Risultati per: Low Back Pain: raccomandazioni

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.

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, Volume 178, Issue 4, Page 558-570, April 2025.

Annals of Internal Medicine, Volume 178, Issue 4, April 2025.

Annals of Internal Medicine, Ahead of Print.

Annals of Internal Medicine, Volume 178, Issue 4, Page 600-601, April 2025.

Annals of Internal Medicine, Ahead of Print.

Annals of Internal Medicine, Ahead of Print.

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.

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.

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.

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.

Circulation, Volume 151, Issue 11, Page e762-e762, March 18, 2025.

Background
Nearly half of individuals who sustain orthopaedic trauma develop chronic pain and experience significant levels of depression and anxiety. Emotional awareness and expression therapy (EAET) is a newly developed psychological intervention designed to treat chronic pain by helping patients process psychological trauma and conflict to reduce pain. The purpose of this study is to examine the feasibility of delivering EAET to individuals who sustained traumatic orthopaedic injuries requiring surgery and who have chronic pain 6 months after hospital discharge.

Methods and analysis
The study will consist of a single-arm design. Thirty individuals who sustained traumatic orthopaedic injuries requiring surgery and who reported chronic pain 6 months after hospital discharge will be recruited. Participants will receive eight sessions of individually administered EAET delivered via telehealth and complete self-report questionnaires at three timepoints (pretreatment, post-treatment and 3-month follow-up). Quantitative sensory testing will also be done before and after treatment. The primary outcome of the study is feasibility (eg, per cent of eligible patients recruited and per cent of study completers) and acceptability as reported by responses to a self-report questionnaire.

Ethics and dissemination
This study has been approved by the Johns Hopkins Institutional Review Board. All data are expected to be collected by 2026, with results of this study to be disseminated via relevant peer-reviewed journals and scientific conferences.

Trial registration number
ClinicalTrials.gov NCT05989230. Registered on 14 August 2023.

In a meta-analysis, clinically significant depression and anxiety each were found in 40% of patients.