, on average, 0.90 pain intensity units less than patients classified as Non-DP at follow-up. Patients who demonstrated DP CEN did not have clinically significant lower pain intensity or disability at follow-up than patients who demonstrated Non-DP.

Discussion:

The results of this investigation need to be interpreted with caution with respect to the study design and it’s subsequent strengths and limitations.

Level of Evidence:

1b.     

Repetition of intentional drug overdose: a population-based study

Context: Intentional overdose is a leading method of self-harm and suicide, and repeat attempts strongly predict eventual death by suicide.

Objectives: To determine the risk of recurrence after a first intentional overdose. Secondary objectives included characterization of the temporal course and potential predictors of repeat overdose, a strong risk factor for death from suicide.

Methods: Design: Population-based cohort study.

Setting: Ontario, Canada, from 1 April 2002 to 31 March 2013.

Participants: All Ontario residents presenting to an emergency department after a first intentional overdose.

Main outcome measures: The incidence and timing of recurrent overdose.

Results: We followed 81,675 patients discharged from hospital after a first intentional overdose. Overall, 13,903 (17.0%) returned with a repeat overdose after a median interval of 288 (inter-quartile range: 62 to 834) days. Of these, 4493 (5.5%) had multiple repeat episodes. Factors associated with repeat self-poisoning included psychiatric care in the preceding year (adjusted hazard ratio [aHR] 1.55; 95% confidence interval [CI] 1.50 to 1.61), alcohol dependence (aHR 1.41; 95% CI 1.35 to 1.46) and documented depression (aHR 1.39; 95% CI 1.34 to 1.44). Female sex, rural residence, lower socioeconomic status, ingestion of psychoactive drugs and younger age were also weakly associated with repeat overdose.

Discussion: Hospital presentation for repetition of intentional overdose is common, with recurrent episodes often far removed from the first. While several factors predict overdose repetition, none is particularly strong.

Conclusion: Secondary prevention initiatives should be implemented for all individuals who present to the emergency department and survive intentional overdose.     

Patient trajectories in a Norwegian unit of municipal emergency beds

Objective: The Coordination reform was implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit.

Design: Cross-sectional, observational study.

Setting: A two-bed emergency care unit.

Subjects: All patients admitted to the unit during one year.

Main outcome measures: Patients’ age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate.

Results: Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals.

Conclusion: Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions.     

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

Objective: Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor’s list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors’ services in collaborative parts of the health care system.

Design: An observational study.

Setting: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before–after setting in a Finnish city.

Subjects: Patients who consulted different doctors in a local health care unit.

Main outcome measures: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

Results: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

Conclusions: The data suggested that the reverse triage causes redistribution of the use of doctors’ services rather than a true decrease in the use of these services.     

The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews

Objective:

to review and update the evidence for different forms of manual therapy (MT) for patients with different stages of non-specific low back pain (LBP).

Data sources:

MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE.

Method:

A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent reviewers according to Cochrane and PRISMA guidelines. A total of 360 studies were evaluated using qualitative criteria. Two stages of LBP were categorized; combined acute–subacute and chronic. Further sub-classification was made according to MT intervention: MT1 (manipulation); MT2 (mobilization and soft-tissue-techniques); and MT3 (MT1 combined with MT2). In each sub-category, MT could be combined or not with exercise or usual medical care (UMC). Consequently, quantitative evaluation criteria were applied to 56 eligible randomized controlled trials (RCTs), and hence 23 low-risk of bias RCTs were identified for review. Only studies providing new updated information (11/23 RCTs) are presented here.

Results:

Acute–subacute LBP: STRONG-evidence in favour of MT1 when compared to sham for pain, function and health improvements in the short-term (1–3 months). MODERATE-evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain, function and health improvements in the short-term.

Chronic LBP:

MODERATE to STRONG-evidence in favour of MT1 in comparison to sham for pain, function and overall-health in the short-term. MODERATE-evidence in favour of MT3 combined with exercise or UMC in comparison to exercise and back-school was established for pain, function and quality-of-life in the short and long-term. LIMITED-evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term. LIMITED-evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term.

Conclusion:

This systematic review updates the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies.     

The effects of whole-body vibration (WBV) intervention on body functions,activity limitations,and participation restrictions in people with neurological conditions

Background:

Vibration intervention has recently become a popular modality in professional sport and fitness and has also been suggested to offer potential in augmenting exercises in the rehabilitation field for various neurological conditions.

Objectives:

The main objective of this review was to assess the effects of whole-body vibration (WBV) intervention on body functions, activity limitations, and participation restrictions in people with neurological conditions. The second objective was to assist healthcare professionals in their clinical practice by evaluating the main parameters of WBV intervention that may be of benefit.

Methods:

Electronic databases (EMBASE, Academic Search Complete, AMED, MEDLINE, CINAHL Plus, SPORTDiscus, PEDro, and Cochrane library) were searched. Intervention studies with a comparison group, investigating the effect of WBV intervention on people with neurological conditions, were included. The methodological quality of papers was independently assessed by two raters using the Physiotherapy Evidence Database scale.

Results:

Sixteen randomized controlled trials (RCTs) were included. Only one paper was considered ‘excellent’ methodological quality study (9 out of 10 points). Four studies evaluated changes when WBV was compared to no intervention and two found significant improvements for strength, gait, and balance. Twelve compared WBV to other interventions and only two found significant differences in favour of the WBV group, for strength and gait.

Conclusion:

The cumulative findings for strength, balance, and gait suggest that while groups improve following WBV, this improvement is not consistently greater than either no intervention or a comparison intervention. This suggests insufficient evidence to support the effects of WBV training.     

Identification of the affected ear in lateral canal benign paroxysmal positional vertigo

Background:

The effective management of lateral canal benign paroxysmal positional vertigo (LC-BPPV) is dependent upon the accurate identification of the affected ear. The supine roll test is the gold standard for diagnosing LC-BPPV. However, in some cases, the elicited nystagmus has a similar intensity when the head is rolled to the right or to the left.

Objectives:

The purpose of this systematic review was to determine the effectiveness of accessory diagnostic procedures, used in conjunction with the supine roll test, at accurately identifying the affected ear in individuals with LC-BPPV.

Methods:

The following databases were searched: (1) CINAHL Plus with Full Text, (2) ProQuest Medical Library, and (3) MEDLINE. The following search terms were used: (1) ‘lateral canal’ OR ‘horizontal canal’ AND (2) ‘positional vertigo’ OR ‘positioning vertigo’ OR ‘positional nystagmus’ OR ‘positioning nystagmus’. Evidence level was examined with the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence method, and methodological rigour was examined with the QUADAS method.

Results:

A database search originally identified 1348 records, and nine studies were ultimately included in the qualitative synthesis. This systematic review revealed four index tests that, when used in conjunction with the supine roll test, were able to accurately identify the affected ear in a majority of individuals with LC-BPPV.

Conclusions:

The pseudo-spontaneous test was found to be slightly superior to the other three index tests in terms of eliciting nystagmus during its administration and identifying the same affected ear as the supine roll test.