Factors Contributing to the Link between Physical Well-Being and Chronic Pain in Young People from Galicia, Northwest Spain.

Introduction: The relation between physical well-being and chronic pain is complex and involves several subjective and objective covariates. We aimed to assess the role of mediator, confounder, or interactor played by covariates, including sleep quality, physical activity, perceived stress, smoking, and alcohol drinking in the relation between physical well-being and chronic pain. Method: We used Poisson regression to obtain incidence rate ratios (IRR) of the association between physical well-being and chronic pain in a cohort study carried out among university students. We applied General Structural Equation Modeling (GSEM) to assess mediation and stratum-specific analyses to distinguish confounding from interaction. We computed Relative Excess Risks due to Interaction (RERI), Attributable Proportion (AP), and the Synergy index (S) to measure additive interaction. Results: High physical well-being is related to a large decrease in the risk of chronic pain (IRRTotal Effect = 0.58; 95% CI: 0.50-0.81). Perceived stress mediates 12.5% of the total effect of physical well-being on chronic pain. The stratum-specific IRRs of current smokers and non-current smokers were different from each other and were larger than the crude IRR (IRR = 1.49; 95% CI: 1.24-1.80), which indicates that smoking could be both confounder and interactor. Interaction analyses showed that physical activity could act as a potential interactor (RERI = 0.25; 95% CI: 0.13, 0.60). Conclusions: Perceived stress is an important mediator of the relation between physical well-being and chronic pain, while smoking is both a confounder and an interactor. Our findings may prove useful in distinguishing high-risk groups from low-risk groups, in the interventions aimed at reducing chronic pain.

Sleep quality as a mediator of the relation between depression and chronic pain: a systematic review and meta-analysis.

BACKGROUND: Chronic pain and depression represent two global health problems with considerable economic consequences. Although existing literature reports on the relation between depression and pain conditions, meta-analytic evidence backing the mediating role of sleep disturbance as one of the main symptoms of depression is scarce. To examine the extent to which sleep disturbance mediates the depression-chronic pain association, we conducted a systematic review and meta-analysis of the associations of chronic pain, depression, and sleep quality. METHODS: We systematically searched for literature in MEDLINE and other relevant databases and identified cohort and case-control studies on depression, sleep disturbance, and chronic pain. Forty-nine studies were eligible, with a total population of 120 489 individuals. We obtained direct and indirect path coefficients via two-stage meta-analytic structural equation modelling, examined heterogeneity via subgroup analyses, and evaluated primary studies quality. RESULTS: We found a significant, partial mediation effect of sleep disturbance on the relation between depression and chronic pain. The pooled path coefficient (coef.) of the indirect effect was 0.03 (95% confidence interval [CI]: 0.01-0.05) and accounted for 12.5% of the total effect of depression on chronic pain. This indirect effect also existed for cohort studies (coef. 0.02; 95% CI: 0.002-0.04), European studies (coef. 0.03; 95% CI: 0.004-0.05), and studies that adjusted for confounders (coef. 0.04; 95% CI: 0.01-0.09). CONCLUSIONS: Sleep disturbance partially mediates the association between depression and pain. Although plausible mechanisms could explain this mediation effect, other explanations, including reverse causation, must be further explored. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42022338201.

Association between alcohol consumption and chronic pain: a systematic review and meta-analysis.

INTRODUCTION: Chronic pain represents a global health problem with a considerable economic burden. The relation of alcohol intake and chronic pain conditions was assessed in several studies with conflicting results. We used dose-response meta-analysis techniques to answer the question of whether alcohol intake is related to chronic pain occurrence. METHODS: We searched MEDLINE, Embase, and other databases to identify cohort and case-control studies on alcohol consumption and chronic pain. Sixteen studies were eligible with a total population of 642 587 individuals. Fixed-effects and random-effects pooled estimates were obtained by weighting log odds ratios (ORs) in case-control studies and log incidence rate ratios in cohort studies by the inverse of their variance. A heterogeneity assessment and a dose-response analysis were carried out. Quality scoring was also performed. RESULTS: Our results show that any alcohol consumption was related to lower odds of chronic pain (pooled OR=0.76; 95% confidence interval [CI], 0.61-0.95). The association was non-linear. The ORs by quartile of alcohol doses were as follows: OR2nd quartile=0.74; 95% CI, 0.64-0.87; OR3rd quartile=0.67; 95% CI, 0.53-0.86; and OR4th quartile=0.75; 95% CI, 0.50-1.14. This association was observed for cohort studies (OR=0.77; 95% CI, 0.61-0.98) and European studies (OR=0.65; 95% CI, 0.48-0.87) only. Studies with complete adjustment for confounding factors showed a stronger relation than those with incomplete adjustment (OR=0.69; 95% CI, 0.48-0.99 and OR=0.85; 95% CI, 0.65-1.11, respectively). CONCLUSION: Alcohol consumption presents a non-linear inverse association with the occurrence of chronic pain. Although plausible mechanisms could explain this protective effect, other explanations, including reverse causation, are probable.

Education level and misuse of antibiotics in the general population: a systematic review and dose-response meta-analysis.

BACKGROUND: Numerous studies evaluated the association of education level with misuse of antibiotics by the general population, yet divergent findings were reported. Therefore, a meta-analysis was conducted to summarize this association. METHODS: A categorical and continuous dose-response meta-analysis of the association of education level with antibiotic misuse was undertaken. Summary odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated using random-effect model. RESULTS: The meta-analysis included 85 studies from 42 countries of different socioeconomic status. Compared to low education (≤ 9 years), medium education (> 9-12 years) is associated with 20% lower odds of antibiotic misuse in high-income countries (OR = 0.80; 95% CI 0.66, 0.97), while high education (> 12 years) is associated with 14% lower odds of any aspect of antibiotic misuse (OR = 0.86; 95% CI 0.72, 1.03). The association is more pronounced in Middle East (OR = 0.64; 95% CI 0.42, 1.00) and countries of lower-middle economies (OR = 0.67, 95% CI 0.41, 1.11). Inversely, in Europe, high education is associated with 25% higher odds of antibiotic misuse (OR = 1.25, 95% CI 1.00, 1.58). Each additional year of education was associated with 4% lower odds of any aspect of antibiotic misuse in lower-middle economies (OR = 0.96; 95% CI 0.92, 1.00) and in Middle East (OR = 0.96; 95% CI 0.93, 1.00). Conversely, it was associated with 3% higher odds of antibiotic storage, a specific type of misuse (OR = 1.03, 95% CI 1.01, 1.06). CONCLUSION: Individuals misuse antibiotics irrespective of their education level. Intervention programs to enhance the proper use of antibiotics should target all communities independent of their education level.

Development and Validation of a Knowledge, Attitude and Practice Questionnaire on Antibiotic Use in Arabic and French Languages in Lebanon.

OBJECTIVES: Validated knowledge-attitude-practice (KAP) questionnaires are essential to design and evaluate intervention programs on antibiotic use. Recently, we validated the first KAP questionnaire on antibiotics in Spain. Cross-cultural adaptation and validation of research tools increase their universal usefulness. Here, we aimed to validate the questionnaire in a developing country with different socioeconomic characteristics from that of Spain. METHODS: We translated the previously developed KAP-questionnaire into Arabic and French, tailored it and then validated it in adult population in Lebanon. The item content validity index (I-CVI), scale content validity index (S-CVI/Ave) and modified Kappa (k*) were calculated. The construct validity of the questionnaire was evaluated using confirmatory factorial analysis (CFA, N = 1460) and its reliability was assessed using intraclass correlation coefficients (ICC, N = 100) and Cronbach's alpha statistic. RESULTS: ICV-I (>0.78), k* (equal to ICV-I for all items) and S-CVI/Ave (≥0.95) confirmed the questionnaire content validity. Pilot testing (N = 40) and face validity showed the understandability of the questionnaire by the population. Test-retest reliability analysis (N = 100) yielded ICC ≥ 0.59 for all knowledge and attitude items, showing the capacity of the questionnaire to generate reproducible results. CFA evidenced adequate fit of the chosen model, thus establishing the construct validity of the questionnaire (root mean squared error approximation = 0.053, standardized root mean square residual = 0.045, comparative fit index = 0.92 and Tucker-Lewis index = 0.90). The questionnaire showed an acceptable internal reliability (Cronbach's alpha = 0.62) and was highly accepted in Lebanon (response rate = 96% and item response rates ≥ 94%). CONCLUSIONS: The validity of the KAP-questionnaire on antibiotics in Arabic and French was demonstrated in Lebanon.

Income level and antibiotic misuse: a systematic review and dose-response meta-analysis.

OBJECTIVES: To quantify the association between income and antibiotic misuse including unprescribed use, storage of antibiotics and non-adherence. METHODS: We identified pertinent studies through database search, and manual examination of reference lists of selected articles and review reports. We performed a dose-response meta-analysis of income, both continuous and categorical, in relation to antibiotic misuse. Summary odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated under a random-effects random effects model. RESULTS: Fifty-seven studies from 22 countries of different economic class were included. Overall, the data are in agreement with a flat linear association between income standardized to socio-economic indicators and antibiotic misuse (OR per 1 unit increment = 1.00, p-value = 0.954, p-value non-linearity = 0.429). Data were compatible with no association between medium and high income with general antibiotic misuse (OR 1.04; 95% CI 0.89, 1.20 and OR 1.03; 95% CI 0.82, 1.29). Medium income was associated with 19% higher odds of antibiotic storage (OR 1.19; 95% CI 1.07, 1.32) and 18% higher odds of any aspect of antibiotic misuse in African studies (OR 1.18; 95% CI 1.00, 1.39). High income was associated with 51% lower odds of non-adherence to antibiotic treatment (OR 0.49; 95% CI 0.34, 0.60). High income was also associated with 11% higher odds of any antibiotic misuse in upper-middle wealth countries (OR 1.11; 95% CI 1.00, 1.22). CONCLUSIONS: The association between income and antibiotic misuse varies by type of misuse and country wellness. Understanding the socioeconomic properties of antibiotic misuse should prove useful in developing related intervention programs and health policies.

Immunohistochemical analysis of epithelium adjacent to lip cancer: A meta-analysis.

OBJECTIVES: To identify the immunohistochemical pattern of non-tumoral epithelium adjacent to lip cancer (ANTE) to unveil molecular alterations and potential biomarkers in lip cancer patients. MATERIALS AND METHODS: A systematic search at MEDLINE, EMBASE and proceedings Web of Science, OpenGrey and WorldCat. The PICOS outline (Population: lip cancer patients; Intervention: immunostaining with biomarkers in surgical specimens; Comparisons: ANTE versus LC; Outcomes: primary-to identify the immunohistochemical pattern of peritumoral epithelium and secondary-to assess the immunoreactivity of LC epithelium; and Study design: cross-sectional, case-control and cohort studies). RESULTS: A total of 339 records were identified. Seven studies reporting on ANTE and LCs were included in the qualitative synthesis, and 4 of them (p53 immunostaining) were selected for meta-analysis. In the ANTE group, the pooled prevalence of p53 was 0.74 (95% CI: 0.66 - 0.82), while in the lip squamous cell carcinoma group this prevalence was 0.83 (95% CI: 0.75 - 0.89). CONCLUSIONS: Similar immunoexpression was found in lip epithelium adjacent to lip carcinoma, even in epithelia with normal appearance or mild histological alterations. The role of biomarkers in the follow-up of actinic cheilitis patients deserves additional clinical assessment.

Diabetes mellitus and oral lichen planus: A systematic review and meta-analysis.

OBJECTIVE: To undertake a meta-analysis of the association of Oral Lichen Planus (OLP) with diabetes, two diseases with an important impact on public health and the economy, but the evidence of which about their association is inconsistent. METHODS: Relevant studies were localized by searching MEDLINE, EMBASE, Conference Proceedings, and other databases from inception to October 2020, without restrictions. The reference lists of included studies and of related reviews were also inspected. Global pooled odds ratios were calculated, and predefined subgroup analyses were performed. The heterogeneity between studies and publication bias was assessed and sensitivity analysis was carried out. RESULTS: Thirty-two studies were included in the meta-analysis. Pooled ORs showed a moderate association between diabetes and OLP [OR: 1.87 (95%CI: 1.57, 2.34)]. The association is limited to studies carried out on adults only [OR: 2.12 (95%CI: 1.75, 2.57)] and is observed in all study designs. Globally, the heterogeneity was low to moderate. Studies carried out in European populations show a stronger association of diabetes and OLP than Asiatic studies [OR: 2.49 (95%CI: 1.87, 3.32) and 1.60 (95%CI: 1.25, 2.03), respectively]. CONCLUSIONS: Diabetes and OLP are moderately associated. Systematic diagnosis of diabetes in OLP patients could prove useful.

Social factors and chronic pain: the modifying effect of sex in the Stockholm Public Health Cohort Study.

OBJECTIVES: To assess the relationship between social factors (socio-economic status, household load and job strain) and chronic pain occurrence, and the role of gender in this relationship. METHODS: We used data corresponding to 8 years of follow-up of the Stockholm Public Health Cohort Study (2006-2014) to compute Adjusted Incidence Rate Ratios (IRRs) and additive interaction measures of chronic pain episodes, social factors, and sex in 16 687 subjects. RESULTS: For men, increased rates of chronic pain occurrence were observed for skilled workers (IRR = 1.27, 95% CI: 0.99, 1.61) and lower non-manual employees (IRR = 1.37, 95% CI: 1.05, 1.78), compared with unskilled workers; subjects with high household load (IRR = 1.39; 95% CI: 1.03, 1.88), compared with those with a null score; and subjects with active jobs (IRR = 1.27, 95% CI: 1.06, 1.51), compared with those with low-strain jobs. For women, we observed decreased rates of chronic pain occurrence in lower (IRR = 0.82, 95% CI: 0.68, 0.99), intermediate (IRR = 0.74, 95% CI: 0.63, 0.88) and higher non-manual employees (IRR = 0.65, 95% CI: 0.54, 0.79), compared with unskilled workers. Compared with subjects with a null score, women with low household load showed a lower rate of chronic pain occurrence (IRR = 0.85; 95% CI: 0.72, 1.00). Compared with subjects with low-strain jobs, those with passive jobs (IRR = 1.21; 95% CI: 1.02, 1.44) and high-strain jobs (IRR = 1.46; 95% CI: 1.02, 2.09) showed higher rates of chronic pain occurrence. CONCLUSION: In general, our analysis yielded different, if not opposite, results when data were stratified by sex. Sex may then represent an effect modifier of the relationship between social factors and chronic pain.

Sleep quality and risk of recurrent aphthous ulcers: A Spanish cohort study.

OBJECTIVE: Recurrent aphthous stomatitis (RAS) is a condition that affects 20% of the world population and is characterized by painful ulcers in the oral mucosa. So far, the epidemiology and risk factors of RAS have been infrequently studied. Our objective was to determine whether sleep-related factors are related to the occurrence of RAS in the first prospective study carried out on this topic. METHODS: A cohort of 11210 Spanish students, 13-17 years old, was followed up for one year. Sleep disorders were assessed at baseline using a standard validated questionnaire. RESULTS: We detected 2655 new cases of RAS with a total of 287,262 person-week of follow-up. Subjects with high (4th quartile) Insomnia Index showed an incidence rate ratio (IRR) of RAS of 1.29 (95% confidence interval (CI) 1.15-1.45), while subjects with high Hypersomnia Index presented an IRR of 1.42 (95% CI 1.26-1.61). A high score of sleep-related phenomena was also associated with an increased IRR: 1.53 (95% CI 1.37-1.69). Adolescents with high level of sleep satisfaction were at lower risk of RAS: 0.88 (95% CI 0.77-1.01). CONCLUSION: These findings suggest that sleep disorders are moderately associated with RAS in adolescents.

Association of knowledge and attitudes with the misuse of tranquilizers in parents: a study in Beirut (Lebanon).

OBJECTIVE: To measure the association between knowledge, attitudes and practices of personal misuse of tranquilizers among parents of schoolchildren in Beirut (Lebanon). DESIGN: We carried out a cross-sectional study in 1396 adults recruited from parents of students of eleven public and private schools, from primary schools to high schools, using a Knowledge, Attitude and Practices (KAP) questionnaire of personal use of tranquilizers. MAIN OUTCOME MEASURES: We assessed five patterns of tranquilizers' misuse: unprescribed use, shortened treatment, stored leftovers, doubled forgotten doses or taken when remembered, changed dose without medical recommendation, and a sixth composite outcome: 'any misuse'. RESULTS: Sixty-three (62.2%) of 91 parents who used tranquilizers reported at least one misuse pattern. Higher odds of 'any misuse' were observed among parents who reported taking tranquilizers to sleep better, to enjoy themselves with their families or to work better [2.35 ≤ adjusted interquartile odds ratio (aIqOR) ≤ 1.99]. Storing tranquilizers for future need was strongly associated with misuse [aIqOR: 5.00 (95% CI: 3.30, 7.59)]. Greater awareness about hazards of tranquilizers and the importance of therapeutic compliance was associated with lower odds of specific misuse patterns (0.50 ≤ aIqOR ≤ 0.72). CONCLUSIONS: Poor knowledge and medically disapproved attitudes increase the likelihood of practices of tranquilizer misuse.

Gastroesophageal reflux disease and asthma exacerbation: A systematic review and meta-analysis.

BACKGROUND: Gastroesophageal reflux disease (GORD) is highly prevalent and often coexists with asthma exacerbation. Divergent findings about the association between the two diseases were reported. We conducted a systematic review and meta-analysis to determine whether there exists an association between GORD and asthma. METHODS: We searched MEDLINE, EMBASE, and other databases and then performed a manual search, to identify eligible studies. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated using fixed- and random-effect models. We evaluated the quality of included studies, explored heterogeneity between studies, undertook subgroup analyses, assessed publication bias, and performed sensitivity analyses. RESULTS: We identified 32 eligible studies, conducted in 14 countries and including a total of 1,612,361 patients of all ages. Overall, GORD shows a weak association with asthma exacerbation (OR = 1.27; 95% CI 1.18-1.35). This association was observed in cohort, case-control, and cross-sectional designs and in European as well as non-European populations. Subgroup analyses show that GORD is associated with frequent asthma exacerbations (≥3 exacerbations, OR = 1.59; 95% CI 1.13-2.24) and with exacerbations needing oral corticosteroid therapy (OR = 1.24; 95% CI 1.09-1.41). GORD pediatric patients are at higher odds of asthma exacerbation than adults. We did not detect any evidence of publication bias and the association between GORD and asthma exacerbation held in all undertaken sensitivity analyses. CONCLUSIONS: Gastroesophageal reflux disease and asthma exacerbation are weakly associated.

Comparison of Longitudinal and Cross-Sectional Approaches in Studies on Knowledge, Attitude and Practices Related to Non-Medical Tranquilizer Use.

Research about the association of knowledge and attitudes with practices (KAP) of non-medical tranquilizer use is scarce. We compared findings from cross-sectional and longitudinal approaches in a KAP-based study on non-medical tranquilizer use in Spain using data collected from the same population. Eight-hundred forty-seven participants completed a validated KAP questionnaire at baseline and were then followed-up bimonthly for one year for episodes of non-medical tranquilizer use. Non-medical use was defined as unprescribed use, non-adherence to treatment, storage/sharing of tranquilizers, or a combination of those practices. Adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated using logistic regression from cross-sectional data and generalized linear mixed models for repeated measures in the longitudinal approach. Only the longitudinal approach showed that limited knowledge about the effect of tranquilizers on behaviour [OR: 3.24 (95% CI: 1.12-9.38)] and about the negative effect of their excessive consumption [OR: 4.12 (95% CI: 1.5-11.33)] is associated with storing/sharing tranquilizers. Both cross-sectional and longitudinal analyses indicated that personal attitudes towards tranquilizers and attitudes towards healthcare providers are associated with non-medical tranquilizer use, yet with different magnitude of associations. Differences between the two approaches were also observed for individual types of non-medical use. Certain discrepancies exist between findings from longitudinal and cross-sectional approaches on KAP of non-medical tranquilizer use. KAP studies are the backbone for designing and evaluating prevention programs on non-medical tranquilizer use, and hence choosing a proper study design, scrutinizing the associated biases, and carefully interpreting findings from those studies are required.

Validation of the Arabic and French Versions of a Knowledge, Attitudes and Practices (KAP) Questionnaire on Tranquilizer Misuse.

Tranquilizer misuse is an emerging international public health concern. The psychosocial determinants of this misuse remain understudied. Instruments to measure the Knowledge, Attitudes and Practices (KAP) of tranquilizer misuse are unavailable, except for a recently published questionnaire validated in the Spanish language. We translated the KAP questionnaire into Arabic and French, adapted it and undertook a complete validation procedure in the general adult population in Lebanon. The content validity indicators were good: item content validity index ranged between 0.89 and 1.00, the content validity index scale average was ≥0.95 and the modified Kappa statistic for each of the KAP items was equal to I-CVI. The intra-class correlation coefficient values (n = 100) were ≥0.62 for all Knowledge and Attitudes items, demonstrating the item reliability. Confirmatory factorial analysis (n = 1450) showed that the selected model of Knowledge and Attitude constructs has adequate fit indicators and encompassed three factors that showed acceptable internal reliability: Knowledge (Cronbach's alpha = 0.72), personal Attitudes towards tranquilizers (Cronbach's alpha = 0.79) and Attitudes towards healthcare providers (Cronbach's alpha = 0.65). The Arabic/French questionnaire was highly accepted, with a response rate of 95.72% and item non-response rate ≤3.6%. The availability of a cross-cultural adapted and multilingual validated questionnaire would stimulate research on tranquilizer misuse.

Association of knowledge and attitudes with practices of misuse of tranquilizers: A cohort study in Spain.

BACKGROUND: Tranquilizer misuse represents a growing international public health problem with heavy social and economic consequences. We aimed to identify the psychosocial determinants of this misuse practice, focusing on modifiable factors including knowledge and attitudes towards these medications. METHODS: A prospective cohort study involving 847 adults accompanying children in primary care clinics was carried out in Spain. A validated Knowledge, Attitudes and Practices (KAP) questionnaire on tranquilizer use was self-administered at baseline, and then participants were followed-up bimonthly. A misuse event was defined as unprescribed intake of tranquilizers, storing/sharing leftovers of tranquilizers, and/or not adhering to the prescribed treatment period, timing or dosage. Poisson regression models were applied to estimate adjusted Incidence Rate Ratios (IRRs) of misuse and their 95 % Confidence Intervals (CIs). FINDINGS: Individuals' personal attitudes towards tranquilizers and treating physicians are strongly associated with the misuse of these drugs. These attitudes include: individuals' acceptance of taking tranquilizers to improve sleeping [IRR: 5.10 (95 %CI: 2.74-9.48)], to work better [IRR: 2.04 (95 %CI: 1.05-3.99)], or for recreational purposes [IRR: 1.85 (95 %CI: 1.04-3.32)]; willingness to prolong the course of tranquilizer treatment without medical consultation [IRR: 2.45 (95 %CI: 1.46-4.13)]; agreeing on storing tranquilizers for possible future need [IRR: 5.07 (95 %CI: 2.73-9.40)]; and untrusting the physician's decision about tranquilizer prescription [IRR: 1.92 (95 %CI: 1.12-3.30)]. The level of knowledge is marginally associated with tranquilizer misuse. CONCLUSIONS: There is a strong association between individuals' attitudes towards tranquilizers and the misuse practices of these drugs. Educational interventional studies could help reduce the incidence of tranquilizer misuse.

Paracetamol Intake and Hematologic Malignancies: A Meta-Analysis of Observational Studies.

Hematologic malignancies cause more than half a million deaths every year worldwide. Analgesics were suggested as chemopreventive agents for several cancers but so far, results from individual studies about the relationship between paracetamol (acetaminophen) use and hematologic malignancies are conflicting. Therefore, we decided to perform a systematic review and meta-analysis. We retrieved studies published in any language by systematically searching Medline, Embase, Conference Proceedings Citation Index, Open Access Theses and Dissertations, and the five regional bibliographic databases of the World Health Organization until December 2020. Pooled odds ratios (OR) and their 95% confidence intervals (CI) were calculated according to the inverse of their variances. We performed separate analyses by histologic type. We also evaluated publication bias and assessed quality. A total of 17 study units met our inclusion criteria. The results show an association of hematologic malignancies with any paracetamol intake (OR 1.49, 95% CI 1.23-1.80) and with high paracetamol intake (OR 1.77, 95% CI 1.45-2.16). By subtype, risk was higher for multiple myeloma (OR 2.13, 95% CI 1.54-2.94) for any use and OR 3.16, 95% CI 1.96-5.10 for high intake, while risk was lower and non-significant for non-Hodgkin lymphoma. This meta-analysis provides evidence that paracetamol intake may be associated with hematologic malignancies and suggests that a dose-response effect is plausible. These results are unlikely to be due to publication bias or low quality of studies. Future research should focus on assessing the dose-response relationship.

Social factors and pain worsening: a retrospective cohort study.

BACKGROUND: Pain, specifically chronic pain, is a major public health issue worldwide with considerable health-related consequences and large economic impact. The relation between socioeconomic status and pain occurrence is well established. However, little is known on the relation between socioeconomic factors and worsening of pain, including progression from non-chronic pain to chronic pain. METHODS: To assess the relation between socioeconomic status and pain worsening, we used the Stockholm Public Health Cohort Study from 2006 to 2014 and analysed data of 9721 participants who completed follow-up. The adjusted incidence rate ratios (IRRs) of moderate and severe pain worsening episodes were computed, using a pain amplification model, which encompasses spreading, somatisation, and psychological distress components. Multiple imputation analysis was performed subsequently to adjust for cohort attrition. RESULTS: Compared with non-skilled workers, self-employed subjects (IRR=1.18; 95% confidence interval [CI], 1.01-1.39) and non-manual employees were at higher risk of moderate worsening (lower non-manual employees: IRR=1.21; 95% CI, 1.03-1.41; intermediate non-manual employees: IRR=1.26; 95% CI, 1.10-1.44; higher non-manual employees: IRR=1.25; 95% CI, 1.08-1.45). This risk increase was limited to worsening starting at stage 0 (non-chronic pain). No association was found between socioeconomic status and severe pain worsening. CONCLUSION: Our results support a moderate association between intermediate and high socioeconomic status, and moderate pain worsening. This association could be explained by the heterogeneous composition of the socioeconomic variable used in this cohort, and by changes in exposure and other time-varying covariables' status during follow-up.

Comparison of Longitudinal and Cross-Sectional Approaches in Studies About Knowledge, Attitude, and Practices Related to Antibiotic Misuse.

INTRODUCTION: Cross-sectional studies on the association between knowledge, attitudes, and practices of antibiotic misuse are abundant. Conversely, longitudinal studies are unavailable. OBJECTIVE: The objective of this study was to compare findings from cross-sectional and longitudinal data analyses of the same study on knowledge and attitudes related to practices of antibiotic misuse in the general adult population. METHODS: A validated knowledge, attitudes, and practices questionnaire was self-administered at baseline and participants were followed up bimonthly. Logistic regression was used on baseline data to compute adjusted odds ratios in the cross-sectional data analysis. In the longitudinal approach, Poisson regression and generalized linear mixed models were used to estimate adjusted incidence rate ratios and adjusted odds ratios, respectively. RESULTS: Seven hundred and forty-seven adults completed the baseline and the follow-up questionnaires. In the cross-sectional analysis, 78 participants misused antibiotics and strong associations were observed between agreement with various knowledge and attitudes statements and antibiotic misuse practices, with odds ratios between 1.94 and 5.66. In the longitudinal data analysis using Poisson regression, 46 events of antibiotic misuse were detected. No associations were observed between knowledge, attitudes, and misuse practices, except for two statements about the preference of storing antibiotics [adjusted incidence rate ratio: 2.33 (95% confidence interval 1.20-4.54)] and taking antibiotics when getting a cold [adjusted incidence rate ratio: 2.28 (95% confidence interval 1.24-4.21)]. The magnitude of these associations was lower than that observed in the cross-sectional analysis. Findings of the generalized linear mixed-model analysis were similar to those yielded by Poisson regression. CONCLUSIONS: The cross-sectional and the longitudinal approaches yield divergent results in our setting. Risk of bias in both analyses should be scrutinized.

Development and validation of a knowledge, attitude and practice questionnaire of personal use of tranquilizers.

BACKGROUND: Tranquilizer misuse is insufficiently acknowledged as a public health problem despite its alarming consequences. Instruments to measure psychosocial factors related to tranquilizer misuse are lacking. We aimed to develop and validate a Knowledge, Attitude and Practice questionnaire of tranquilizer misuse by adults in Spain. METHODS: The questionnaire was designed after an extensive literature review and several meetings with experts. We assessed face and content validity, and pilot tested the questionnaire. We examined its reliability by test-retest analysis in a sample of 145 adults. We distributed the questionnaire to 879 individuals, tested the construct validity through Confirmatory Factor Analysis (CFA), measured its overall reliability and determined its acceptability. RESULTS: The Item Content Validity Index (I-CVI from 0.78 to 1.00), the Scale Content Validity Index, using the averaging method (S-CVI/Ave = 0.95) and the fact that the modified Kappa statistic for each of the Knowledge, Attitude and Practice items was equal to I-CVI demonstrated the content validity of the questionnaire. The Intra-Class Correlation coefficients for Knowledge and Attitude items were > 0.5, establishing their reliability. The Knowledge and Attitude construct was modeled using CFA and the model showed a good fit, thus establishing its validity. The overall reliability of the construct was revealed by Cronbach՚s alpha values > 0.6. The questionnaire was highly accepted (response rate = 95 % and item non-response ≤ 4%). CONCLUSIONS: The validity of the developed questionnaire was established. Its availability will stimulate the initiation of research on tranquilizer misuse and will consequently help in designing related public health interventions.

Socioeconomic status and occurrence of chronic pain: a meta-analysis.

OBJECTIVE: To examine the association between socioeconomic status (SES) and the occurrence of chronic pain, defined as pain that persists or recurs for >3 months. METHODS: We performed a structured search in Medline, Embase, WHO Global Index Medicus and Conference Proceedings Citation Index-Science databases to identify cohort and case-control studies on chronic pain and SES and its subgroups (SES combined index, educational level, income and occupational status). We extracted study characteristics, outcome measures and measures of association and their 95% CIs. Literature search, data extraction and risk of bias assessment were conducted by two independent researchers. We performed main and subgroup meta-analyses using random-effects model, and formally assessed heterogeneity and publication bias. RESULTS: A total of 45 studies, covering a population of ∼175 000 individuals, were meta-analysed, yielding a pooled Odds Ratio (OR) of 1.32 (95% CI: 1.21, 1.44) and 1.16 (95% CI: 1.09, 1.23) for low and medium SES levels, respectively, compared with high level. We obtained similar results in all the subgroup analyses. Heterogeneity was generally moderate to high across strata, and some evidence of publication bias for low socioeconomic status was found. CONCLUSION: Our results support a moderate increase in the risk of chronic pain for low and medium SES when compared with high SES, a feature that remained constant in all measures of exposure or outcome used. Further prospective research on populations from developing countries are needed to confirm our findings as the studies available for this meta-analysis were carried out exclusively in developed countries.