Risultati per: LBP (Low Back Pain): Cosa dicono le linee guida del mal di schiena

Objective
To explore the short-term and long-term lived experiences of patients with chronic pain and angina pectoris with spinal cord stimulation.

Design
An interpretive qualitative study with thematic analysis of one-off, semistructured interviews, following Braun and Clarke (2006).

Setting
A multidisciplinary, publicly funded pain service in Auckland, New Zealand. Patients usually undergo a comprehensive medical, psychological and functional assessment and an in-house pain management programme before proceeding to spinal cord stimulator implantation.

Participants
Participants implanted with a spinal cord stimulator between 1998 and 2019 who had their stimulator for ≥1 year, purposively sampled to increase the range of ethnicities.

Main outcome
The themes identified from the interviews.

Results
24 participants with chronic pain of varied aetiology and a median (range) of 5.2 (2.4–23.2) years since stimulator implantation participated. 22 participants had the device in situ, and 2 had been explanted. Five main themes were identified: (1) embodiment: stimulator and body as one; (2) technical factors: batteries and type of stimulation; (3) improved well-being; (4) social connection and (5) healthcare system interaction. Most participants reported pain relief, but many had experienced complications and discomfort. They emphasised the importance of ongoing support from the pain service. Acceptance of pain, coping and embodiment emerged as common motifs across these themes. 21 participants were satisfied with their treatment.

Conclusion
Within the context of a multidisciplinary pain clinic, despite some discomfort and various complications, most participants valued the ongoing reduction of pain achieved with spinal cord stimulation. Timely access to support from the pain service influenced their experience and satisfaction with their stimulators. Acceptance of pain and embodiment of the stimulator helped participants adapt to living with their stimulator, often over many years.

Objectives
This study aimed to investigate the safety and effectiveness of opioid-free anaesthesia (OFA) versus conventional opioid anaesthesia (OA) for postoperative pain management and recovery in patients undergoing laparoscopic surgery.

Design
Systematic review and meta-analysis.

Data sources
The databases of PubMed, Embase, Cochrane Library and Web of Science were searched from inception to August 2023.

Eligibility criteria for selecting studies
We included any randomised controlled trial comparing OFA (at least two drugs or two more alternatives to opioids) with OA for laparoscopic surgery. The primary outcomes included postoperative pain scores, measured on a Numerical Rating Scale or Visual Analogue Scale ranging from 0 to 10, at 0–2 hours and 24 hours postoperatively; postoperative analgesic consumption, measured in morphine equivalent doses (mg); and quality of recovery, assessed using the QoR-40 score (ranging from 40 to 200). The secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), antiemetic use, extubation time (measured in minutes), post-anaesthesia care unit discharge time (measured in minutes), shivering, bradycardia, hypotension and pruritus.

Data extraction and synthesis
Meta-analyses were performed using Stata16 software, using the DerSimonian and Laird’s method and inverse variance to summarise effect sizes for each outcome under a random effects model for all outcomes. Outcomes were reported as OR for binary outcome indicators and mean difference (MD) for continuous outcome indicators, with corresponding 95% CIs. I² coefficients were used to assess high, medium and low heterogeneity. RoB was used to assess the risk of bias of the included studies. GRADE assessed the certainty of the evidence using a systematic framework for rating the quality of evidence and strength of recommendations.

Results
Ultimately, 12 studies involving 983 patients undergoing laparoscopic surgery were included in this systematic evaluation and meta-analysis. The results of the meta-analysis showed an association of OFA with reduced early postoperative 0–2-hour pain response (MD –1.29; 95% CI –2.23 to –0.36; I²=92%; p

Objectives
This study aimed to investigate whether the Chinese diagnosis-related group (C-DRG) payment system would reduce low-value coronary revascularisation services among coronary heart disease (CHD) inpatients without affecting high-value coronary revascularisation services.

Design
Retrospective observational study.

Setting
Routinely collected claims data from a health insurance database including all inpatients in 22 public hospitals in Sanming, Southern China.

Participants
All patients with CHD are admitted to public hospitals from 1 January 2017 through 31 December 2020.

Intervention/exposure
The implementation of the C-DRG-based payment system on 1 January 2018.

Main outcome measures
Using a health insurance database, we identified two cohorts: beneficiaries for whom the value of coronary revascularisation is lower (those with ischaemic heart disease without acute myocardial infarction, unstable angina and congestive heart failure during hospitalisation) and beneficiaries for whom its value is higher (those with acute coronary syndrome). Then, the rates of low-value or high-value coronary revascularisation were compared before and after the implementation of C-DRG policy, including the use of an interrupted time series analysis.

Results
An interrupted time series analysis demonstrated that the C-DRG policy was associated with a statistically significant immediate decrease in the rate of low-value coronary revascularisation of –9.78% (95% CI: –11.08% to –8.48%). Further, after introducing C-DRG, the rate of low-value coronary revascularisation decreased by –0.59% (95% CI: –0.88% to –0.30%) every quarter compared with before C-DRG. In addition, after C-DRG, the rate of high-value coronary revascularisation increased by 1.27% (95% CI: 0.14% to 2.41%) every quarter compared with before C-DRG.

Conclusions
This study suggested that C-DRG policy achieved at least short-term success in reducing use of low-value coronary revascularisation without evidence of decreasing high-value coronary revascularisation services. These results can support policymakers in reducing low-value care in China and other countries that use similar systems.

Objectives
Music listening for pain relief is well studied in diverse healthcare settings, but its implementation remains challenging. While healthcare providers generally have a positive attitude, there is a lack of knowledge about healthcare recipients’ perceptions and attitudes. Therefore, the aim of this study is to explore healthcare recipients’ perceptions of listening to music for pain management, focusing on their general attitudes, implementation strategies and subjective experiences of how music helps (or does not help).

Design
A multi-method study comprising a quantitative survey and qualitative interviews. It is a follow-up conducted 6 months after a randomised experimental study, which assessed the influence of different music genres on pain tolerance. At the end of the original experiment, participants received advice on listening to music in painful situations.

Setting
Rotterdam, The Netherlands.

Participants
The survey involved 169 participants (age mean 30.6, SD 9.8; 61.9% female) who participated in the initial trial. Following this, 20 in-depth interviews were conducted.

Outcome measures
Perceptions of music for pain management were investigated, revealing general trends in the quantitative survey data. Data-led thematic analysis of the qualitative interviews focused on individual perceptions.

Results
Participants showed a high willingness to use music for pain relief, particularly for so-called emotional pain (eg, anxiety, stress and heartbreak). Individual attitudes varied regarding different situations, types of music and types of pain. Barriers such as not considering the option and social sensitivity within healthcare contexts were discussed. A proactive approach by healthcare professionals and autonomy of healthcare recipients were suggested to overcome these barriers. Interestingly, the ‘wrong’ type of music or the ‘wrong’ situation were mentioned as non-beneficial or even harmful.

Conclusions
Awareness of individual needs and potential negative effects is crucial for the use of music for pain relief. A proactive and personalised approach is needed to effectively implement music in healthcare.

Stroke, Ahead of Print. BACKGROUND:Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH.METHODS:A multicenter, prospective observational cohort study of 2997 patients with ICH enrolled between 2010 and 2016 was assessed. Patients with baseline hemoglobin measurements and serial computed tomography neuroimaging were included for analyses. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with hematoma expansion (≥33% and/or ≥6 mL growth) and poor long-term neurological outcomes (modified Rankin Scale score of 4–6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic versus nonanemic C57/BL6 mice, intergroup differences in ICH lesion volume, lesion volume changes, and early mortality were assessed.RESULTS:Among 1190 ICH patients analyzed, the mean age was 61 years old, and 62% of the cohort were males. Lower baseline hemoglobin levels are associated with increased odds of hematoma expansion (adjusted odds ratio per −1 g/dL hemoglobin decrement, 1.10 [95% CI, 1.02–1.19]) and poor 3-month clinical outcomes (adjusted odds ratio per −1 g/dL hemoglobin decrement, 1.11 [95% CI, 1.03–1.21]). Similar relationships were seen with poor 6- and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, 24-hour lesion volumes, and greater mortality, as compared with nonanemic mice.CONCLUSIONS:These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in hematoma expansion and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.

IPV co-occurrence remains high, particularly among women with little or no education. Education-focused interventions are urgently needed to reduce IPV risk and its severe impact. However, the findings may be influenced by potential reporting biases and cross-country variability in IPV measurement methodologies, which may limit generalizability.

Introduction
The clinical environment is recognised to influence learning for healthcare professionals, with the described challenges likely extenuated in low- and middle-income countries that are tackling resource limitations. There is limited research on factors influencing learning in clinical environments in low- and middle-income countries, with no scoping review on this topic published to date. This review will identify the key factors described to shape learning in clinical environments for healthcare professionals in low- and middle-income countries.

Methods and analysis
A scoping review will be performed according to Joanna Briggs Institute (JBI) methodology and reported following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Databases to be searched include MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Web of Science, ERIC (Education Resources Information Center) and Global Health (CABI) from 1990 to present with no language restriction. Following abstract and full-text screening by two independent reviewers, data will be extracted by two independent reviewers and presented in diagrammatic or tabular form, accompanied by a narrative summary. Results will be summarised using quantitative and qualitative analyses. Data will be organised using the components of the clinical learning environment to present factors shaping learning, described challenges, outcomes of interventions and reported recommendations for improvement.

Ethics and dissemination
Ethics approval is not required. Findings will be disseminated through conference presentations and publication in a scientific journal. Results will be used to inform future studies exploring stakeholder perspectives on clinical learning in paediatric oncology in low- and middle-income countries.

Trial registration details
This protocol was registered on Open Science Framework on 5 September 2024; https://osf.io/ysedk.

Annals of Internal Medicine, Ahead of Print.

Annals of Internal Medicine, Ahead of Print.

Annals of Internal Medicine, Ahead of Print.

Ductal carcinoma in situ (DCIS) is considered a nonobligate precursor of invasive breast cancer. Surgery is thought to reduce this risk, as evidenced by studies demonstrating cause-specific survival of 97% to 98% after treatment with mastectomy or lumpectomy with or without radiotherapy. Invasive cancer is found at surgical excision in 26% of all women diagnosed with DCIS by core biopsy and in 20% of those with low- to intermediate-grade DCIS or lesions of 2 cm or smaller on mammography. Despite the apparent success of surgery, significant concerns about overtreatment of DCIS have been raised. The substantial increase in the detection of DCIS between 1992 and 2011 that coincided with the widespread adoption of screening mammography did not result in parallel reductions in invasive cancer detection or breast cancer mortality, suggesting that a proportion of the DCIS being identified would have never progressed to invasive cancer. The very high cause-specific survival after surgery and the limited knowledge of the evolution of untreated DCIS raises the possibility that similar excellent outcomes might be obtained with a less aggressive approach such as active monitoring, with surgery reserved for patients showing evidence of progression to invasive cancer; however, the safety of this approach is uncertain. Ideally, a subset of DCIS patients at low risk of progression to invasive cancer could be identified by molecular profiling, but at present, this goal remains aspirational.

New research may mitigate concerns that glucagon-like peptide-1 (GLP-1) receptor agonists increase the risk of thyroid cancer, according to 2 recent studies.

Ductal carcinoma in situ (DCIS) is defined as “a neoplastic proliferation of cells within the ductal-lobular structures of the breast that has not penetrated the myoepithelial basement membrane interface.” DCIS is considered to be a nonobligate precursor to invasive cancer, such that the purpose of therapy is primarily to avoid the occurrence of invasive cancer. To achieve this end, DCIS has historically been treated in the same way as invasive breast cancer: surgery, often followed by radiation and antiestrogen therapy (if the DCIS is hormone receptor positive). Advances in mammography and the increasing use of magnetic resonance imaging for breast cancer screening have led to the detection of smaller, low-risk lesions. Growing evidence suggests that low-risk DCIS is unlikely to develop into invasive cancer, leading to a question of whether DCIS can be managed with active surveillance alone, thereby avoiding treatment-associated morbidity.

This randomized noninferiority trial assesses the effect of a strategy of active monitoring vs guideline-concordant care on 2-year risk of ipsilateral invasive breast cancer among women with low-risk breast ductal carcinoma in situ.

Background
Sexual and reproductive health (SRH) programmes and services aim to prevent complications of pregnancy and childbirth, unintended pregnancies, unsafe abortions, complications caused by sexually transmitted infections, including HIV, sexual violence and impacts from avoidable cancer.

Objective
To systematically identify published economic evaluations of SRH programmes and services, assess the methods used and analyse how costs and outcomes are estimated in these studies.

Settings
Low- and middle-income countries.

Design
Systematic review and narrative synthesis.

Methods
Eight databases were searched, including EMBASE, MEDLINE, Scopus, Health Technology Assessment, Web of Science, PsycINFO, National Health Service Economic Evaluation Database (NHS EED) and African Journals Online (AJOL) from 1998 to December 2023. The inclusion and exclusion criteria were developed using the Population, Intervention, Comparator, Outcome and Study Design framework. The review included economic evaluations alongside randomised trials and economic studies with modelling components. Study characteristics, methods and results of economic evaluations were extracted and tabulated. The quality of the studies was assessed using the Consensus Health Economic Criteria list and Philips checklists for trial-based and model-based studies, respectively. The review followed the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the results were synthesised narratively in line with Centre for Reviews and Dissemination guidance.

Results
7575 studies were screened and categorised. 20 studies were included in the review. The studies assessed the cost-effectiveness and costs of SRH programmes and services from an individual, healthcare or societal perspective. The main SRH programme considered was contraceptive services. The main outcome measures reported were disability-adjusted life years, quality-adjusted life years, couple years of protection and pregnancies averted. Most of the studies did not indicate the costing approach used, and many of the studies evaluated direct medical costs only. Most of the study designs were model-based with significant heterogeneity between the models. The review showed that many studies did not fulfil all of the requirements for a high-quality economic evaluation. 1 out of the 20 studies reviewed considered equity.

Conclusions
The review revealed heterogeneity in approaches to evaluating the costs and outcomes of SRH programmes. These methodological limitations may have implications for their use by public health decision-makers to inform optimal decision-making.

PROSPERO registration number
CRD42023435241.