Estimating the population health burden of musculoskeletal conditions using primary care electronic health records.

OBJECTIVES: Better indicators from affordable, sustainable data sources are needed to monitor population burden of musculoskeletal conditions. We propose five indicators of musculoskeletal health and assessed if routinely available primary care electronic health records (EHR) can estimate population levels in musculoskeletal consulters. METHODS: We collected validated patient-reported measures of pain experience, function and health status through a local survey of adults (≥35 years) presenting to English general practices over 12 months for low back pain, shoulder pain, osteoarthritis and other regional musculoskeletal disorders. Using EHR data we derived and validated models for estimating population levels of five self-reported indicators: prevalence of high impact chronic pain, overall musculoskeletal health (based on Musculoskeletal Health Questionnaire), quality of life (based on EuroQoL health utility measure), and prevalence of moderate-to-severe low back pain and moderate-to-severe shoulder pain. We applied models to a national EHR database (Clinical Practice Research Datalink) to obtain national estimates of each indicator for three successive years. RESULTS: The optimal models included recorded demographics, deprivation, consultation frequency, analgesic and antidepressant prescriptions, and multimorbidity. Applying models to national EHR, we estimated that 31.9% of adults (≥35 years) presenting with non-inflammatory musculoskeletal disorders in England in 2016/17 experienced high impact chronic pain. Estimated population health levels were worse in women, older aged and those in the most deprived neighbourhoods, and changed little over 3 years. CONCLUSION: National and subnational estimates for a range of subjective indicators of non-inflammatory musculoskeletal health conditions can be obtained using information from routine electronic health records.

Development and validation of a pain monitoring app for patients with musculoskeletal conditions (The Keele pain recorder feasibility study).

BACKGROUND: Assessing daily change in pain and related symptoms help in diagnosis, prognosis, and monitoring response to treatment. However, such changes are infrequently assessed, and usually reviewed weeks or months after the start of treatment. We therefore developed a smartphone application (Keele Pain Recorder) to record information on the severity and impact of pain on daily life. Specifically, the study goal was to assess face, content and construct validity of data collection using the Pain Recorder in primary care patients receiving new analgesic prescriptions for musculoskeletal pain, as well as to assess its acceptability and clinical utility. METHODS: The app was developed with Keele's Research User Group (RUG), a clinical advisory group (CAG) and software developer for use on Android devices. The app recorded pain levels, interference, sleep disturbance, analgesic use, mood and side effects. In a feasibility study, patients aged > 18 attending their general practitioner (GP) with a painful musculoskeletal condition were recruited to use the app twice per day for 28 days. Face and construct validity were assessed through baseline and post-study questionnaires (Spearman's rank correlation coefficient). Usability and acceptability were determined through post-study questionnaires, and patient, GP, RUG and CAG interviews. RESULTS: An app was developed which was liked by both patients and GPs. It was felt that it offered the opportunity for GPs to discuss pain control with their patients in a new way. All participants found the app easy to use (it did not interfere with their activities) and results easy to interpret. Strong associations existed between the first 3 days (Spearman r = 0.79) and last 3 days (r = 0.60) of pain levels and intensity scores on the app with the validated questionnaires. CONCLUSIONS: Collaborating with patient representatives and clinical stakeholders, we developed an app which can be used to help clinicians and patients monitor painful musculoskeletal conditions in response to analgesic prescribing. Recordings were accurate and valid, especially, for pain intensity ratings, and it was easy to use. Future work needs to examine how pain trajectories can help manage changes in a patient's condition, ultimately assisting in self-management.

Mercury removal from municipal secondary effluent with hydrous ferric oxide reactive filtration.

This study evaluated the ability of hydrous ferric oxide reactive filtration (HFO-RF) to remove mercury (Hg) from municipal secondary effluent at four study sites. Pilot HFO-RF systems (136 m3 /day) at two sites demonstrated total Hg concentration removal efficiencies of 96% (inflow/outflow mean total Hg: 43.6/1.6  ng/L) and 80% (4.2/0.8 ng/L). A lightly loaded medium-scale HFO-RF system (950 m3 /day) had a concentration removal efficiency of 53% (0.98/0.46 ng/L) and removed 0.52 mg/day of total Hg and 2.2 µg/day of methyl-Hg. A full-scale HFO-RF system (11,400 m3 /day) yielded a total Hg concentration removal efficiency of 97% (87/2.7 ng/L) and removed an estimated 0.36 kg/year of Hg. Results suggest that the quality of secondary effluent, including dissolved organic matter content, affects achievable minimum total Hg concentrations in effluent from HFO-RF systems. Low HFO-RF effluent concentrations (<1 ng/L) can be expected when treating secondary effluent from suspended-growth biological treatment systems. PRACTITIONER POINTS: Trace levels of mercury in municipal secondary effluent can negatively impact receiving waters. Hydrous ferric oxide reactive filtration (HFO-RF) can remove mercury from municipal secondary effluent to levels below the Great Lakes Initiative discharge standard of 1.3 ng/L. Mercury removal to low concentrations (< 1 ng/L) using HFO-RF appears to be associated with secondary effluents with low dissolved organic matter content. HFO-RF can also remove total phosphorus and turbidity to low concentrations.

The acceptability and feasibility of conducting a randomised controlled trial to test the effectiveness of a walking intervention for older people with persistent musculoskeletal pain in primary care: A mixed methods evaluation of the iPOPP pilot trial.

INTRODUCTION: Persistent musculoskeletal (MSK) pain is associated with physical inactivity in older people. While walking is an acceptable form of physical activity, the effectiveness of walking interventions in this population has yet to be established. OBJECTIVES: To assess the acceptability and feasibility of conducting a randomised controlled trial (RCT) to test the effectiveness of a healthcare assistant-led walking intervention for older people with persistent MSK pain (iPOPP) in primary care. METHODS: A mixed method, three arm pilot RCT was conducted in four general practices and recruited patients aged ≥65 years with persistent MSK pain. Participants were randomised in a 1:1:1 ratio to: (i) usual care, (ii) usual care plus a pedometer intervention, or (iii) usual care plus the iPOPP walking intervention. Descriptive statistics were used in an exploratory analysis of the quantitative data. Qualitative data were analysed using thematic analysis. A triangulation protocol was used to integrate the analyses from the mixed methods. RESULTS: All pre-specified success criteria were achieved in terms of feasibility (recruitment, follow-up and iPOPP intervention adherence) and acceptability. Triangulation of the data identified the need, in the future, to make the iPOPP training (for intervention deliverers) more patient-centred to better support already active patients and the use of individualised goal setting and improve accelerometry data collection processes to increase the amount of valid data. CONCLUSIONS: This pilot trial suggests that the iPOPP intervention and a future full-scale RCT are both acceptable and feasible. The use of a triangulation protocol enabled more robust conclusions about acceptability and feasibility to be drawn.

Effects of aerobic and anaerobic conditions on P, N, Fe, Mn, and Hg accumulation in waters overlaying profundal sediments of an oligo-mesotrophic lake.

Concentrations of key nutrients and metals in water overlaying profundal sediments were evaluated in replicate experimental chambers containing undisturbed sediment-water interface samples from Deer Lake, an oligo-mesotrophic lake in eastern Washington. Chambers were incubated under three sequential phases: aerobic (21d), anaerobic (27d), and second aerobic (14d). In general, nutrients and metals in chamber water were lower under aerobic versus anaerobic conditions. However, in some cases compounds anticipated to appear only under anaerobic conditions, including ammonia, phosphate, and manganese, were observed during aerobic conditions. Correlation analysis elucidated a number of interactions between compounds. Phosphate correlated significantly (p<0.05) with iron during all incubation phases, suggesting that phosphorus cycling was controlled by iron. Cycling of nitrate and ammonia was tightly and significantly coupled under aerobic conditions. During both aerobic phases, nitrate increased while ammonia decreased, likely as a result of biological nitrification. Finally, mercury appeared during mildly reducing conditions and showed a significant correlation with manganese during the anaerobic phase, suggesting that Mn oxide reduction was the source of Hg in chamber water.

Surface-air mercury fluxes across Western North America: A synthesis of spatial trends and controlling variables.

Mercury (Hg) emission and deposition can occur to and from soils, and are an important component of the global atmospheric Hg budget. This paper focuses on synthesizing existing surface-air Hg flux data collected throughout the Western North American region and is part of a series of geographically focused Hg synthesis projects. A database of existing Hg flux data collected using the dynamic flux chamber (DFC) approach from almost a thousand locations was created for the Western North America region. Statistical analysis was performed on the data to identify the important variables controlling Hg fluxes and to allow spatiotemporal scaling. The results indicated that most of the variability in soil-air Hg fluxes could be explained by variations in soil-Hg concentrations, solar radiation, and soil moisture. This analysis also identified that variations in DFC methodological approaches were detectable among the field studies, with the chamber material and sampling flushing flow rate influencing the magnitude of calculated emissions. The spatiotemporal scaling of soil-air Hg fluxes identified that the largest emissions occurred from irrigated agricultural landscapes in California. Vegetation was shown to have a large impact on surface-air Hg fluxes due to both a reduction in solar radiation reaching the soil as well as from direct uptake of Hg in foliage. Despite high soil Hg emissions from some forested and other heavily vegetated regions, the net ecosystem flux (soil flux+vegetation uptake) was low. Conversely, sparsely vegetated regions showed larger net ecosystem emissions, which were similar in magnitude to atmospheric Hg deposition (except for the Mediterranean California region where soil emissions were higher). The net ecosystem flux results highlight the important role of landscape characteristics in effecting the balance between Hg sequestration and (re-)emission to the atmosphere.

Effects of hypolimnetic oxygen addition on mercury bioaccumulation in Twin Lakes, Washington, USA.

Twin Lakes, located on the Confederated Tribes of the Colville Indian Reservation in eastern Washington, USA, include North Twin Lake (NT) and South Twin Lake (ST). The mesotrophic, dimictic lakes are important recreational fishing sites for both warm-water bass and cold-water trout. To improve summertime cold-water habitat for trout in NT, dissolved oxygen (DO) addition to the hypolimnion, using liquid oxygen as an oxygen gas source, started in 2009. This study assessed mercury (Hg) in the water column, zooplankton and fish, and related water quality parameters, in Twin Lakes from 2009 to 2012. Because methylmercury (MeHg) buildup in lake bottom water is commonly associated with hypolimnetic anoxia, hypolimnetic oxygenation was hypothesized to reduce Hg in bottom waters and biota in NT relative to ST. Oxygen addition led to significantly higher DO (mean hypolimnetic DO: 2-8 mg/L versus <1 mg/L) and lower MeHg (peak mean hypolimnetic MeHg: 0.05-0.2 ng/L versus 0.15-0.4 ng/L) in North Twin. In North Twin, years with higher DO (2009 and 2011) exhibited lower MeHg in bottom waters and lower total Hg in zooplankton, inferring a positive linkage between oxygen addition and lower bioaccumulation. However, when comparing between the two lakes, Hg levels were significantly higher in zooplankton (total Hg range: 100-200 versus 50-100 µg/kg dry weight) and trout (spring 2010 stocking cohort of eastern brook trout mean total Hg: 74.9 versus 49.9 µg/kg wet weight) in NT relative to ST. Lower Hg bioaccumulation in ST compared to NT may be related to bloom dilution in chlorophyll-rich bottom waters, a vertical disconnect between the location of zooplankton and MeHg in the water column, and high binding affinity between sulfide and MeHg in bottom waters.

Relative hypotension and image guidance: tools for training in sinus surgery.

OBJECTIVES: To quantify the safety and efficiency of Postgraduate-Year II head-and-neck-surgery residents who perform endoscopic sinus surgery, to observe any changes that accompanied accrued experience, and to measure and correlate blood loss and temporal efficiency with anesthesia-induced relative hypotension. DESIGN: Retrospective study. SETTING: University of California, San Diego, Medical Center. PATIENTS: One hundred two patients with chronic rhinosinusitis operated on between July 1, 2005, and June 30, 2006, by 3 Postgraduate-Year II head-and-neck-surgery residents. INTERVENTION: Endoscopic sinus surgery. MAIN OUTCOME MEASURES: Operative times, blood loss, case complexity, and anesthetic components were recorded and analyzed. RESULTS: One hundred two patients with chronic rhinosinusitis with and without polyposis received operative management. Mean operative time, with the inclusion of injection (10 minutes) and image guidance setup (5 minutes), was 77 minutes. Estimated blood loss averaged 42 mL for patients with chronic rhinosinusitis and 58 mL for patients with chronic rhinosinusitis and nasal polyps. The mean intraoperative blood pressure was 101/65 mm Hg. No major complications occurred. CONCLUSIONS: Endoscopic sinus surgery may be safely performed by Postgraduate-Year II head-and-neck-surgery residents by means of hypotensive anesthesia techniques and image guidance. Outcome analysis demonstrates minimal blood loss, efficient operative times, and no significant complications.