Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

BACKGROUND: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Ambient temperature and genotype differentially affect developmental and phenotypic plasticity in Arabidopsis thaliana.

BACKGROUND: Global increase in ambient temperatures constitute a significant challenge to wild and cultivated plant species. Forward genetic analyses of individual temperature-responsive traits have resulted in the identification of several signaling and response components. However, a comprehensive knowledge about temperature sensitivity of different developmental stages and the contribution of natural variation is still scarce and fragmented at best. RESULTS: Here, we systematically analyze thermomorphogenesis throughout a complete life cycle in ten natural Arabidopsis thaliana accessions grown under long day conditions in four different temperatures ranging from 16 to 28 °C. We used Q10, GxE, phenotypic divergence and correlation analyses to assess temperature sensitivity and genotype effects of more than 30 morphometric and developmental traits representing five phenotype classes. We found that genotype and temperature differentially affected plant growth and development with variing strengths. Furthermore, overall correlations among phenotypic temperature responses was relatively low which seems to be caused by differential capacities for temperature adaptations of individual accessions. CONCLUSION: Genotype-specific temperature responses may be attractive targets for future forward genetic approaches and accession-specific thermomorphogenesis maps may aid the assessment of functional relevance of known and novel regulatory components.

Patient safety culture transformation in a children's hospital: an interprofessional approach.

In 2008, a children's hospital based in the Midwest of the USA launched a hospital-wide safety transformation initiative to improve the safety and quality of care resulting in a decrease in the number of critical safety incidents. In order to build on the early successes of the Hospital's safety program and further improve safety metrics, investigators developed a set of multi-pronged, interprofessional interventions designed to improve overall safety outcomes. The interprofessional interventions focused on didactic training, simulation exercises and safety rounding components. Study results indicate that the didactic portion of the study intervention was the most effective component in terms of safety behavior knowledge gained and satisfaction. The student groups had statistically significant higher post-didactic (86.2 versus 77.7, p < 0.001) and post-simulation (85 versus 81.8, p < 0.05) knowledge scores than did the staff groups. After gaining knowledge in basic safety training didactic instruction, students and staff maintained the knowledge gain throughout the study, but no significant knowledge gains were observed after simulation experiences and rounding with safety coaches. An overall increase in hospital metrics (all safety events) of the study year, compared retrospectively to the previous year, was observed. Investigators attribute the increase in the metric indicators to greater attention to reporting safety events.

Breaking the mold: new paradigms for physician leadership in patient safety.

Look at the steps taken at a children's hospital in Michigan that led to increased patient safety efforts and a reduction in medical mistakes.

Insurance-associated disparities in hospitalization outcomes of Michigan children.

OBJECTIVE: To investigate whether children in Michigan with private insurance have better hospitalization-related outcomes than those with public or no insurance. STUDY DESIGN: Population-based hospitalization rates were calculated for newborns and children aged <18 years in Michigan for the years 2001-2006 and stratified by age, disease grouping, and health insurance status using inpatient records from the Michigan Inpatient Database and population estimates from the US Census Current Population Survey. RESULTS: Michigan children with public/no insurance had significantly higher overall hospital admission rates and admission rates for ambulatory-sensitive conditions, and were more likely to be admitted through the emergency room, compared with those with private health insurance. Similarly, newborns with public/no insurance had significantly higher rates of hospitalization-related outcomes. Hospital charges per child were higher in the public/no insurance population, translating to potential excess charges of between $309.8 and $401.8 million in 2006. CONCLUSIONS: There are disparities in health outcomes and charges between Michigan children and newborns with public/no insurance and those with private health insurance, presenting a significant opportunity to improve the efficiency and efficacy of care.

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study.

BACKGROUND: Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. OBJECTIVE: The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). DESIGN AND METHODS: Using the EQUATOR Network's methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. RESULTS: There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. LIMITATIONS: The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. CONCLUSIONS: The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

FitKids360: design, conduct, and outcomes of a stage 2 pediatric obesity program.

This paper describes FitKids360, a stage 2 pediatric weight management program. FitKids360 is a physician-referred, multicomponent, low-cost healthy lifestyle program for overweight and obese youth 5-16 years of age and their families. FitKids360 provides an evidence-based approach to the treatment of pediatric overweight by targeting patients' physical activity, screen time, and dietary behaviors using a family-centered approach. The intervention begins with a two-hour orientation and assessment period followed by six weekly sessions. Assessments include lifestyle behaviors, anthropometry, and the Family Nutrition and Physical Activity (FNPA) survey, which screens for obesogenic risk factors in the home environment. Outcomes are presented from 258 patients who completed one of 33 FitKids360 classes. After completing FitKids360, patients increased moderate to vigorous physical activity by 14 minutes (P = 0.019), reduced screen time by 44 minutes (P < 0.001), and improved key dietary behaviors. Overall, FNPA scores increased by 9% (P < 0.001) and 69% of patients with "high risk" FNPA scores at baseline dropped below the "high risk" range by followup. Patients also lowered BMIs (P = 0.011) and age- and sex-adjusted BMI z-scores (P < 0.001) after completing the 7-week program. We hope this report will be useful to medical and public health professionals seeking to develop stage 2 pediatric obesity programs.

The DET1-COP1-HY5 pathway constitutes a multipurpose signaling module regulating plant photomorphogenesis and thermomorphogenesis.

Developmental plasticity enables plants to respond to elevated ambient temperatures by adapting their shoot architecture. On the cellular level, the basic-helix-loop-helix (bHLH) transcription factor phytochrome interacting factor 4 (PIF4) coordinates this response by activating hormonal modules that in turn regulate growth. In addition to an unknown temperature-sensing mechanism, it is currently not understood how temperature regulates PIF4 activity. Using a forward genetic approach in Arabidopsis thaliana, we present extensive genetic evidence demonstrating that the de-etiolated 1 (DET1)-constitutive photomorphogenic 1 (COP1)-elongated hypocotyl 5 (HY5)-dependent photomorphogenesis pathway transcriptionally regulates PIF4 to coordinate seedling growth in response to elevated temperature. Our findings demonstrate that two of the most prevalent environmental cues, light and temperature, share a much larger set of signaling components than previously assumed. Similar to the toolbox concept in animal embryonic patterning, multipurpose signaling modules might have evolved in plants to translate various environmental stimuli into adaptational growth processes.

Building capacity for childhood obesity prevention and treatment in the medical community: call to action.

Large gaps exist in the capacity of the US medical system to participate meaningfully in childhood obesity-prevention efforts and to meet the treatment needs of obese children. Current primary care practice for the prevention and treatment of childhood obesity often varies from evidence-based recommendations. Childhood obesity specialists have partnered successfully with schools of medicine, professional societies, and other organizations to collaboratively engage with primary care providers in quality improvement for obesity prevention and treatment. This review and commentary targets 2 audiences. For childhood obesity experts and their organizational partners, methods to support change in primary practice and the evidence supporting their use are outlined. For primary care providers and non-obesity specialists, effective strategies for changing practice and the potential benefits of addressing childhood obesity systematically are discussed.

Identification and treatment of obesity as a standard of care for all patients in children's hospitals.

Obese children and adolescents have unique needs for specialized medical equipment while hospitalized and might require special diets and physical activity options as part of their medical treatment. It is important that patients with a diagnosis of obesity be identified on admission so that appropriate equipment and resources can be provided. We examined what components a healthy hospital environment should include and sought to determine if children's hospitals provide a healthy hospital environment that offers these components. In addition, we sought to determine if children's hospitals have policies in place to identify children with obesity so that appropriate resources and services can be offered to treat that diagnosis. We surveyed National Association of Children's Hospitals and Related Institutions member hospitals via a Web-based questionnaire and found that the majority of them do not have policies in place to identify patients with obesity. We did find that the majority of hospitals reported innovative programs or services to provide a healthy hospital environment for their patients, visitors, and staff but acknowledged limitations in providing some services. Specifically, children's hospitals can and should improve on their identification and management of obese pediatric patients.

Female scarcity reduces women's marital ages and increases variance in men's marital ages.

When women are scarce in a population relative to men, they have greater bargaining power in romantic relationships and thus may be able to secure male commitment at earlier ages. Male motivation for long-term relationship commitment may also be higher, in conjunction with the motivation to secure a prospective partner before another male retains her. However, men may also need to acquire greater social status and resources to be considered marriageable. This could increase the variance in male marital age, as well as the average male marital age. We calculated the Operational Sex Ratio, and means, medians, and standard deviations in marital ages for women and men for the 50 largest Metropolitan Statistical Areas in the United States with 2000 U.S Census data. As predicted, where women are scarce they marry earlier on average. However, there was no significant relationship with mean male marital ages. The variance in male marital age increased with higher female scarcity, contrasting with a non-significant inverse trend for female marital age variation. These findings advance the understanding of the relationship between the OSR and marital patterns. We believe that these results are best accounted for by sex specific attributes of reproductive value and associated mate selection criteria, demonstrating the power of an evolutionary framework for understanding human relationships and demographic patterns.