A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study.

PURPOSE: To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care. METHODS: We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points). RESULTS: We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC. CONCLUSIONS: Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.

Single-operator cholangioscopy unveiling a pinehole post-cholecystectomy biliary strictures.

77-year-old female with history of cholecystectomy was admitted at emergency department with fever and myalgia, without other complaints. Physical examination revealed fever, and laboratory tests indicated cholestasis (total bilirubin: 1.5xULN, glutamyltransferase: 20xULN, alkaline phosphatase: 5xULN). Computed Tomography revealed common bile duct (CBD) dilation (9mm), with suspected choledocholithiasis. Given the diagnosis of acute cholangitis, antibiotics were started and ERCP was performed. ERCP revealed a short CBD stenosis (< 2mm length), close to surgical clip, with upstream dilation of the CBD; an 8mm stone in the distal CBD was observed and successfully removed. As guidewire advancement failed after multiple attempts, a SpyGlass DS cholangioscopy was performed showing a fibrotic pinehole stenosis. Guidewire was passed through the stenosis under direct visualization, and an 80-mmx10mm fully covered metal stent deployed.

Intrapancreatic accessory spleen: there can be smoke without fire.

Case 1: A 69-year-old male underwent magnetic resonance imaging (MRI) to evaluate hepatic hemangiomas that incidentally revealed a homogeneous hypervascular solid nodule (19 mm) in pancreatic tail. Differential diagnosis included neuroendocrine tumor (NET). Normal chromogranin A and CA19.9 levels. PET-68Ga-DOTANOC scan showed pancreatic tail enhancement consistent with NET. Suspicion of neoplasia persisted after two Endoscopic Ultrasounds with Fine-Needle Aspiration without neoplastic cells. Consequently, distal pancreatectomy was performed, revealing an accessory intrapancreatic spleen. Case 2: A 77-year-old female with dyspepsia performed an abdominal CT followed by MRI and both revealed a solid nodule (11.7 mm) in pancreatic tail with regular margins, suggestive of accessory spleen or pancreatic neoplasia. EUS confirmed a hypoechoic, homogeneous nodule consistent with accessory spleen (11.7mm). A scintigraphy using fragile erythrocytes (4) confirmed intrapancreatic accessory spleen, which requires no treatment.

Exploring Professional Practice Environments and Organisational Context Factors Affecting Nurses' Adoption of Evidence-Based Practice: A Scoping Review.

This scoping review, conducted within the Joanna Briggs Institute (JBI) framework, analysed the recent literature (January 2018 to March 2023) addressing factors inherent to professional practice environments and organisational contexts influencing nurses' adoption of evidence-based practice (EBP). This review included studies involving nurses regardless of sector, practice setting, and scope of practice. A systematic search was undertaken across the PubMed, Web of Science, CINAHL, and MEDLINE databases, as well as the EThOS, OATD, and RCAAP platforms. The extracted textual elements underwent a content analysis, resulting in a coding structure established through an inductive approach that categorised information into main categories and subcategories linked by similarity and thematic affinity. Forty-one studies were included, revealing four main categories of factors impacting EBP adoption by nurses: (1) organisational dynamics, (2) management and leadership, (3) teamwork and communication, and (4) resources and infrastructure. The study's limitations acknowledge the subjective nature of categorisation, recognising potential variations based on individual perspectives despite adopting procedures to minimise the risk of bias. The results provide a substantial foundation for developing interventions to cultivate environments conducive to EBP adoption by nurses, thereby enhancing the integration of evidence into nurses' professional practice contexts. This review was prospectively registered on the Open Science Framework (registration no. osf.io/e86qz).

Minimal Intervention of Patient Education for Low Back Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: To explore the effects of minimal intervention of patient education (MIPE) for reducing disability and pain intensity in patients with low back pain (LBP). DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials. LITERATURE SEARCH: We searched the MEDLINE, Embase, CENTRAL, CINAHL, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Trials comparing MIPE, consisting of a single session of patient education, to no or other interventions in patients with LBP. DATA SYNTHESIS: Random effects meta-analysis was conducted where possible. A noninferiority margin of 5 points (0-100 scale) was considered for noninferiority hypotheses. We assessed risk of bias using the revised Cochrane risk-of-bias tool (RoB 2), and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. RESULTS: A total of 21 trials were included. There were no differences between MIPE and no intervention for effects on disability and pain intensity. There was low-certainty evidence that MIPE had inferior effects on short-term disability (mean difference = 3.62; 95% CI: 0.85, 6.38; 15 trials; n = 3066; I2 = 75%) and pain intensity (mean difference = 9.43; 95% CI: 1.31, 17.56; 10 trials; n = 1394; I2 = 90%) than other interventions. No differences were found for subsequent time points. CONCLUSION: As an intervention delivered in isolation, and without tailoring (ie, one-size-fits-all intervention), MIPE on average did not provide benefits for reducing disability and pain intensity over no or other interventions. We encourage clinicians to consider using additional/other or more tailored treatments when helping people manage LBP. J Orthop Sports Phys Ther 2024;54(2):1-13. Epub 16 November 2023. doi:10.2519/jospt.2023.11865.

Are sarcopenia, frailty and malnutrition prognostic markers of liver disease decompensation in the ambulatory setting? - A prospective cohort study.

BACKGROUND: Sarcopenia, frailty and malnutrition are associated with adverse outcomes in liver cirrhosis. Studies assessing the prognostic value of these conditions in ambulatory patients with cirrhosis are scarce. METHODS: A prospective cohort study was conducted, with consecutive inclusion of all patients with cirrhosis observed in the Hepatology outpatient clinic of a Portuguese tertiary centre. At study enrolment, evaluation of muscle mass (ultrasound quadriceps femoris thickness), muscle strength (handgrip dynamometry) and nutritional status (Patient-Generated Subjective Global Assessment Short Form) was held. Follow-up ended upon the occurrence of a composite endpoint, comprising liver decompensation events and liver-related death, or last medical appointment/non-liver related death before the end of the study. The prognostic value of anthropometrical parameters and nutritional status in the composite endpoint was assessed using a multivariate Cox regression analysis, adjusted for several confounders. RESULTS: Ninety patients were enrolled (80% male), with a mean age of 63.5±10.5 years. The median follow-up was 30 (interquartile range 38) weeks, during which 12 patients reached the composite endpoint. These patients presented a lower mean handgrip strength [23.1±6.41 vs 30.3±10.4 Kg, p=0.04], compared to patients who did not reach the composite endpoint. On Cox regression multivariate analysis, however, no independent predictors of the composite endpoint were found, apart from previous decompensation episodes. CONCLUSION: In this study, muscle strength was lower in the group of patients with cirrhosis who presented a liver-related event. Handgrip strength might be a promising tool in the ambulatory setting to identify patients at risk of liver decompensation and liver-related death in the short term.

TDP-43 pathology is associated with increased tau burdens and seeding.

BACKGROUND: Most Alzheimer's Disease (AD) cases also exhibit limbic predominant age-related TDP-43 encephalopathy neuropathological changes (LATE-NC), besides amyloid-ß plaques and neurofibrillary tangles (NFTs) containing hyperphosphorylated tau (p-tau). LATE-NC is characterized by cytoplasmic aggregates positive for pathological TDP-43 and is associated with more severe clinical outcomes in AD, compared to AD cases lacking TDP-43 pathology TDP-43: AD(LATE-NC-). Accumulating evidence suggests that TDP-43 and p-tau interact and exhibit pathological synergy during AD pathogenesis. However, it is not yet fully understood how the presence of TDP-43 affects p-tau aggregation in symptomatic AD. METHODS: In this study, we investigated the impact of TDP-43 proteinopathy on p-tau pathology with different approaches: histologically, in a human post-mortem cohort (n = 98), as well as functionally using a tau biosensor cell line and TDP-43A315T transgenic mice. RESULTS: We found that AD cases with comorbid LATE-NC, AD(LATE-NC+), have increased burdens of pretangles and/or NFTs as well as increased brain levels of p-tau199, compared to AD(LATE-NC-) cases and controls. The burden of TDP-43 pathology was also correlated with the Braak NFT stages. A tau biosensor cell line treated with sarkosyl-insoluble, brain-derived homogenates from AD(LATE-NC+) cases displayed exacerbated p-tau seeding, compared to control and AD(LATE-NC-)-treated cells. Consistently, TDP-43A315T mice injected with AD(LATE-NC+)-derived extracts also exhibited a more severe hippocampal seeding, compared to the remaining experimental groups, albeit no TDP-43 aggregation was observed. CONCLUSIONS: Our findings extend the current knowledge by supporting a functional synergy between TDP-43 and p-tau. We further demonstrate that TDP-43 pathology worsens p-tau aggregation in an indirect manner and increases its seeding potential, probably by increasing p-tau levels. This may ultimately contribute to tau-driven neurotoxicity and cell death. Because most AD cases present with comorbid LATE-NC, this study has an impact on the understanding of TDP-43 and tau pathogenesis in AD and LATE, which account for the majority of dementia cases worldwide. Moreover, it highlights the need for the development of a biomarker that detects TDP-43 during life, in order to properly stratify AD and LATE patients.

Assessment and Comparison of Microplastic Contamination in Atlantic Navigation Routes with Known Uncertainty.

Microplastics (MP) have been found in various environments worldwide. However, not many studies focus on the open ocean due to logistical restraints. Between January and May 2020, the NRP Sagres sampled 123 linear paths of subsurface water of the Atlantic Ocean, passing by Cape Verde, the east coast of South America, and the west coast of Africa. The water was sampled through the ship's water system. The membranes were analyzed by the Hydrographic Institute of Portugal and the Norwegian Institute for Water Research by micro-FTIR. The contamination levels were reported with uncertainty, for 99% confidence level (CL), normalized for filtered water volume and the distance traveled during sampling. Uncertainties were calculated through a detailed ″bottom-up″ evaluation. MP were found in about a third of the stations (48 out of 123), and most of those stations (43 out of 48) presented concentrations below 1 m-3 km-1. The sites where higher concentrations were registered were the port of the island of Santiago (Cape Verde) ((5.9 ± 5.2) m-3 km-1), the Guanabara Bay in Rio de Janeiro (Brazil) ((41 ± 27) m-3 km-1), and close to South Africa ((4.9 ± 2.4) m-3 km-1). Most MP found were polyamide, polyester, polyethylene, ethylene vinyl acetate, and poly(methyl methacrylate). The estimated contamination levels cannot be directly compared with information obtained in other studies due to differences in how MP were determined and the unknown uncertainty of their measured values. This article presents a relevant and reliable contribution to understanding the MP distribution in the Atlantic Ocean.

Dataset of an energy community with prosumer consumption, photovoltaic generation, battery storage, and electric vehicles.

A challenge that consistently arises when reviewing and justifying novel energy models and theorems is the accuracy of the electrical data used. Therefore, this paper presents a dataset representing a complete European residential community based on real-life data. In this case, a community of 250 residential households was constructed with actual energy consumption and photovoltaic generation profiles collected by smart meters in households in different European locations. Additionally, 200 members of the community were ascribed with their photovoltaic generation, while 150 were owners of a battery storage system. New profiles were generated from the sample collected and were randomly given to each end-user according to their previously defined characteristics. Furthermore, one regular and one premium vehicle were allocated to each household - a total of 500 electric vehicles - with information on their capacity, state of charge, and usage. Moreover, data on the location, type, and prices of public electric vehicle chargers were specified.

Using MCDA to assist an Intermunicipal community develop a resilience strategy in face of the pandemic caused by the SARS-CoV-2.

The topic of regional economic resilience has been the subject of intense debate in the academic and political fields over the past decade and gained a new sense of urgency because of the pandemic caused by the SARS-CoV-2 virus as territories faced relevant impacts on their economies and social structures. The economic downturn, the increase in unemployment, and the deterioration of social conditions lead policy makers to search for solutions to make their territories more resilient to this type of event. The current article discusses how multicriteria decision analysis (MCDA) was used to help a Portuguese Intermunicipal Community, formed by 16 councils, develop a strategy to make its territory more cohesive, competitive, sustainable, and resilient. In addition to discussing an innovative application of a MCDA technique, this article illustrates how, through a MCDA approach, it was possible to reach a consensus among several policymakers, despite each of them having their own political agendas.

Ferric carboxymaltose for anemia in Crohn's disease patients at a tertiary center: A retrospective observational cohort study.

BACKGROUND: Although the gastrointestinal tract is the most affected by Crohn's disease (CD), the condition triggers other consequent manifestations, and iron deficiency anemia (IDA) is one of the most common. Intravenous (IV) iron replacement is currently available through several drugs, such as ferric hydroxide sucrose and ferric carboxymaltose (FCM). However, the clinical management of these conditions can be challenging. AIM: To elucidate the drug's effectiveness, the present study analyzed, through medical records, the clinical and epidemiological data of a cohort of patients with active CD who received IV FCM for the IDA treatment. METHODS: This retrospective observational study included 25 patients with active CD, severe anemia, and refractory to previous conventional treatments. Patients were evaluated two times: During the last treatment with ferric hydroxide sucrose and treatment with FCM. RESULTS: After treatment with FCM, parameters of IDA assessment significantly improved, serum hemoglobin (Hb) levels increased in 93% of patients (P < 0.0001), and in 44%, there was an increase of ≥ 2 g/dL in a single application. In addition, 86% of the patients showed an increase in serum iron (P < 0.0001) and ferritin (P = 0.0008) and 50% in transferrin saturation (P = 0.01). The serum iron levels at baseline showed a negative association with the ileal and colonic CD and use of biologics and a positive association with patients who developed CD later in life after the age of 40 (A3) and with a stenosing (B2) and fistulizing (B3) phenotype. The values of Hb and hematocrit after ferric hydroxide sucrose treatment remained similar to those found before treatment. CONCLUSION: This study demonstrated that FCM is an important therapeutic strategy for treating IDA in CD patients, achieving satisfactory results in refractory cases.

Clinical courses, impact and prognostic indicators for a persistent course of low back pain: Results from a population-based cohort study.

BACKGROUND: Low back pain (LBP) is a long-term health condition with distinct clinical courses. Its characterization together with the identification of prognostic factors for a persistent LBP course may trigger the development of personalized interventions. This study aimed to investigate the courses of chronic LBP (CLBP), its cumulative impact, and the indicators for the persistence of pain. MATERIAL AND METHODS: Patients with active CLBP from the EpiDoC, a population-based cohort study of a randomly recruited sample of 10.661 adults with prolonged follow-up, were considered. Pain, disability, and health-related quality of life (HRQoL) were assessed at three time-points over five years. According to their pain symptoms over time, participants were classified as having a persistent (pain at the baseline and at all the subsequent time-points) or a relapsing pain course (pain at the baseline and no pain at least in one of the subsequent time-points). A mixed ANOVA was used to compare mean differences within and between patients of distinct courses. Prognostic indicators for the persistent LBP course were modulated through logistic regression. RESULTS: Among the 1.201 adults with active CLBP at baseline, 634 (52.8%) completed the three time-points of data collection: 400 (63.1%) had a persistent and 234 (36.9%) a relapsing course. Statistically significant interactions were found between the group and time on disability (F (2,1258) = 23.779, p<0.001) and HRQoL (F (2,1252) = 82.779, p<0.001). In the adjusted model, the persistent course was associated with the disability level (OR 1.86, CI95% 1.40-2.40, p<0.001), depressive symptoms (OR 1.96, CI95% 1.21-3.18, p = 0.007), female gender (OR 1.90, CI95% 1.26-2.87, p = 0.002) and having a manual job (OR 1.46, CI95% 1.02-2.10, p = 0.040). CONCLUSION: In the long-term, patients with CLBP may follow a persistent or relapsing course of pain. Being female, presenting depressive symptoms, having a manual job and higher disability at baseline predicts a persistent course of LBP.

Can white-light endoscopy or narrow-band imaging avoid biopsy of colorectal endoscopic mucosal resection scars? A multicenter randomized single-blind crossover trial.

BACKGROUND : Current guidelines suggest that routine biopsy of post-endoscopic mucosal resection (EMR) scars can be abandoned, provided that a standardized imaging protocol with virtual chromoendoscopy is used. However, few studies have examined the accuracy of advanced endoscopic imaging, such as narrow-band imaging (NBI) vs. white-light endoscopy (WLE) for prediction of histological recurrence. We aimed to assess whether NBI accuracy is superior to that of WLE and whether one or both techniques can replace biopsies. METHODS : The study was a multicenter, randomized, pathologist-blind, crossover trial, with consecutive patients undergoing first colonoscopy after EMR of lesions ≥ 20 mm. Computer-generated randomization and opaque envelope concealed allocation. Patients were randomly assigned to scar examination with NBI followed by WLE (NBI + WLE), or WLE followed by NBI (WLE + NBI). Histology was the reference method, with biopsies being performed for all tissues. RESULTS : The study included 203 scars (103 in the NBI + WLE group, 100 in the WLE + NBI group). Recurrence was confirmed histologically in 29.6 % of the scars. The diagnostic accuracy of NBI was not statistically different from that of WLE (95 % [95 %CI 92 %-98 %] vs. 94 % [95 %CI 90 %-97 %]; P = 0.48). The negative predictive values (NPVs) were 96 % (95 %CI 93 %-99 %) for NBI and 93 % (95 %CI 89 %-97 %) for WLE (P = 0.06). CONCLUSIONS : The accuracy of NBI for the diagnosis of recurrence was not superior to that of WLE. Endoscopic assessment of EMR scars with WLE and NBI achieved an NPV that would allow routine biopsy to be avoided in cases of negative optical diagnosis.

The effect of tDCS on improving physical performance and attenuating effort perception during maximal dynamic exercise in non-athletes.

OBJECTIVES: This study aimed to test the effects of transcranial direct current stimulation (tDCS), using different electrode positioning and montages, on physical performance in maximum incremental tests of healthy non-athlete subjects. DESIGN: A double-blinded, crossover, sham-controlled study. METHOD: Fifteen subjects (aged 25.8 ± 5 years, nine women) received one of five different tDCS protocols: (i) anodal tDCS on the primary motor cortex (M1) (a-tDCS/M1), (ii) anodal tDCS on the left temporal cortex (T3) (a-tDCS/T3), (iii) cathodal tDCS on M1 (c-tDCS/M1), (iv) cathodal on T3 (c-tDCS/T3), or (v) sham tDCS. The protocols were assigned in a random order in separate sessions. After tDCS, the volunteers performed the maximal incremental exercise test (MIT) on a cycle ergometer in each session. The following measures were used to evaluate physical performance (primary outcome) during MIT: time to exhaustion (TE), maximum power (MAX-P), and Borg Rating of Perceived Exertion (RPE) scale. In addition, as a secondary outcome measure, we assessed the lower-limb corticospinal excitability and electrical muscular activity. RESULTS: tDCS applied over T3 or M1 did not influence electrical muscular activity or increase physical performance during MIT in healthy non-athlete subjects. However, our data confirmed that a-tDCS on the M1 increases lower-limb cortical excitability. CONCLUSIONS: Our results suggest that tDCS is not effective in improving performance during maximal dynamic exercise in non-athletes. However, we confirmed that the a-tDCS M1 protocol used in this study might increase cortical excitability in the lower limb motor cortex.

Demand Response Contextual Remuneration of Prosumers with Distributed Storage.

Prosumers are emerging in the power and energy market to provide load flexibility to smooth the use of distributed generation. The volatile behavior increases the production prediction complexity, and the demand side must take a step forward to participate in demand response events triggered by a community manager. If balance is achieved, the participants should be compensated for the discomfort caused. The authors in this paper propose a methodology to optimally manage a community, with a focus on the remuneration of community members for the provided flexibility. Four approaches were compared and evaluated, considering contextual tariffs. The obtained results show that it was possible to improve the fairness of the remuneration, which is an incentive and compensation for the loss of comfort. The single fair remuneration approach was more beneficial to the community manager, since the total remuneration was lower than the remaining approaches (163.81 m.u. in case study 3). From the prosumers' side, considering a clustering method was more advantageous, since higher remuneration was distributed for the flexibility provided (196.27 m.u. in case study 3).

Dataset of an energy community's generation and consumption with appliance allocation.

Energy data measured on-site from buildings can help describe the consumption behavior of end-users and can be used to examine and prove certain theorems and models, that require a large volume of data to be gathered. However, the direct extraction of this data can often be a lengthily and costly process. As a result, a dataset of a residential community was constructed based on real data, where sample consumption and photovoltaic generation profiles were attributed to 50 residential households and a public building (municipal library), a total of 51 buildings. In addition, the overall power consumption of these houses was desegregated into the consumption of 10 commonly used appliances using real energy profiles. First, several consumption and photovoltaic generation profiles, as well as a vast collection of appliance profiles, were gathered. These profiles were obtained from household readings in different locations, while the public building's profile was based on the consumption and photovoltaic production profiles of the research building GECAD. The profiles went through the process of normalization and new profiles were generated to complete the number of end-users needed. Moreover, these profiles were given a maximum consumption and production level at random before being accepted by one of the end-users. Therefore, fourteen of these households and the public building were randomly attributed with renewable solar energy. Finally, if possible, the tool created allocated, at random in previously determined intervals, the appliances' load profiles into each end-user's available consumption areas.

Extracellular Prostaglandins E1 and E2 and Inflammatory Cytokines Are Regulated by the Senescence Program in Potentially Premalignant Oral Keratinocytes.

Potentially pre-malignant oral lesions (PPOLs) are composed of keratinocytes that are either mortal (MPPOL) or immortal (IPPOL) in vitro. We report here that MPPOL, but not generally IPPOL, keratinocytes upregulate various extracellular tumor-promoting cytokines (interleukins 6 and 8) and prostaglandins E1 (ePGE1) and E2 (ePGE2) relative to normal oral keratinocytes (NOKs). ePGE upregulation in MPPOL was independent of PGE receptor status and was associated with some but not all markers of cellular senescence. Nevertheless, ePGE upregulation was dependent on the senescence program, cyclo-oxygenase 2 (COX2) and p38 mitogen-activated protein kinase and was partially regulated by hydrocortisone. Following senescence in the absence of p16INK4A, ePGEs accumulated in parallel with a subset of tumor promoting cytokine and metalloproteinase (MMP) transcripts, all of which were ablated by ectopic telomerase. Surprisingly, ataxia telangiectasia mutated (ATM) function was not required for ePGE upregulation and was increased in expression in IPPOL keratinocytes in line with its recently reported role in telomerase function. Only ePGE1 was dependent on p53 function, suggesting that ePGEs 1 and 2 are regulated differently in oral keratinocytes. We show here that ePGE2 stimulates IPPOL keratinocyte proliferation in vitro. Therefore, we propose that MPPOL keratinocytes promote the progression of IPPOL to oral SCC in a pre-cancerous field by supplying PGEs, interleukins and MMPs in a paracrine manner. Our results suggest that the therapeutic targeting of COX-2 might be enhanced by strategies that target keratinocyte senescence.