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© 2023 European Academy of Neurology, Hariz and colleagues [1] argue that the new EAN/MDS GL contradicts the repeated endorsements of pallidotomy by the MDS. The MDS has previously published “evidence based medicine (EBM) reviews,” which appraise each treatment on the basis of welldefined criteria but are not GLs. Clinical GLs, such as the new EAN/MDS GL, also take into consideration other variables, including context, summarizing the current medical knowledge, weighing the benefits and harms of treatments, and giving specific recommendations based on this information. The specific GRADE GL methodology allows for the evaluation of available scientific evidence with a sophisticated evaluation process that includes grading the strength of the evidence and the certainty of that evidence, out of which the recommendations are developed. These steps are well documented in our appendices 1 and 2 for methodology and appendices 3 and 4 for outcomes. Thus, the case of radiofrequency pallidotomy and deep brain stimulation (DBS) of the pallidum, which is discussed by Hariz et al, illustrates the difference between EBM reviews and GLs. The EBM review ranks pallidotomy at the same level as globus pallidus internus (GPi)-DBS: both treatments are considered “efficacious,” “clinically useful,” and coming with a “clinically acceptable risk with specialized monitoring,” but it does not express whether the treatments are equal in their application in patients overall. In our GL using the GRADE methodology, in contrast, GPi-DBS is recommended, whereas pallidotomy is recommended only with restrictions.

[Background and Purpose] This update of the treatment guidelines was commissioned by the European Academy of Neurology and the European section of the Movement Disorder Society. Although these treatments are initiated usually in specialized centers, the general neurologist and general practitioners taking care of PD patients should know the therapies and their place in the treatment pathway., [Methods] Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the spectrum of approved interventions including deep brain stimulation (DBS) or brain lesioning with different techniques (radiofrequency thermocoagulation, radiosurgery, magnetic resonance imaging–guided focused ultrasound surgery [MRgFUS] of the following targets: subthalamic nucleus [STN], ventrolateral thalamus, and pallidum internum [GPi]). Continuous delivery of medication subcutaneously (apomorphine pump) or through percutaneous ileostomy (intrajejunal levodopa/carbidopa pump [LCIG]) was also included. Changes in motor features, health-related quality of life (QoL), adverse effects, and further outcome parameters were evaluated. Recommendations were based on high-class evidence and graded in three gradations. If only lower class evidence was available but the topic was felt to be of high importance, clinical consensus of the guideline task force was gathered., [Results] Two research questions have been answered with eight recommendations and five clinical consensus statements. Invasive therapies are reserved for specific patient groups and clinical situations mostly in the advanced stage of Parkinson's disease (PD). Interventions may be considered only for special patient profiles, which are mentioned in the text. Therapy effects are reported as change compared with current medical treatment. STN-DBS is the best-studied intervention for advanced PD with fluctuations not satisfactorily controlled with oral medications; it improves motor symptoms and QoL, and treatment should be offered to eligible patients. GPi-DBS can also be offered. For early PD with early fluctuations, STN-DBS is likely to improve motor symptoms, and QoL and can be offered. DBS should not be offered to people with early PD without fluctuations. LCIG and an apomorphine pump can be considered for advanced PD with fluctuations not sufficiently managed with oral treatments. Unilateral MRgFUS of the STN can be considered for distinctly unilateral PD within registries. Clinical consensus was reached for the following statements: Radiosurgery with gamma radiation cannot be recommended, unilateral radiofrequency thermocoagulation of the pallidum for advanced PD with treatment-resistant fluctuations and unilateral radiofrequency thermocoagulation of the thalamus for resistant tremor can be recommended if other options are not available, unilateral MRgFUS of the thalamus for medication-resistant tremor of PD can be considered only within registries, and unilateral MRgFUS of the pallidum is not recommended., [Conclusions] Evidence for invasive therapies in PD is heterogeneous. Only some of these therapies have a strong scientific basis. They differ in their profile of effects and have been tested only for specific patient groups., The GL development was further supported by travel grants for meetings and support for online meetings by EAN/MDS-ES. Katarzyna Śmiłowska was supported with a stipend of the Medical Faculty of the Christian-Albrechts-University, Kiel. Open Access funding enabled and organized by Projekt DEAL. Mir has received grants from the Spanish Ministry of Science and Innovation, the Instituto de Salud Carlos III-Fondo Europeo de Desarrollo Regional, the Consejería de Economía, Innovación, Ciencia y Empleo de la Junta de Andalucía, and the Consejería de Salud y Bienestar Social de la Junta de Andalucía. A. Schrag has received grants from GE Healthcare.

Background: Interleukin-1 (IL-1) blocking agents have been used for treating severe coronavirus disease 2019 (COVID-19), on the premise that their immunomodulatory effect might be beneficial in people with COVID-19. Objectives: To assess the effects of IL-1 blocking agents compared with standard care alone or with placebo on effectiveness and safety outcomes in people with COVID-19. We will update this assessment regularly. Search methods: We searched the Cochrane COVID-19 Study Register and the COVID-19 L-OVE Platform (search date 5 November 2021). These sources are maintained through regular searches of MEDLINE, Embase, CENTRAL, trial registers and other sources. We also checked the World Health Organization International Clinical Trials Registry Platform, regulatory agency websites, Retraction Watch (search date 3 November 2021). Selection criteria: We included randomised controlled trials (RCTs) evaluating IL-1 blocking agents compared with standard care alone or with placebo for people with COVID-19, regardless of disease severity. Data collection and analysis: We followed Cochrane methodology. The protocol was amended to reduce the number of outcomes considered. Two researchers independently screened and extracted data and assessed the risk of bias with the Cochrane Risk of Bias 2 tool. We rated the certainty of evidence using the GRADE approach for the critical outcomes of clinical improvement (Day 28; ≥ D60); WHO Clinical Progression Score of level 7 or above (i.e. the proportion of participants with mechanical ventilation +/- additional organ support OR death) (D28; ≥ D60); all-cause mortality (D28; ≥ D60); incidence of any adverse events; and incidence of serious adverse events. Main results: We identified four RCTs of anakinra (three published in peer-reviewed journals, one reported as a preprint) and two RCTs of canakinumab (published in peer-reviewed journals). All trials were multicentre (2 to 133 centres). Two trials stopped early (one due to futility and one as the trigger for inferiority was met). The median/mean age range varied from 58 to 68 years; the proportion of men varied from 58% to 77%. All participants were hospitalised; 67% to 100% were on oxygen at baseline but not intubated; between 0% and 33% were intubated at baseline. We identified a further 16 registered trials with no results available, of which 15 assessed anakinra (four completed, four terminated, five ongoing, three not recruiting) and one (completed) trial assessed canakinumab. Effectiveness of anakinra for people with COVID-19. Anakinra probably results in little or no increase in clinical improvement at D28 (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.97 to 1.20; 3 RCTs, 837 participants; absolute effect: 59 more per 1000 (from 22 fewer to 147 more); moderate-certainty evidence. The evidence is uncertain about an effect of anakinra on 1) the proportion of participants with a WHO Clinical Progression Score of level 7 or above at D28 (RR 0.67, 95% CI 0.36 to 1.22; 2 RCTs, 722 participants; absolute effect: 55 fewer per 1000 (from 107 fewer to 37 more); low-certainty evidence) and ≥ D60 (RR 0.54, 95% CI 0.30 to 0.96; 1 RCT, 606 participants; absolute effect: 47 fewer per 1000 (from 72 fewer to 4 fewer) low-certainty evidence); and 2) all-cause mortality at D28 (RR 0.69, 95% CI 0.34 to 1.39; 2 RCTs, 722 participants; absolute effect: 32 fewer per 1000 (from 68 fewer to 40 more); low-certainty evidence). The evidence is very uncertain about an effect of anakinra on 1) the proportion of participants with clinical improvement at ≥ D60 (RR 0.93, 95% CI 0.78 to 1.12; 1 RCT, 115 participants; absolute effect: 59 fewer per 1000 (from 186 fewer to 102 more); very low-certainty evidence); and 2) all-cause mortality at ≥ D60 (RR 1.03, 95% CI 0.68 to 1.56; 4 RCTs, 1633 participants; absolute effect: 8 more per 1000 (from 84 fewer to 147 more); very low-certainty evidence). Safety of anakinra for people with COVID-19. Anakinra probably results in little or no increase in adverse events (RR 1.02, 95% CI 0.94 to 1.11; 2 RCTs, 722 participants; absolute effect: 14 more per 1000 (from 43 fewer to 78 more); moderate-certainty evidence). The evidence is uncertain regarding an effect of anakinra on serious adverse events (RR 0.95, 95% CI 0.58 to 1.56; 2 RCTs, 722 participants; absolute effect: 12 fewer per 1000 (from 104 fewer to 138 more); low-certainty evidence). Effectiveness of canakinumab for people with COVID-19. Canakinumab probably results in little or no increase in clinical improvement at D28 (RR 1.05, 95% CI 0.96 to 1.14; 2 RCTs, 499 participants; absolute effect: 42 more per 1000 (from 33 fewer to 116 more); moderate-certainty evidence). The evidence of an effect of canakinumab is uncertain on 1) the proportion of participants with a WHO Clinical Progression Score of level 7 or above at D28 (RR 0.72, 95% CI 0.44 to 1.20; 2 RCTs, 499 participants; absolute effect: 35 fewer per 1000 (from 69 fewer to 25 more); low-certainty evidence); and 2) all-cause mortality at D28 (RR:0.75; 95% CI 0.39 to 1.42); 2 RCTs, 499 participants; absolute effect: 20 fewer per 1000 (from 48 fewer to 33 more); low-certainty evidence). The evidence is very uncertain about an effect of canakinumab on all-cause mortality at ≥ D60 (RR 0.55, 95% CI 0.16 to 1.91; 1 RCT, 45 participants; absolute effect: 112 fewer per 1000 (from 210 fewer to 227 more); very low-certainty evidence). Safety of canakinumab for people with COVID-19. Canakinumab probably results in little or no increase in adverse events (RR 1.02; 95% CI 0.86 to 1.21; 1 RCT, 454 participants; absolute effect: 11 more per 1000 (from 74 fewer to 111 more); moderate-certainty evidence). The evidence of an effect of canakinumab on serious adverse events is uncertain (RR 0.80, 95% CI 0.57 to 1.13; 2 RCTs, 499 participants; absolute effect: 44 fewer per 1000 (from 94 fewer to 28 more); low-certainty evidence). Authors' conclusions: Overall, we did not find evidence for an important beneficial effect of IL-1 blocking agents. The evidence is uncertain or very uncertain for several outcomes. Sixteen trials of anakinra and canakinumab with no results are currently registered, of which four are completed, and four terminated. The findings of this review are updated on the COVID-NMA platform (covid-nma.com).

Different forms of vaccines have been developed to prevent the SARS-CoV-2 virus and subsequent COVID-19 disease. Several are in widespread use globally. OBJECTIVES: To assess the efficacy and safety of COVID-19 vaccines (as a full primary vaccination series or a booster dose) against SARS-CoV-2.We searched the Cochrane COVID-19 Study Register and the COVID-19 L·OVE platform (last search date 5 November 2021). We also searched the WHO International Clinical Trials Registry Platform, regulatory agency websites, and Retraction Watch.We included randomized controlled trials (RCTs) comparing COVID-19 vaccines to placebo, no vaccine, other active vaccines, or other vaccine schedules.We used standard Cochrane methods. We used GRADE to assess the certainty of evidence for all except immunogenicity outcomes. We synthesized data for each vaccine separately and presented summary effect estimates with 95% confidence intervals (CIs). MAIN RESULTS: We included and analyzed 41 RCTs assessing 12 different vaccines, including homologous and heterologous vaccine schedules and the effect of booster doses. Thirty-two RCTs were multicentre and five were multinational. The sample sizes of RCTs were 60 to 44,325 participants. Participants were aged: 18 years or older in 36 RCTs; 12 years or older in one RCT; 12 to 17 years in two RCTs; and three to 17 years in two RCTs. Twenty-nine RCTs provided results for individuals aged over 60 years, and three RCTs included immunocompromized patients. No trials included pregnant women. Sixteen RCTs had two-month follow-up or less, 20 RCTs had two to six months, and five RCTs had greater than six to 12 months or less. Eighteen reports were based on preplanned interim analyses. Overall risk of bias was low for all outcomes in eight RCTs, while 33 had concerns for at least one outcome. We identified 343 registered RCTs with results not yet available. This abstract reports results for the critical outcomes of confirmed symptomatic COVID-19, severe and critical COVID-19, and serious adverse events only for the 10 WHO-approved vaccines. For remaining outcomes and vaccines, see main text. The evidence for mortality was generally sparse and of low or very low certainty for all WHO-approved vaccines, except AD26.COV2.S (Janssen), which probably reduces the risk of all-cause mortality (risk ratio (RR) 0.25, 95% CI 0.09 to 0.67; 1 RCT, 43,783 participants; high-certainty evidence). Confirmed symptomatic COVID-19 High-certainty evidence found that BNT162b2 (BioNtech/Fosun Pharma/Pfizer), mRNA-1273 (ModernaTx), ChAdOx1 (Oxford/AstraZeneca), Ad26.COV2.S, BBIBP-CorV (Sinopharm-Beijing), and BBV152 (Bharat Biotect) reduce the incidence of symptomatic COVID-19 compared to placebo (vaccine efficacy (VE): BNT162b2: 97.84%, 95% CI 44.25% to 99.92%; 2 RCTs, 44,077 participants; mRNA-1273: 93.20%, 95% CI 91.06% to 94.83%; 2 RCTs, 31,632 participants; ChAdOx1: 70.23%, 95% CI 62.10% to 76.62%; 2 RCTs, 43,390 participants; Ad26.COV2.S: 66.90%, 95% CI 59.10% to 73.40%; 1 RCT, 39,058 participants; BBIBP-CorV: 78.10%, 95% CI 64.80% to 86.30%; 1 RCT, 25,463 participants; BBV152: 77.80%, 95% CI 65.20% to 86.40%; 1 RCT, 16,973 participants). Moderate-certainty evidence found that NVX-CoV2373 (Novavax) probably reduces the incidence of symptomatic COVID-19 compared to placebo (VE 82.91%, 95% CI 50.49% to 94.10%; 3 RCTs, 42,175 participants). There is low-certainty evidence for CoronaVac (Sinovac) for this outcome (VE 69.81%, 95% CI 12.27% to 89.61%; 2 RCTs, 19,852 participants). Severe or critical COVID-19 High-certainty evidence found that BNT162b2, mRNA-1273, Ad26.COV2.S, and BBV152 result in a large reduction in incidence of severe or critical disease due to COVID-19 compared to placebo (VE: BNT162b2: 95.70%, 95% CI 73.90% to 99.90%; 1 RCT, 46,077 participants; mRNA-1273: 98.20%, 95% CI 92.80% to 99.60%; 1 RCT, 28,451 participants; AD26.COV2.S: 76.30%, 95% CI 57.90% to 87.50%; 1 RCT, 39,058 participants; BBV152: 93.40%, 95% CI 57.10% to 99.80%; 1 RCT, 16,976 participants). Moderate-certainty evidence found that NVX-CoV2373 probably reduces the incidence of severe or critical COVID-19 (VE 100.00%, 95% CI 86.99% to 100.00%; 1 RCT, 25,452 participants). Two trials reported high efficacy of CoronaVac for severe or critical disease with wide CIs, but these results could not be pooled. Serious adverse events (SAEs) mRNA-1273, ChAdOx1 (Oxford-AstraZeneca)/SII-ChAdOx1 (Serum Institute of India), Ad26.COV2.S, and BBV152 probably result in little or no difference in SAEs compared to placebo (RR: mRNA-1273: 0.92, 95% CI 0.78 to 1.08; 2 RCTs, 34,072 participants; ChAdOx1/SII-ChAdOx1: 0.88, 95% CI 0.72 to 1.07; 7 RCTs, 58,182 participants; Ad26.COV2.S: 0.92, 95% CI 0.69 to 1.22; 1 RCT, 43,783 participants); BBV152: 0.65, 95% CI 0.43 to 0.97; 1 RCT, 25,928 participants). In each of these, the likely absolute difference in effects was fewer than 5/1000 participants. Evidence for SAEs is uncertain for BNT162b2, CoronaVac, BBIBP-CorV, and NVX-CoV2373 compared to placebo (RR: BNT162b2: 1.30, 95% CI 0.55 to 3.07; 2 RCTs, 46,107 participants; CoronaVac: 0.97, 95% CI 0.62 to 1.51; 4 RCTs, 23,139 participants; BBIBP-CorV: 0.76, 95% CI 0.54 to 1.06; 1 RCT, 26,924 participants; NVX-CoV2373: 0.92, 95% CI 0.74 to 1.14; 4 RCTs, 38,802 participants). For the evaluation of heterologous schedules, booster doses, and efficacy against variants of concern, see main text of review.Compared to placebo, most vaccines reduce, or likely reduce, the proportion of participants with confirmed symptomatic COVID-19, and for some, there is high-certainty evidence that they reduce severe or critical disease. There is probably little or no difference between most vaccines and placebo for serious adverse events. Over 300 registered RCTs are evaluating the efficacy of COVID-19 vaccines, and this review is updated regularly on the COVID-NMA platform (covid-nma.com). Implications for practice Due to the trial exclusions, these results cannot be generalized to pregnant women, individuals with a history of SARS-CoV-2 infection, or immunocompromized people. Most trials had a short follow-up and were conducted before the emergence of variants of concern. Implications for research Future research should evaluate the long-term effect of vaccines, compare different vaccines and vaccine schedules, assess vaccine efficacy and safety in specific populations, and include outcomes such as preventing long COVID-19. Ongoing evaluation of vaccine efficacy and effectiveness against emerging variants of concern is also vital.

Corticosteroids are medications with anti-inflammatory and immunosuppressant properties. Systemic corticosteroids administered through the oral, intravenous, or intramuscular routes have been used to treat various types of low back pain, including radicular back pain (not due to spinal stenosis), non-radicular back pain, and spinal stenosis. However, there is uncertainty about the benefits and harms of systemic corticosteroids for low back pain.To evaluate the benefits and harms of systemic corticosteroids versus placebo or no corticosteroid for radicular low back pain, non-radicular low back pain, and symptomatic spinal stenosis in adults.We used standard, extensive Cochrane search methods. The latest search date was September 2021.We included randomized and quasi-randomized trials in adults of systematic corticosteroids versus placebo or no corticosteroid.We used standard Cochrane methods. The major outcomes were pain, function, need for surgery, serious adverse effect, and presence of hyperglycemia. The minor outcomes were quality of life, successful outcomes, non-serious adverse events, and withdrawal due to adverse events. We used GRADE to assess the certainty of evidence for each outcome.Thirteen trials (1047 participants) met the inclusion criteria. Nine trials included participants with radicular low back pain, two trial with low back pain, and two trials with spinal stenosis. All trials blinded participants to receipt of systemic corticosteroids. Seven trials were at low risk of bias, five at unclear risk, and one at high risk of selection bias. Two trials were at high risk of attrition bias. Doses and duration of systemic corticosteroid therapy varied. Radicular low back pain For radicular low back pain, moderate-certainty evidence indicated that systemic corticosteroids probably slightly decrease pain versus placebo at short-term follow-up (mean difference (MD) 0.56 points better, 95% confidence interval (CI) 1.08 to 0.04 on a 0 to 10 scale) and may slightly increase the likelihood of experiencing improvement in pain at short-term follow-up (risk ratio (RR) 1.21, 95% CI 0.88 to 1.66; absolute effect 5% better (95% CI 5% worse to 15% better). Systemic corticosteroids may not improve function at short-term follow-up (standardized mean difference (SMD) 0.14 better; range 0.49 better to 0.21 worse) and probably increase the likelihood of improvement in function at short-term follow-up (RR 1.52, 95% CI 1.22 to 1.91; absolute effect 19% better, 95% CI 8% better to 30% better). Systemic corticosteroids were associated with greater improvement in function versus placebo at long-term follow-up (MD -7.40, 95% CI -12.55 to -2.25 on the 0 to 100 Oswestry Disability Index) and greater likelihood of functional improvement (RR 1.29, 95% CI 1.06 to 1.56), based on a single trial. There was no difference in likelihood of surgery (RR 1.00, 95% CI 0.68 to 1.47). Evidence indicated that systemic corticosteroids (administered as a single dose or as a short course of therapy) are not associated with increased risk of any adverse event, serious adverse events, withdrawal due to adverse events, or hyperglycemia, but estimates were imprecise as some trials did not report harms, and harms reporting was suboptimal in trials that did provide data. Limitations included variability across trials in interventions (e.g. corticosteroid used, dose and duration of treatment), clinical settings, and participants (e.g. duration of symptoms, methods for diagnosis); limited utility of subgroup analyses due to small numbers of trials; methodologic limitations or suboptimal reporting of methods by some trials; and too few trials to formally assess for publication bias using graphical or statistical tests for small sample effects. Non-radicular low back pain Evidence on systemic corticosteroids versus placebo for non-radicular pain was limited and suggested that systemic corticosteroids may be associated with slightly worse short-term pain but slightly better function. Spinal stenosis For spinal stenosis, limited evidence indicated that systemic corticosteroids are probably no more effective than placebo for short-term pain or function.Systemic corticosteroids appear to be slightly effective at improving short-term pain and function in people with radicular low back pain not due to spinal stenosis, and might slightly improve long-term function. The effects of systemic corticosteroids in people with non-radicular low back pain are unclear and systemic corticosteroids are probably ineffective for spinal stenosis. A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harms, but evidence is limited.

To determine the frequency of red flag signs and symptoms in patients presenting with back pain to the Emergency Department (ED) and association with serious pathologies and investigations performed. This retrospective observational study evaluated consecutive patients presenting with back pain to a Melbourne ED over a 14-month period. Data regarding red flags, patient characteristics, ED-initiated investigations, and diagnoses were extracted from medical records. Prevalence of each red flag and sensitivity, specificity, and likelihood ratios for diagnosing serious spinal or non-spinal pathology were calculated. Analysis was undertaken on 1000 eligible participants with back pain. 69% had red flags. Participants were categorised into diagnostic groups: musculoskeletal (80.6%), serious spinal (3.3%), and serious non-spinal (14.6%) pathologies. A number of red flags had positive likelihood ratios (LR) > 5, indicating a higher probability of serious pathology (spinal/non-spinal) including fever (LR + 68.8), tuberculosis history (LR + 13.8), known nephrolithiasis/abdominal aortic aneurysm (LR + 10.2), unexplained weight-loss (LR + 9.2), writhing in pain (LR + 6.9), urinary symptoms (LR + 5.4), and flank pain (LR + 5.2). Red flags with positive LR > 5 indicating a higher probability of serious spinal pathology were saddle anaesthesia (LR + 11.0), tuberculosis history (LR + 9.8), intravenous drug-use (LR + 6.9), acute-onset urinary retention (LR + 6.4), and anal tone loss (LR + 6.3). The majority of this study cohort had back pain of benign cause. Some red flags were associated with greater risk of serious pathology, others were not. Further evidence regarding red flags and their association with serious pathology is required, to better inform clinical guidelines.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: We aim to assess population‐level effects of human papillomavirus (HPV) vaccination programmes on HPV‐related disease and harms from vaccination.

Introduction Although several non-pharmacological interventions have been tested in the management of Fibromyalgia (FM), there is little consensus regarding the best options for the treatment of this health condition. The purpose of this network meta-analysis (NMA) is to investigate the comparative efficacy and acceptability of non-pharmacological interventions for FM, in order to assist clinical decision making through a ranking of interventions in relation to the most important clinical outcomes in these patients. Methods and analysis We will perform a systematic search to identify randomised controlled trials of non-pharmacological interventions endorsed in guidelines and systematic reviews. Information sources searched will include major bibliographic databases without language or date restrictions (MEDLINE, Cochrane Library, EMBASE, AMED, PsycINFO and PEDro). Our primary outcomes will be pain intensity, patient-reported quality of life (QoL), and acceptability of treatment will be our secondary outcome. Risk of bias of the included trials will be assessed using the Cochrane risk of bias tool (RoB2). For each pairwise comparison between the different interventions, we will present mean differences (MDs) for pain intensity and QoL outcomes and Relative Risks (RRs) for acceptability, both with respective 95% confidence intervals (CIs). Initially, standard pairwise meta-analyses will be performed using a DerSimonian-Laird random effects model for all comparisons with at least two trials and then we will perform a frequentist NMA using the methodology of multivariate meta-analysis assuming a common heterogeneity parameter, using the mvmeta command and network suite in STATA. In the NMA, two different types of control group, such as placebo/sham and no intervention/waiting list will be combined as one node called “Control”. The competing interventions will be ranked using the P-score, which is the frequentist analogue of surface under the cumulative ranking curve (SUCRA) for the outcomes of interest at immediate- (intervention duration of up to 2 weeks), short- (over 2 weeks up to 12 weeks) and long-terms (over 12 weeks). The confidence in the results from NMA will be assessed using the Confidence in Network Meta‐analysis (CINeMA) framework. Ethics and dissemination This work synthesises evidence from previously published studies and does not require ethics review or approval. A manuscript describing the findings will be submitted for publication in a peer-reviewed scientific journal. Registration OSF (DOI: 10.17605/OSF.IO/7MS25) and registered in the PROSPERO database (CRD42020216374).

Background Refugees, and other forcibly displaced people, face mental distress and may be disproportionately affected by risk factors for suicide. Little is known about suicidal behaviour in these highly mobile populations because collecting timely, relevant, and reliable data is challenging. Methods and findings A systematic review was performed to identify studies of any design reporting on suicide, suicide attempts, or suicidal ideation among populations of displaced people. A sensitive electronic database search was performed in August 2020, and all retrieved studies were screened for relevance by two authors. Studies were categorised by the population being evaluated: refugees granted asylum, refugees living in temporary camps, asylum seekers, or internally displaced people. We distinguished between whether the sampling procedure in the studies was likely to be representative, or the sample examined a specific non-representative subgroup of displaced people (such as those already diagnosed with mental illness). Data on the rates of suicide or the prevalence of suicide attempts or suicidal ideation were extracted by one reviewer and verified by a second reviewer from each study and converted to common metrics. After screening 4347 articles, 87 reports of 77 unique studies were included. Of these, 53 were studies in representative samples, and 24 were based on samples of specific target populations. Most studies were conducted in high-income countries, and the most studied population subgroup was refugees granted asylum. There was substantial heterogeneity across data sources and measurement instruments utilised. Sample sizes of displaced people ranged from 33 to 196,941 in studies using general samples. Suicide rates varied considerably, from 4 to 290 per 100,000 person-years across studies. Only 8 studies were identified that compared suicide rates with the host population. The prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies and varied according to the prevalence period evaluated. Suicidal ideation prevalence varied from 0.17% to 70.6% across studies. Among refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in 4 of 5 studies. In contrast, in asylum seekers there was evidence of a higher suicide risk in 2 of 3 studies, and of a higher risk of suicidal ideation among refugees living in camps in 2 of 3 studies compared to host populations. Conclusion While multiple studies overall have been published in the literature on this topic, the evidence base is still sparse for refugees in camps, asylum seekers, and internally displaced people. Less than half of the included studies reported on suicide or suicide attempt outcomes, with most reporting on suicidal ideation. International research networks could usefully define criteria, definitions, and study designs to help standardise and facilitate more research in this important area. Registration PROSPERO CRD42019137242.

Background Vaccines may reduce antibiotic use and the development of resistance. Objectives To provide a comprehensive, up-to-date assessment of the evidence base relating to the effect of vaccines on antibiotic use. Data sources Ovid MEDLINE, Embase, the Cochrane Library, ClinicalTrials.gov and WHO Trials Registry. Study eligibility criteria Randomized controlled trials (RCTs) and observational studies published from January 1998 to March 2018. Participants Any population. Interventions Vaccines versus placebo, no vaccine or another vaccine. Methods Titles, abstracts and full-texts were screened independently by two reviewers. Certainty of RCT evidence was assessed using GRADE. Results In all, 4980 records identified; 895 full-text reports assessed; 96 studies included (24 RCTs, 72 observational). There was high-certainty evidence that influenza vaccine reduces days of antibiotic use among healthy adults (one RCT; n = 4253; rate reduction 28·1%; 95% CI 16·0–38·4); moderate-certainty evidence that influenza vaccines probably reduce antibiotic use in children aged 6 months to 14 years (three RCTs; n = 610; ratio of means 0·62; 95% CI 0·54–0·70) and probably reduce community antibiotic use in children aged 3–15 years (one RCT; n = 10 985 person-seasons; risk ratio 0·69, 95% CI 0·58–0·83); and moderate-certainty evidence that pneumococcal vaccination probably reduces antibiotic use in children aged 6 weeks to 6 years (two RCTs; n = 47 945; rate ratio 0·93, 95% CI 0·87–0·99) and reduces illness episodes requiring antibiotics in children aged 12–35 months (one RCT; n = 264; rate ratio 0·85, 95% CI 0·75–0·97). Other RCT evidence was of low or very low certainty, and observational evidence was affected by confounding. Conclusions The evidence base is poor. Although some vaccines may reduce antibiotic use, collection of high-quality data in future vaccine trials is needed to improve the evidence base. PROSPERO registration CRD42018103881.

ObjectiveTo determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat.MethodsSearches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology.ResultsWhen compared with MI, CT did not improve pain (weighted mean difference (WMD) −2.6, 95% CI −6.5 to 1.2) or function (WMD 1.8, 95% CI −2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI −0.1 to 1.4) or function (WMD −6.6, 95% CI −13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD −0.5, 95% CI −1.4 to 0.4) or function (WMD −2.3, 95 % –9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83).Summary/ConclusionOur estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Background Ministries of health, donors, and other decision‐makers are exploring how they can use mobile technologies to acquire accurate and timely statistics on births and deaths. These stakeholders have called for evidence‐based guidance on this topic. This review was carried out to support World Health Organization (WHO) recommendations on digital interventions for health system strengthening. Objectives Primary objective: To assess the effects of birth notification and death notification via a mobile device, compared to standard practice. Secondary objectives: To describe the range of strategies used to implement birth and death notification via mobile devices and identify factors influencing the implementation of birth and death notification via mobile devices. Search methods We searched CENTRAL, MEDLINE, Embase, the Global Health Library, and POPLINE (August 2, 2019). We searched two trial registries (August 2, 2019). We also searched Epistemonikos for related systematic reviews and potentially eligible primary studies (August 27, 2019). We conducted a grey literature search using mHealthevidence.org (August 15, 2017) and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies in Web of Science and Google Scholar (May 15, 2020). We searched for studies published after 2000 in any language. Selection criteria For the primary objective, we included individual and cluster‐randomised trials; cross‐over and stepped‐wedge study designs; controlled before‐after studies, provided they have at least two intervention sites and two control sites; and interrupted time series studies. For the secondary objectives, we included any study design, either quantitative, qualitative, or descriptive, that aimed to describe current strategies for birth and death notification via mobile devices; or to explore factors that influence the implementation of these strategies, including studies of acceptability or feasibility. For the primary objective, we included studies that compared birth and death notification via mobile devices with standard practice. For the secondary objectives, we included studies of birth and death notification via mobile device as long as we could extract data relevant to our secondary objectives. We included studies of all cadres of healthcare providers, including lay health workers; administrative, managerial, and supervisory staff; focal individuals at the village or community level; children whose births were being notified and their parents/caregivers; and individuals whose deaths were being notified and their relatives/caregivers. Data collection and analysis For the primary objective, two authors independently screened all records, extracted data from the included studies and assessed risk of bias. For the analyses of the primary objective, we reported means and proportions, where appropriate. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a 'Summary of Findings' table. For the secondary objectives, two authors screened all records, one author extracted data from the included studies and assessed methodological limitations using the WEIRD tool and a second author checked the data and assessments. We carried out a framework analysis using the Supporting the Use of Research Evidence (SURE) framework to identify themes in the data. We used the GRADE‐CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in the evidence and we prepared a 'Summary of Qualitative Findings' table. Main results For the primary objective, we included one study, which used a controlled before‐after study design. The study was conducted in Lao People’s Democratic Republic and assessed the effect of using mobile devices for birth notification on outcomes related to coverage and timeliness of Hepatitis B vaccination. However, we are uncertain of the effect of this approach on these outcomes because the certainty of this evidence was assessed as very low. The included study did not assess resource use or unintended consequences. For the primary objective, we did not identify any studies using mobile devices for death notification. For the secondary objective, we included 21 studies. All studies were conducted in low‐ or middle‐income settings. They focussed on identification of births and deaths in rural, remote, or marginalised populations who are typically under‐represented in civil registration processes or traditionally seen as having poor access to health services. The review identified several factors that could influence the implementation of birth‐death notification via mobile device. These factors were tied to the health system, the person responsible for notifying, the community and families; and include: ‐ Geographic barriers that could prevent people’s access to birth‐death notification and post‐notification services ‐ Access to health workers and other notifiers with enough training, supervision, support, and incentives ‐ Monitoring systems that ensure the quality and timeliness of the birth and death data ‐ Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers ‐ Community awareness of the need to register births and deaths ‐ Socio‐cultural norms around birth and death ‐ Government commitment ‐ Cost to the system, to health workers and to families ‐ Access to electricity and network connectivity, and compatibility with existing systems ‐ Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of concerns about methodological limitations and data adequacy. Authors' conclusions We need more, well‐designed studies of the effect of birth and death notification via mobile devices and on factors that may influence its implementation., Plain language summary Birth and death notification via mobile devices: a mixed methods review What is the aim of this review? In this Cochrane Review, we aimed to assess the effect of using mobile devices to notify births and deaths. We also aimed to describe how these mobile solutions are being used in practice and the factors that influence their use. We collected and analysed all relevant studies to answer these questions. Key messages We know very little about the effects of using mobile devices to notify births and deaths. Factors that can influence the implementation of this approach include factors tied to the health system and the notification system, the person responsible for notifying, the community, and the families involved. What was studied in the review? By registering notified births and deaths, governments can track the health of their population, identify needs and problems, and design better services. In many countries, births and deaths are not properly registered. Sometimes this is because government systems are poorly designed to facilitate registration, government workers do not have proper training, people live far from government services, or are not aware of the need to register births or deaths. In many cases, registration is affected by delays in or lack of birth or death notification. Governments are starting to use mobile devices such as mobile phones to reduce problems with birth or death notification. In some settings, members of the public, healthcare workers and others use mobile phones to notify a birth or death to the health system or to a central registration system. The main aim of our review was to assess what happens when people use mobile devices to notify births and deaths, compared to other systems or no systems at all. For instance, do they register more birth and deaths, and do they do this at the right time? And does this lead more babies and children to use or receive health services, such as immunisation? We also wanted to find out how people are using these mobile systems in practice and what influences their use. What are the main results of the review? We found 21 relevant studies. All of the studies were from low‐ or middle‐income countries. Most of these studies focussed on the notification of births and deaths in rural, remote, or marginalised populations who are often under‐represented in birth or death registration processes or have poor access to health services. Only one of the studies assessed the effect of using mobile devices for notification systems. This study focussed on birth notification. We did not find any studies that assessed the effect of using mobile devices for death notification. We are uncertain of the effect of this approach on the number of births and deaths that are properly notified because the certainty of this evidence was assessed as very low. The other studies had information about how people use the mobile device‐based birth and death notification systems in practice. These studies pointed to several factors that could influence the implementation of birth‐death notification via mobile devices. These factors were tied to the health system and the notification system, the person responsible for notifying, the community, and the families involved. They include: ‐ Geographic barriers that could prevent people’s access to birth‐death notification and post‐notification services ‐ Access to health workers and other notifiers with enough training, supervision, support, and incentives ‐ Monitoring systems that ensure the quality and timeliness of the birth and death data ‐ Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers ‐ Community awareness of the need to register births and deaths ‐ Socio‐cultural norms around birth and death ‐ Government commitment ‐ Cost to the system, to health workers and to families ‐ Access to electricity and network connectivity, and compatibility with existing systems ‐ Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of the ways in which the studies were designed and small amounts of data. How up‐to‐date is this review? We searched for studies that had been published up to August 2, 2019.

Background: Interleukin 6 (IL-6) blocking agents have been used for treating severe coronavirus disease 2019 (COVID-19). Their immunosuppressive effect might be valuable in patients with COVID-19 characterised by substantial immune system dysfunction by controlling inflammation and promoting disease tolerance. Objectives: To assess the effect of IL-6 blocking agents compared to standard care alone or with placebo on efficacy and safety outcomes in COVID-19. We will update this assessment regularly. Search methods: We searched the World Health Organization (WHO) International Clinical Trials Registry Platform (up to 11 February 2021) and the L-OVE platform, and Cochrane COVID-19 Study Register to identify trials up to 26 February 2021. Selection criteria: We included randomised controlled trials (RCTs) evaluating IL-6 blocking agents compared with standard care alone or with placebo for people with COVID-19, regardless of disease severity. Data collection and analysis: We followed standard Cochrane methodology. The protocol was amended to reduce the number of outcomes considered. Two review authors independently collected data and assessed the risk of bias with the Cochrane Risk of Bias 2 tool. We rated the certainty of evidence with the GRADE approach for the critical outcomes such as clinical improvement (defined as hospital discharge or improvement on the scale used by trialists to evaluate clinical progression or recovery) (day (D) 28 / ≥ D60); WHO Clinical Progression Score of level 7 or above (i.e. the proportion of participants with mechanical ventilation +/- additional organ support OR death) (D28 / ≥ D60); all-cause mortality (D28 / ≥ D60); incidence of any adverse events; and incidence of serious adverse events. Main results: We identified 10 RCTs with available data including one platform trial comparing tocilizumab and sarilumab with standard of care. These trials evaluated tocilizumab (nine RCTs including two platform trials; seven were reported as peer-reviewed articles, two as preprints; 6428 randomised participants); and two sarilumab (one platform trial reported as peer reviewed article, one reported as preprint, 880 randomised participants). All trials included were multicentre trials. They were conducted in Brazil, China, France, Italy, UK, USA, and four were multi-country trials. The mean age range of participants ranged from 56 to 65 years; 4572 (66.3%) of trial participants were male. Disease severity ranged from mild to critical disease. The reported proportion of participants on oxygen at baseline but not intubated varied from 56% to 100% where reported. Five trials reported the inclusion of intubated patients at baseline. We identified a further 20 registered RCTs of tocilizumab compared to placebo/standard care (five completed without available results, five terminated without available results, eight ongoing, two not recruiting); 11 RCTs of sarilumab (two completed without results, three terminated without available results, six ongoing); six RCTs of clazakisumab (five ongoing, one not recruiting); two RCTs of olokizumab (one completed, one not recruiting); one of siltuximab (ongoing) and one RCT of levilimab (completed without available results). Of note, three were cancelled (2 tocilizumab, 1 clazakisumab). One multiple-arm RCT evaluated both tocilizumab and sarilumab compared to standard of care, one three-arm RCT evaluated tocilizumab and siltuximab compared to standard of care and consequently they appear in each respective comparison. Tocilizumab versus standard care alone or with placebo. a. Effectiveness of tocilizumab for patients with COVID-19. Tocilizumab probably results in little or no increase in the outcome of clinical improvement at D28 (RR 1.06, 95% CI 1.00 to 1.13; I2 = 40.9%; 7 RCTs, 5585 participants; absolute effect: 31 more with clinical improvement per 1000 (from 0 fewer to 67 more); moderate-certainty evidence). However, we cannot exclude that some subgroups of patients could benefit from the treatment. We did not obtain data for longer-term follow-up (≥ D60). The effect of tocilizumab on the proportion of participants with a WHO Clinical Progression Score of level of 7 or above is uncertain at D28 (RR 0.99, 95% CI 0.56 to 1.74; I2 = 64.4%; 3 RCTs, 712 participants; low-certainty evidence). We did not obtain data for longer-term follow-up (≥ D60). Tocilizumab reduces all-cause mortality at D28 compared to standard care alone or placebo (RR 0.89, 95% CI 0.82 to 0.97; I2 = 0.0%; 8 RCTs, 6363 participants; absolute effect: 32 fewer deaths per 1000 (from 52 fewer to 9 fewer); high-certainty evidence). The evidence suggests uncertainty around the effect on mortality at ≥ D60 (RR 0.86, 95% CI 0.53 to 1.40; I2 = 0.0%; 2 RCTs, 519 participants; low-certainty evidence). b. Safety of tocilizumab for patients with COVID-19. The evidence is very uncertain about the effect of tocilizumab on adverse events (RR 1.23, 95% CI 0.87 to 1.72; I2 = 86.4%; 7 RCTs, 1534 participants; very low-certainty evidence). Nevertheless, tocilizumab probably results in slightly fewer serious adverse events than standard care alone or placebo (RR 0.89, 95% CI 0.75 to 1.06; I2 = 0.0%; 8 RCTs, 2312 participants; moderate-certainty evidence). Sarilumab versus standard care alone or with placebo. The evidence is uncertain about the effect of sarilumab on all-cause mortality at D28 (RR 0.77, 95% CI 0.43 to 1.36; 2 RCTs, 880 participants; low certainty), on all-cause mortality at ≥ D60 (RR 1.00, 95% CI 0.50 to 2.0; 1 RCT, 420 participants; low certainty), and serious adverse events (RR 1.17, 95% CI 0.77 to 1.77; 2 RCTs, 880 participants; low certainty). It is unlikely that sarilumab results in an important increase of adverse events (RR 1.05, 95% CI 0.88 to 1.25; 1 RCT, 420 participants; moderate certainty). However, an increase cannot be excluded. No data were available for other critical outcomes. Authors' conclusions: On average, tocilizumab reduces all-cause mortality at D28 compared to standard care alone or placebo and probably results in slightly fewer serious adverse events than standard care alone or placebo. Nevertheless, tocilizumab probably results in little or no increase in the outcome clinical improvement (defined as hospital discharge or improvement measured by trialist-defined scales) at D28. The impact of tocilizumab on other outcomes is uncertain or very uncertain. With the data available, we were not able to explore heterogeneity. Individual patient data meta-analyses are needed to be able to identify which patients are more likely to benefit from this treatment. Evidence for an effect of sarilumab is uncertain and evidence for other anti-IL6 agents is unavailable. Thirty-nine RCTs of IL-6 blocking agents with no results are currently registered, of which nine are completed and seven trials were terminated with no results available. The findings of this review will be updated as new data are made available on the COVID-NMA platform (covid-nma.com).

ObjectiveWe undertook a systematic review of the literature to explore the prevalence of post-traumatic stress disorder (PTSD) in Palestinian children and adolescents exposed to political violence. This is the first systematic review and meta-analysis of the prevalence of PTSD in this population.MethodsPubMed, Embase, PsycInfo, Google Scholar and Cochrane library were searched until June 2020. To estimate the prevalence of PTSD, sub-group and meta-analysis were conducted.ResultsThe search resulted in 2786 studies, of which 28 articles representing 32 samples with a total of 15,121 participants from Gaza Strip and West Bank met either the DSM-4 or DSM-5 criteria and were included. The pooled prevalence of PTSD was 36% (95% CI 30–41%;I298.6%) and ranged from 6% to 70%. Sub-group analysis showed that the PTSD prevalence did not differ according to region (West Bank, Gaza Strip) and tended to decrease after including only studies using a representative sample (ppConclusionWe identified high prevalence of PTSD among Palestinian children and adolescents exposed to political violence. However, the pooled results should be interpreted with caution, due to the high heterogeneity and risk of bias in the included studies. These limitations also reflect the challenge in conceptualizing and measuring PTSD in the Palestinian context with a background of continuous and cumulative trauma. Understanding the contextual factors and developing locally adapted survey measures are of relevance to future research, public health planning, and the provision of mental healthcare in Palestine.

Background Health systems need timely and reliable access to essential medicines and health commodities, but problems with access are common in many settings. Mobile technologies offer potential low‐cost solutions to the challenge of drug distribution and commodity availability in primary healthcare settings. However, the evidence on the use of mobile devices to address commodity shortages is sparse, and offers no clear way forward. Objectives Primary objective To assess the effects of strategies for notifying stock levels and digital tracking of healthcare‐related commodities and inventory via mobile devices across the primary healthcare system Secondary objectives To describe what mobile device strategies are currently being used to improve reporting and digital tracking of health commodities To identify factors influencing the implementation of mobile device interventions targeted at reducing stockouts of health commodities Search methods We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Global Index Medicus WHO, POPLINE K4Health, and two trials registries in August 2019. We also searched Epistemonikos for related systematic reviews and potentially eligible primary studies. We conducted a grey literature search using mHealthevidence.org, and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies. We searched for studies published after 2000, in any language. Selection criteria For the primary objective, we included individual and cluster‐randomised trials, controlled before‐after studies, and interrupted time series studies. For the secondary objectives, we included any study design, which could be quantitative, qualitative, or descriptive, that aimed to describe current strategies for commodity tracking or stock notification via mobile devices; or aimed to explore factors that influenced the implementation of these strategies, including studies of acceptability or feasibility. We included studies of all cadres of healthcare providers, including lay health workers, and others involved in the distribution of health commodities (administrative staff, managerial and supervisory staff, dispensary staff); and all other individuals involved in stock notification, who may be based in a facility or a community setting, and involved with the delivery of primary healthcare services. We included interventions aimed at improving the availability of health commodities using mobile devices in primary healthcare settings. For the primary objective, we included studies that compared health commodity tracking or stock notification via mobile devices with standard practice. For the secondary objectives, we included studies of health commodity tracking and stock notification via mobile device, if we could extract data relevant to our secondary objectives. Data collection and analysis For the primary objective, two authors independently screened all records, extracted data from the included studies, and assessed the risk of bias. For the analyses of the primary objectives, we reported means and proportions where appropriate. We used the GRADE approach to assess the certainty of the evidence, and prepared a 'Summary of findings' table. For the secondary objective, two authors independently screened all records, extracted data from the included studies, and applied a thematic synthesis approach to synthesise the data. We assessed methodological limitation using the Ways of Evaluating Important and Relevant Data (WEIRD) tool. We used the GRADE‐CERQual approach to assess our confidence in the evidence, and prepared a 'Summary of qualitative findings' table. Main results Primary objective For the primary objective, we included one controlled before‐after study conducted in Malawi. We are uncertain of the effect of cStock plus enhanced management, or cStock plus effective product transport on the availability of commodities, quality and timeliness of stock management, and satisfaction and acceptability, because we assessed the evidence as very low‐certainty. The study did not report on resource use or unintended consequences. Secondary objective For the secondary objectives, we included 16 studies, using a range of study designs, which described a total of eleven interventions. All studies were conducted in African (Tanzania, Kenya, Malawi, Ghana, Ethiopia, Cameroon, Zambia, Liberia, Uganda, South Africa, and Rwanda) and Asian (Pakistan and India) countries. Most of the interventions aimed to make data about stock levels and potential stockouts visible to managers, who could then take corrective action to address them. We identified several factors that may influence the implementation of stock notification and tracking via mobile device. These include challenges tied to infrastructural issues, such as poor access to electricity or internet, and broader health systems issues, such as drug shortages at the national level which cannot be mitigated by interventions at the primary healthcare level (low confidence). Several factors were identified as important, including strong partnerships with local authorities, telecommunication companies, technical system providers, and non‐governmental organizations (very low confidence); availability of stock‐level data at all levels of the health system (low confidence); the role of supportive supervision and responsive management (moderate confidence); familiarity and training of health workers in the use of the digital devices (moderate confidence); availability of technical programming expertise for the initial development and ongoing maintenance of the digital systems (low confidence); incentives, such as phone credit for personal use, to support regular use of the system (low confidence); easy‐to‐use systems built with user participation (moderate confidence); use of basic or personal mobile phones to support easier adoption (low confidence); consideration for software features, such as two‐way communication (low confidence); and data availability in an easy‐to‐use format, such as an interactive dashboard (moderate confidence). Authors' conclusions We need more, well‐designed, controlled studies comparing stock notification and commodity management via mobile devices with paper‐based commodity management systems. Further studies are needed to understand the factors that may influence the implementation of such interventions, and how implementation considerations differ by variations in the intervention., Plain language summary Using mobile phones to keep track of medicines and notify superiors when more are needed What is the aim of this review? In this Cochrane Review, we aimed to assess if health workers would have better access to medicines and other supplies, if they used mobile phones or other mobile devices to keep track of the amount of supplies they had available, and to notify superiors when they needed more supplies. We also described how health workers are currently using these mobile systems, and what factors influence their use. Key messages We do not know if using mobile phones to keep track of medical supplies gives primary healthcare workers better access to these supplies. This is because the certainty of the available evidence was very low. However, the evidence does point to several factors that could influence the implementation of these systems. These include the sharing of data across all levels of the health system; reliable access to electricity and the internet; easy‐to‐use and functional phones and systems; good technical support; and sufficient training and supervision. Well‐functioning digital systems will only succeed if medical supplies are actually available. What was studied in the review? Healthcare workers need medicines, vaccines, syringes, and other supplies to do their jobs properly. But many healthcare settings, particularly in poor countries, often lack supplies because governments cannot afford to buy them, or because they do not have good systems for distributing them to the right places at the right time. To address some of these problems, managers and health workers can use mobile phones to keep track of supplies, decide how much more to order and when, and let people at higher levels of the system know when supplies are running low. The main aim of our review was to find out if health workers who use these mobile systems had better access to supplies than health workers using other systems, or no systems at all. We also looked at how these mobile systems are being used in primary healthcare settings, and the factors that influences their use. What are the main results of the review? We found one study from Malawi that measured the effect of mobile phone systems on access to medicines and supplies in health facilities. However, we do not know whether these systems improve access or not, because the certainty of this evidence was very low. We found 16 studies conducted in African and Asian countries, in which study authors identified several factors that could help to set up systems successfully. ‐ Study authors suggested that allowing healthcare officials at all levels of the healthcare system to see the data could help them to respond on time and avoid supply shortages (low confidence). ‐ Study authors highlighted how poor access to electricity and internet could make it difficult for health workers to charge phones and send data (moderate confidence). ‐ Study authors pointed to the importance of user‐friendly systems, built with user participation (moderate confidence); access to technical experts to develop and maintain the system (low confidence); proper support and supervision for health workers (moderate confidence); and training of health workers in how to use the mobile system itself (moderate confidence). ‐ One author suggested that adding phone credits to health workers’ mobile phones for their personal use, could motivate them, and improve their use of the system (low confidence). Study authors also suggested several mobile phone functions that could be helpful to health workers using these systems. These included phones that could take pictures and map geographic locations, systems that allowed toll‐free text messaging, two‐way communication, and easy sharing of information (low confidence). But study authors also suggested that health workers might find it easier to use basic phones and maintain their own personal phones (low confidence). ‐ Study authors emphasised that digital notification systems will only give health workers better access to supplies if the supplies are actually available at the district or national level (low confidence). How up‐to‐date is this review? We searched for studies that had been published up to August 2019.

Background Quality of low back pain (LBP) information offered on YouTube ™ is unclear. Objective To describe the current low back pain information available on YouTube ™ and determine if these videos report information that aligns with clinical guidelines. Further analysis explored whether specific features of the videos explain their popularity. Methods A cross-sectional observational study was conducted on videos related to LBP on YouTube™ with the 200 most viewed videos using the term “low back pain.” The videos were independently viewed and assessed by two researchers for specific video characteristics, LBP specific content, and compliance with guidelines. The association between video characteristics or content with popularity (i.e., views, likes, dislikes, and comments) was investigated using regression models. Results The median number of views was 2 018 167. Only 59 (29.5%) of the videos reported at least one diagnostic recommendation from clinical guidelines, and only 100 (50%) reported a treatment recommendation that aligned with clinical guidelines. Apart from year of upload, no variables were identified that were independently associated with popularity or engagement of the videos. Conclusion The information related to LBP offered on YouTube™ is often not evidence-based and there is the tendency to prioritize information on interventions rather than understanding the LBP process. Factors related to engagement with content about LBP on YouTube™ remains uncertain, indicating further need for knowledge translation in this field.

Background The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low‐ and middle‐income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health. Objectives To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents’ and adults' sexual and reproductive health behaviour, health service use, and health and well‐being. Search methods In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification. Selection criteria We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well‐being. Eligible comparators were standard care or no intervention, non‐digital TCC, and digital non‐targeted communication. Data collection and analysis We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross‐checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison. Main results We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high‐income countries. Trials among adult populations were conducted in a range of high‐ to low‐income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low‐certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low‐certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low‐certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non‐digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non‐targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low‐certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low‐certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low‐certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low‐certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low‐certainty evidence, and standardised mean difference 0.44, 95% CI ‐0.14 to 1.02, low‐certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low‐certainty evidence), but there was substantial heterogeneity (I2 = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post‐operative visit; post‐abortion care). For health and well‐being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI ‐8.65 to 36.63; low‐certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low‐certainty evidence). TCCMD versus non‐digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92‐1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non‐targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67‐4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I2 = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status. Authors' conclusions TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality., Plain language summary Communicating to young people and adults through their mobile devices to improve sexual and reproductive health Aim of this review We assessed the effect of sending targeted messages by mobile devices to young people and adults about their sexual and reproductive health (SRH). Sexually transmitted infections (STIs) and unintended pregnancies are important causes of illness and early death worldwide. Key messages There are gaps in the evidence regarding the effects of targeted messages by mobile devices to young people and adults about their SRH. These types of messages may have benefits in a few areas. However, the existing evidence is often of low or very low certainty. What was studied in the review? Targeted client communication (TCC) is an intervention in which the health system sends information to particular people, based on their health status or other factors specific to that population group. Common types of TCC are text messages that remind people to go to appointments or that offer healthcare information and support. Our review assessed whether TCC can change people’s behaviour, use of health services, and health and well‐being. We focused on communication about SRH to young people (aged 10 to 24 years), and to adults. What happens when young people receive targeted messages by mobile device? Compared to people who get no messages Young people may have better SRH knowledge and may use contraceptives slightly more. We don't know if the messages affect young people's condom use; use of SRH services; or the number testing positive for STIs, needing abortions, or adhering to HIV medication, because the evidence is missing or of very low certainty. Compared to people who get messages sent in other ways We do not know what the effect of the messages is because the evidence is missing. Compared to people who get untargeted messages We don't know whether the messages improve SRH knowledge or increase condom or contraceptive use because the certainty of the evidence is very low. The messages may reduce the number of people who get STIs (but it is possible they increase, or make little or no difference to, STIs). The messages may increase the number of young people who attend services for testing for STIs/HIV. We don't know whether the messages affect the number of young people having abortions or help them to take their HIV medication because the evidence is missing. We are uncertain if the messages lead to more unintended consequences among young people than no messages, or other types of communication. What happens when adults receive targeted messages by mobile device? Compared to people who get no messages The messages may slightly increase contraceptive use. They may also reduce the number of adults who need repeated abortions, although it is also possible they increase, or make little or no difference to, the number of abortions. We don't know whether the messages affect adults' condom use or the number of STIs because the evidence is of very low certainty, or missing. The messages may slightly increase adults' adherence to HIV medication among adults with HIV, but may make little or no difference to CD4 count and slightly improve viral load. The messages may slightly increase adults' use of SRH services overall, but results were mixed according to type of health service. Compared to people who get messages sent in other ways Adults receiving messages may attend SRH services more overall, but the evidence is mixed. We do not know what the effect of messages is on other behaviours and health because we lack evidence. Compared to people who get untargeted messages Adults receiving messages may attend SRH services more overall, but the evidence is mixed. We don't know what the effect of messages is on other behaviours and health because we lack evidence. We are uncertain if the messages lead to more unintended consequences among adults than no messages, or other types of communication. How up‐to‐date is this review? We searched for studies that had been published up to August 2017. We carried out a search update in July 2019 and relevant studies are reported in the 'Characteristics of studies awaiting classification' section.

ObjectivesMediation analysis is a widely used quantitative method for investigating how interventions and exposures in randomised controlled trials and observational studies have an effect on healthcare outcomes. This study aimed to assess the importance of items that should be considered in a consensus meeting aimed at developing a guideline for reporting mediation analyses.DesignInternational online Delphi study.ParticipantsInternational experts in the development and application of mediation analysis.Main outcome measuresThe Delphi panel were asked to rate the importance of a list of items for inclusion in a guideline for reporting mediation analyses. Thresholds for disagreement and consensus on importance for inclusion were specified a priori. We used the Research ANd Development/University of California Los Angeles appropriateness method to quantitatively assess the importance for inclusion and panel agreement.ResultsNineteen expert panellists (10 female) from seven countries agreed to participate. All panellists contributed to all three rounds conducted between 10 June 2019 and 6 November 2019. The panel reached consensus on 34 unique reporting items for study design, analytic procedures and effect estimates, with three items rated ‘optional’. Panellists added one extra item and provided 60 qualitative comments for item refinement and prioritisation.ConclusionThis Delphi study used a rigorous consensus process to reach consensus on 34 reporting items for studies that use mediation analysis. These results will inform a consensus meeting that will consolidate a core set of recommended items for reporting mediation analyses.

BACKGROUND: This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP. OBJECTIVES: The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP. SEARCH METHODS: We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching. SELECTION CRITERIA: We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach. MAIN RESULTS: We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison. AUTHORS' CONCLUSIONS: The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

ObjectiveTo determine whether there is a relationship between physical growth and development, as determined by markers of biological maturation, and musculoskeletal conditions in adolescents.DesignSystematic review.Data sourcesElectronic databases (PubMed, EMBASE and the Cumulative Index to Nursing and Allied Health Literature) were searched up to 6 September 2017.Eligibility criteria for selecting studiesStudies that evaluated the association between biological maturation or growth and musculoskeletal conditions in adolescents (chronological age 10–19 years).ResultsFrom 20 361 titles identified by the searches, 511 full-text articles were retrieved and assessed for eligibility; 56 studies, all at high risk of bias, evaluating the relationship between maturation and/or growth and musculoskeletal conditions were included. A total of 208 estimates of association were identified across the included studies, which generally indicated no association or an unclear association between maturation, growth and musculoskeletal conditions.Summary/ConclusionsWhile the relationship between maturation, growth and musculoskeletal conditions remains plausible, the available evidence is not supportive. The current body of knowledge is at high risk of bias, which impedes our ability to establish whether biological maturity and growth are independent risk factors for musculoskeletal conditions.

To determine the frequency of red flag signs and symptoms in patients presenting with back pain to the Emergency Department (ED) and association with serious pathologies and investigations performed.This retrospective observational study evaluated consecutive patients presenting with back pain to a Melbourne ED over a 14-month period. Data regarding red flags, patient characteristics, ED-initiated investigations, and diagnoses were extracted from medical records. Prevalence of each red flag and sensitivity, specificity, and likelihood ratios for diagnosing serious spinal or non-spinal pathology were calculated.Analysis was undertaken on 1000 eligible participants with back pain. 69% had red flags. Participants were categorised into diagnostic groups: musculoskeletal (80.6%), serious spinal (3.3%), and serious non-spinal (14.6%) pathologies. A number of red flags had positive likelihood ratios (LR) 5, indicating a higher probability of serious pathology (spinal/non-spinal) including fever (LR + 68.8), tuberculosis history (LR + 13.8), known nephrolithiasis/abdominal aortic aneurysm (LR + 10.2), unexplained weight-loss (LR + 9.2), writhing in pain (LR + 6.9), urinary symptoms (LR + 5.4), and flank pain (LR + 5.2). Red flags with positive LR 5 indicating a higher probability of serious spinal pathology were saddle anaesthesia (LR + 11.0), tuberculosis history (LR + 9.8), intravenous drug-use (LR + 6.9), acute-onset urinary retention (LR + 6.4), and anal tone loss (LR + 6.3).The majority of this study cohort had back pain of benign cause. Some red flags were associated with greater risk of serious pathology, others were not. Further evidence regarding red flags and their association with serious pathology is required, to better inform clinical guidelines.

© 2016 Elsevier Ireland Ltd Objective Professional appearance is easily modifiable, and might alter the effects of a clinical encounter. We aimed to determine whether professional attire influences a patient's perception of treatment credibility. Methods We performed a single-blind randomized controlled study on 128 patients with acute non-specific low back pain who were about to receive treatment in primary care. The treating clinician was randomly allocated to wear formal attire (experimental condition) or casual attire (control condition) to the consultation. Clinicians provided a standardized briefing on the rationale behind the patient's forthcoming treatment. Treatment credibility (Credibility and Expectancy Questionnaire) was assessed immediately after this briefing. Results All patients received the experimental or control condition as allocated and provided complete primary outcome data. Formal attire had no effect on perceived treatment credibility (Mean difference between groups 1.2 [95%CI-1.1 to 3.5]). Age was the only significant predictor of treatment credibility; older patients rated treatment credibility higher (Beta = 0.16 [95%CI 0.08 to 0.24]). Conclusion In a trial setting, whether or not a clinician is formally dressed has no effect on perceptions of treatment credibility in patients with acute low back pain. Practice implication Clinicians should dress comfortably without fear of losing credibility.

Low back pain is highly prevalent and places a considerable burden on individuals, their families and communities. This back pain burden is unequally distributed around the world and within populations. Clinicians and researchers addressing back pain should be aware of the cultural, social and political context of back pain patients and how this context can influence pain perception, disability and health care use. Culture, which influences the beliefs and behaviour of individuals within a social group, could be considered an important contributor to the unequal distribution of back pain. However, there is paucity of high-quality research exploring the influence of culture on the experience and management of back pain. Further development and testing of specific tools, assessment methods and communication strategies are needed to improve our understanding of how cultural practices, values and identifications affect those dealing with back pain.

ResumoIntroduçãoA prevalência de lombalgia deverá aumentar em todo o mundo com o envelhecimento da população, mas sua prevalência em idosos não é clara, principalmente, em países em desenvolvimento.ObjetivoEstimar a prevalência de lombalgia em idosos brasileiros.MétodosForam feitas buscas eletrônicas nas bases de dados SciELO, Lilacs, Medline, Embase e Cinahl, bem como uma busca manual de estudos que investigaram a prevalência de lombalgia em idosos brasileiros com 60 anos ou mais. Dois revisores independentes selecionaram os estudos que atenderam aos critérios de inclusão, avaliaram o risco de viés de cada estudo incluído e extraíram os dados relevantes. Foi feita uma metanálise quando houve homogeneidade suficiente entre os estudos e o sistema Grade foi usado para resumir a qualidade geral das evidências.ResultadosForam incluídos 16 estudos originais com um total de 28.448 participantes. Foram obtidos dados de prevalência pontual e prevalência no período da lombalgia. Foi feita metanálise de 13 estudos que reportaram a prevalência pontual. A prevalência pontual agrupada de lombalgia foi de 25% = 15% (IC 95% 18 a 32). Outros três estudos investigaram a prevalência no período: em uma semana (IC 95% 13 a 18); em seis meses= 43% (95% IC 42 a 44); e em 12 meses = 13% (IC 95% 11 a 16). Foram feitas análises sensitivas da prevalência pontual e a exclusão de estudos com baixa qualidade metodológica aumentou a prevalência estimada de lombalgia.ConclusãoEvidências de qualidade moderada mostram que em um dado momento no tempo um em cada quatro idosos brasileiros apresenta lombalgia. Esta foi a primeira revisão sistemática que investigou dados nacionais sobre a prevalência de lombalgia em pessoas idosas, contribuindo com importantes evidências clínicas e epidemiológicas para os gestores e profissionais de saúde.AbstractIntroductionPrevalence of low back pain (LBP) is expected to increase worldwide with ageing of the population but its prevalence in older people is not clear, mainly in developing countries.ObjectiveTo estimate the prevalence of LBP in older Brazilians.MethodsElectronic searches on SciELO, Lilacs, Medline, Embase and Cinahl, as well as hand‐searching identified studies investigating prevalence of LBP in older Brazilians aged 60 years or older. Two independent reviewers selected studies fulfilling the inclusion criteria, assessed risk of bias for each included study and extracted relevant data. Meta‐analysis was conducted when enough homogeneity allowed and the GRADE system was used to summarize the overall quality of the evidence.ResultsSixteen studies were included with a total of 28,448 participants. Data from point‐ and period‐prevalence of LBP were obtained. Meta‐analysis was conducted for 13 studies reporting point‐prevalence. Pooled point‐prevalence of LBP was 25.0% (95% CI 18.0 to 32.0). Other three studies investigated period‐prevalence: one‐week prevalence = 15.0% (95% CI 13.0 to 18.0); six‐month prevalence = 43.0% (95% CI 42.0 to 44.0); and 12‐month prevalence = 13.0% (95% CI 11.0 to 16.0). Sensitivity analyses were performed for point‐prevalence and exclusion of studies with poorer methodological quality tended to increase the estimated prevalence of LBP.ConclusionModerate‐quality evidence show that at any point in time one in four older Brazilians suffers from LBP. This is the first systematic review investigating nationwide data on the prevalence of LBP in older people and contributes important clinical and epidemiological evidence for policymakers and health professionals.

Introduction Climate change and rapid population ageing are significant public health challenges. Understanding which health problems are affected by temperature is important for preventing heat and cold-related deaths and illnesses, particularly in the elderly. Here we present a systematic review and meta-analysis on the effects of ambient hot and cold temperature (excluding heat/cold wave only studies) on elderly (65 + years) mortality and morbidity. Methods Time-series or case-crossover studies comprising cause-specific cases of elderly mortality (n = 3,933,398) or morbidity (n = 12,157,782) were pooled to obtain a percent change (%) in risk for temperature exposure on cause-specific disease outcomes using a random-effects meta-analysis. Results A 1 °C temperature rise increased cardiovascular (3.44%, 95% CI 3.10–3.78), respiratory (3.60%, 3.18–4.02), and cerebrovascular (1.40%, 0.06–2.75) mortality. A 1 °C temperature reduction increased respiratory (2.90%, 1.84–3.97) and cardiovascular (1.66%, 1.19–2.14) mortality. The greatest risk was associated with cold-induced pneumonia (6.89%, 20–12.99) and respiratory morbidity (4.93% 1.54–8.44). A 1 °C temperature rise increased cardiovascular, respiratory, diabetes mellitus, genitourinary, infectious disease and heat-related morbidity. Discussion Elevated risks for the elderly were prominent for temperature-induced cerebrovascular, cardiovascular, diabetes, genitourinary, infectious disease, heat-related, and respiratory outcomes. These risks will likely increase with climate change and global ageing., Highlights • Heat and cold exposure elevates elderly risk of cardiovascular and cerebrovascular deaths and respiratory deaths and morbidity. • Climate change and ageing will likely increase the risk of diabetes, renal, infectious disease and heat-induced morbidity. • Temperature risks for elderly populations in Africa, Middle East, Asia and South America are under-represented. We applied a rigorous search strategy on three relevant databases following the PRISMA protocol. The search retrieved 18 mortality, and 30 morbidity publications eligible for meta-analysis, representing 3,933,398 deaths and 12,157,782 morbidity cases. Robust risk estimates were calculated for a wide range of temperature-sensitive health outcomes in the elderly. Temperature was found to significantly elevate cerebrovascular, cardiovascular, diabetes, genitourinary, and especially respiratory mortality or morbidity risks in the elderly. This study highlights considerable adverse health risks from temperature exposure in a large vulnerable population and provides impetus for climate change policy to address these risks.

Summary Background Infant rotavirus vaccines have led to substantial reductions in hospital admissions and deaths due to gastroenteritis, but some studies have reported an elevated risk of intussusception, a rare bowel disorder. This analysis aimed to provide evidence on the potential mortality reduction benefits and intussusception risks of current rotavirus vaccination schedules, and to explore whether alternative schedules could have advantages. Methods All 135 low-income and middle-income countries, defined by gross national income per capita of less than US$12 236 in the 2018 fiscal year, were included in the model. Mortality reduction benefits and intussusception risks of rotavirus vaccination were modelled by use of an Excel-based static cohort model with a finely disaggregated age structure. Numbers of rotavirus gastroenteritis deaths and intussusception deaths in each week of age were calculated for all infants born in the year 2015 between birth and age 5·0 years, with and without restrictions on age at administration. Benefit–risk ratios (rotavirus gastroenteritis deaths prevented per excess intussusception death) and other indicators were calculated for two vaccination schedules currently recommended by WHO and 16 alternative schedules. Of these schedules, it was assumed that between one and three doses would be given; the first dose of the rotavirus vaccine would be co-administered with either BCG or diphtheria–tetanus–pertussis (DTP)1; and the second or third dose would be co-administered with either DTP1, DTP2, DTP3, or measles (Meas)1. Findings A three-dose schedule co-administered with DTP (without age restrictions) could prevent about 74 000 (95% uncertainty interval 59 000–100 000) rotavirus gastroenteritis deaths (38% reduction) and could lead to 201 (77–550) excess intussusception deaths (1·4% increase) compared with no vaccination, resulting in a benefit–risk ratio of 369:1 (160:1–895:1). The benefit–risk ratio was most favourable when the relative risk of intussusception was assumed to decline with the national under-5 mortality rate (2386:1) and least favourable with pessimistic assumptions about access to hospital for intussusception treatment (168:1). Schedules that involve giving the first dose with BCG and the second with DTP1 had the fewest excess intussusception deaths and most favourable benefit–risk ratios. Interpretation Rotavirus vaccines have a favourable benefit–risk profile in LMICs. Neonatal schedules have the potential to prevent more rotavirus gastroenteritis deaths and cause fewer excess intussusception deaths than the schedules currently recommended by WHO, but more efficacious rotavirus vaccines would be needed to achieve more substantial mortality reduction benefits. Funding Bill & Melinda Gates Foundation.

Objectives: The objective of this study was to investigate whether systematic reviews of mediation studies identify limitations in reporting quality and methodological conduct. Study Design and Setting: We conducted an overview of systematic reviews. We searched four databases (MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, and PubMed) to identify systematic reviews of studies that used mediation analysis to investigate mechanisms of health care interventions or exposures in clinical populations between 2007 and 2017. Two reviewers independently screened titles and abstracts. Summary data on the characteristics, reporting quality, and methodological conduct of the studies included in the systematic reviews were extracted independently by two reviewers. The protocol was prospectively registered on PROSPERO (CRD42017059834). Results: Fifty-four systematic reviews were included, representing 11 health care fields, 26 health conditions, and 2008 mediation studies. Eighteen of fifty-four systematic reviews (33%) explicitly stated that the reporting of primary studies was suboptimal. Of these, 14/18 (78%) reviews noted incomplete reporting of effect sizes and precision estimates from mediation analyses. Twenty-nine of fifty-four systematic reviews (54%) identified limitations in the methodological conduct of primary studies. Conclusion: The reporting and methodological conduct of studies investigating mechanisms in health care seems to be suboptimal. Guidance is needed to improve the quality, completeness, and transparency of mediation studies.

We sought datasets with granular age distributions of rotavirus-positive disease presentations among children, We analyzed the age distribution of children

Background Crimean Congo haemorrhagic fever (CCHF) is a tick-borne disease that occurs in parts of Asia, Europe and Africa. Since 2000 the infection has caused epidemics in Turkey, Iran, Russia, Uganda and Pakistan. Good-quality general supportive medical care helps reduce mortality. There is uncertainty and controversy about treating CCHF with the antiviral drug ribavirin. Objectives To assess the effects of ribavirin for treating people with Crimean Congo haemorrhagic fever. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register; the Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (OVID); Science Citation Index-Expanded, Social Sciences Citation index, conference proceedings (Web of Science); and CINAHL (EBSCOHost). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for trials in progress. We conducted all searches up to 16 October 2017. We also contacted experts in the field and obtained further studies from these sources. Selection criteria We evaluated studies assessing the use of ribavirin in people with suspected or confirmed Crimean Congo haemorrhagic fever. We included randomised control trials (RCTs); non-randomised studies (NRSs) that included more than 10 participants designed as cohort studies with comparators; and case-control studies. Data collection and analysis Two review authors assessed eligibility, risk of bias, and extracted data. For non-randomized studies we used the ROBINS-I tool to assess risk of bias. The main effects analysis included all studies where we judged the risk of bias to be low, moderate or high. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and used meta-analyses where appropriate. We carried out a subsidiary appraisal and analysis of studies with critical risk of bias for the primary outcome, as these are often cited to support using ribavirin. Main results For the main effects analysis, five studies met our inclusion criteria: one RCT with 136 participants and four non-randomized studies with 612 participants. We excluded 18 non-randomized studies with critical risk of bias, where none had attempted to control for confounding. We do not know if ribavirin reduces mortality (1 RCT; RR 1.13, 95% confidence interval (CI) 0.29 to 4.32; 136 participants; very low-certainty evidence; 3 non-randomized studies; RR 0.72, 95% CI 0.41 to 1.28; 549 participants; very low-certainty evidence). We do not know if ribavirin reduces the length of stay in hospital (1 RCT: mean difference (MD) 0.70 days, 95% CI -0.39 to 1.79; 136 participants; and 1 non-randomized study: MD -0.80, 95% CI -2.70 to 1.10; 50 participants; very low-certainty evidence). We do not know if it reduces the risk of patients needing platelet transfusions (1 RCT: RR 1.23, 95% CI 0.77 to 1.96; 136 participants; very low-certainty evidence). For adverse effects (including haemolytic anaemia and a need to discontinue treatment), we do not know whether there is an increased risk with ribavirin in people with CCHF as data are insufficient. We do not know if adding ribavirin to early supportive care improves outcomes. One non-randomized study assessed mortality in people receiving ribavirin and supportive care within four days or less from symptom onset compared to after four days since symptom onset: mortality was lower in the group receiving early supportive care and ribavirin, but it is not possible to distinguish between the effects of ribavirin and early supportive medical care alone. In the subsidiary analysis, 18 studies compared people receiving ribavirin with those not receiving ribavirin. All had a critical risk of bias due to confounding, reflected in the mortality point estimates favouring ribavirin. Authors' conclusions We do not know if ribavirin is effective for treating Crimean Congo haemorrhagic fever. Non-randomized studies are often cited as evidence of an effect, but the risk of bias in these studies is high. Ribavirin for treating Crimean Congo haemorrhagic fever What is the aim of this review? The aim of this Cochrane review is to find out if ribavirin is an effective treatment for Crimean Congo haemorrhagic fever. Cochrane researchers collected and analysed all relevant studies to answer this question. We found 23 studies. We include five studies in this review that helped answer the question. We analysed the other 18 studies to help describe the limitations of the evidence. Key messages There is insufficient reliable evidence to show whether ribavirin is effective in treating Crimean Congo haemorrhagic fever. A randomised clinical trial could help answer this question. What was studied in the review? Crimean Congo haemorrhagic fever (CCHF) is an infection spread by tick bites. It has become more common in the last 15 years, particularly in Turkey and parts of Eastern Europe. CCHF can be life threatening. The most important way of caring for people who are seriously unwell with CCHF is to monitor them closely in hospital and give them any fluid or blood products they may need. Ribavirin is an antiviral drug that some doctors use to treat CCHF. It is widely available and is normally taken by mouth. There is debate over whether ribavirin is needed to treat CCHF; some argue that it is an effective treatment, or helps if given early, whilst others say that it has no effect, in terms of the risk of death, the length of time needed in hospital, and the extent of harm from the drug itself. Overall, the study designs did not take into account factors other than taking ribavirin that could result in better outcomes in the intervention group, including how ill the patient was when diagnosed, or when good supportive medical care was started. This made any association between ribavirin and lower mortality problematic. We found five studies that took into account important factors that could confound the risk of dying with whether or not a patient received ribavirin. These include how sick the study participants were, what other care they received, and how long after they became sick they received medical care. All included studies were conducted in Turkey and Iran, and compared people with CCHF who received ribavirin and supportive care to those who received supportive care alone. We looked at five different outcomes relating to ribavirin use in CCHF, and found that there is insufficient reliable evidence to determine whether ribavirin is effective. How up to date is the review? The review authors searched for studies that had been published up to 16 October 2017.

Aim Sarcopenia is the age-related loss of muscle mass and function that evolves into disability, loss of independence and death. In Brazil the number of older people is rapidly growing, resulting in an increased prevalence of chronic conditions associated with old age. As prevalence estimates provide essential information to policymakers when developing healthcare strategies, this systematic review and meta-analysis aimed to estimate the prevalence of sarcopenia in older Brazilians. Methods Electronic database searches and hand-searching in relevant journals and reference lists were carried out without language restriction. Studies that reported the prevalence of sarcopenia in Brazilians aged 60 years or older were considered for inclusion. Sarcopenia was defined as low muscle mass, low muscle function or low muscle mass and function. Meta-analysis was carried out using a random-effects model. Results A total of 31 studies were included pooling 9416 participants. The overall prevalence of sarcopenia in older Brazilians was 17.0% (95% CI 13.0–22.0). Sensitivity analysis showed rates of 20.0% (95% CI 11.0–32.0) in women and 12.0% (95% CI 9.0–16.0) in men. Prevalence was 16.0% (95% CI 12.0–23.0) based on low muscle mass and function; and 17.0% (95% CI 9.0–31.0) based only on low muscle mass. The difference between these two criteria was not significant (P = 0.96). Conclusions Sarcopenia is an emerging public health issue in Brazil. Attention should be paid to changes in prevalence rates over the next years because of the increase in the older population. Geriatr Gerontol Int 2017; 17: 5–16.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: In the context of primary healthcare settings, we aim to assess: effects of digitally tracking clients' health service use and status combined with decision support conducted via mobile device; effects of digitally tracking clients’ health service use and status combined with TCCs accessible via mobile device; and effects of digitally tracking clients' health service use and status combined with decision support conducted via mobile device and TCCs accessible via mobile device.

Aim: To describe fundamental movement skills (FMS), physical fitness and level of physical activity among Australian children with juvenile idiopathic arthritis (JIA) and compare this with healthy peers. Methods: Children aged 6-16 years with JIA were recruited from hospital rheumatology clinics and private rheumatology rooms in Sydney, Australia. All children attended an assessment day, where FMS were assessed by a senior paediatric physiotherapist, physical fitness was assessed using the multistage 20-metre shuttle run test, and physical activity and physical and psychosocial well-being were assessed with questionnaires. These results were compared with age- and gender-matched peers from the NSW Schools Physical Activity and Nutrition Survey and the Health of Young Victorians Study using logistic regression analysis. Results: Twenty-eight children with JIA participated in this study. There were no differences in the proportion of children who had mastered FMS between children with JIA and their healthy peers (P > 0.05). However, there was a trend for children with JIA to have poorer physical fitness and be less physically active than healthy peers. Parents of children with JIA indicated more physical and psychosocial impairments among their children and themselves compared with parents of healthy children (P < 0.05). Conclusions: This is the first study in Australia to compare FMS, physical activity and fitness in children with JIA and their peers. While older children with JIA appear to have poorer physical fitness and physical activity levels than their peers, there is no difference in FMS. © 2014 The Authors.

Objectives: To provide an overview of reporting and methodological quality in diagnostic test accuracy (DTA) studies in the musculoskeletal field and evaluate the use of the QUality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist. Study Design and Setting: A literature review identified all systematic reviews that evaluated the accuracy of clinical tests to diagnose musculoskeletal conditions and used the QUADAS checklist. Two authors screened all identified reviews and extracted data on the target condition, index tests, reference standard, included studies, and QUADAS items. A descriptive analysis of the QUADAS checklist was performed, along with Rasch analysis to examine the construct validity and internal reliability. Results: A total of 19 systematic reviews were included, which provided data on individual items of the QUADAS checklist for 392 DTA studies. In the musculoskeletal field,.uninterpretable or intermediate test results are commonly not reported with 175 (45%), scoring no to this item. The proportion of studies fulfilling certain items varied from 22%. (item 11) to 91% (item 3). The interrater reliability of the QUADAS checklist was good and Rasch analysis showed excellent construct validity and internal consistency. Conclusion: This overview identified areas where the reporting and performance of diagnostic studies within the musculoskeletal field can be improved. (C) 2014 Elsevier Inc. All rights reserved.

Background: While many treatment options have been advocated to speed recovery in adults with back pain, it is still unclear whether older patients with back pain respond differently to treatment when compared to younger patients. Aims: This study aims to evaluate if age modifies response to treatment in patients with back pain, by conducting secondary analyses of seven randomized clinical trials of common interventions for back pain. Methods: Data from 1233 participants were sourced from two randomized clinical trials on patients with acute back pain and five on patients with persistent back pain. Trials were conducted between 2001 and 2010 and assessed conservative treatments for back pain, including exercise, spinal manipulative therapy and anti-inflammatory drugs. Individual participant data analyses were performed using a ‘one-stage’ approach including all available data in a single two-level model, with participants being one level and trials being the second level. Only pain outcomes assessed immediately after treatment were included in the analyses. Results: Mean combined age of included participants was 49 years (SD: 15.4). Multivariate fractional polynomial analyses revealed no significant interaction (p > 0.05) between age and treatment effect sizes in patients with low back pain for any of the treatment comparisons. Conclusion: These results offer preliminary evidence suggesting that the generally small effects of conservative treatments for low back pain are in fact observed across all age groups.

OBJECTIVES: To determine predictors of satisfaction with care and symptoms in patients with acute low back pain 1 year after presentation to primary care.METHODS: The study is a secondary analysis of an existing cohort study of 1343 patients with acute low back pain presenting to primary care. Participants presenting to general practitioners, physiotherapists, or chiropractors were assessed at the initial consultation and followed up over 12 months. Putative predictors of patient satisfaction were extracted from baseline questionnaires. Multivariate logistic regression models were developed to predict satisfaction with care and satisfaction with symptoms at the 12-month follow-up.RESULTS: Most patients were highly satisfied with the care received (76%) and a smaller proportion with their symptoms (55%) at 12 months. Pain intensity at 12 months had a strong association with both measures of satisfaction. After controlling for the level of pain intensity, those born outside Australia, older people, and those reporting more symptoms of depression were less likely to be satisfied with the care received. Patients reporting poor general health at the initial visit and more symptoms of depression were less likely to be satisfied with their symptoms at the 12-month follow-up.DISCUSSION: Pain intensity at the 12-month follow-up has a strong association with patient satisfaction. Primary care practitioners should remain aware of the influence of cultural, demographic, and psychological factors on satisfaction with care and symptoms.

Background: Stroke remains among the leading causes of death and disability worldwide. The recent advances in acute stroke therapy further validate the need for an efficient ‘stroke system,’ of which the first step is rapid and accurate identification of stroke. Currently, there is no agreed upon standard prehospital stroke scale. Methods: In conjunction with the Cochrane Stroke Group we developed an electronic search strategy to identify relevant studies in MEDLINE. We then adapted it to seven other databases. Scales had to have been used in the emergency or prehospital setting, have a discharge diagnosis of stroke by a neurologist and needed to demonstrate at a minimum, the data needed to construct a two by two table. Our database search yielded 8479 references with 16 full texts articles and 4 abstracts (7 scales) meeting our inclusion criteria. We applied the Quadas-2 tool to eleiminate bias. Results: The ROSIER scale demonstrated the highest median sensitivity at 90% (95%CI, range 85%-97%) as well as the smallest confidence intervals. The LAPSS demonstrated the best pooled specificity, 91% (95%CI, range 84%-95%). Conclusion: In the acute stroke setting a highly sensitive scale for stroke identification is of great value. This Cochrane Systematic review demonstrated that of all currently validated scales, the ROSIER scale has the greatest sensitivity for detecting stroke in the the prehospital or emergency setting.

Injection therapy and denervation procedures are commonly used in the management of chronic low-back pain (LBP) despite uncertainty regarding their effectiveness and safety. To provide an evaluation of the current evidence associated with the use of these procedures, a systematic review was performed. Existing systematic reviews were screened, and the Cochrane Back Review Group trial register was searched for randomized controlled trials (RCTs) fulfilling the inclusion criteria. Studies were included if they recruited adults with chronic LBP, evaluated the use of injection therapy or denervation procedures and measured at least one clinically relevant outcome (such as pain or functional status). Two review authors independently assessed studies for eligibility and risk of bias (RoB). A meta-analysis was performed with clinically homogeneous studies, and the GRADE approach was used to determine the quality of evidence. In total, 27 RCTs were included, 14 on injection therapy and 13 on denervation procedures. 18 (66%) of the studies were determined to have a low RoB. Because of clinical heterogeneity, only two comparisons could be pooled. Overall, there is only low to very low quality evidence to support the use of injection therapy and denervation procedures over placebo or other treatments for patients with chronic LBP. However, it cannot be ruled out that in carefully selected patients, some injection therapy or denervation procedures may be of benefit.

Objective To determine the prevalence of serious pathology in patients presenting to primary care settings with acute low back pain, and to evaluate the diagnostic accuracy of recommended “red flag” screening questions. Methods An inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain was recruited from primary care clinics in Sydney, Australia. At the initial consultation, clinicians recorded responses to 25 red flag questions and then provided an initial diagnosis. The reference standard was a 12-month followup supplemented with a specialist review of a random subsample of participants. Results There were 11 cases (0.9%) of serious pathology, including 8 cases of fracture. Despite the low prevalence of serious pathology, most patients (80.4%) had at least 1 red flag (median 2, interquartile range 1–3). Only 3 of the red flags for fracture recommended for use in clinical guidelines were informative: prolonged use of corticosteroids, age >70 years, and significant trauma. Clinicians identified 5 of the 11 cases of serious pathology at the initial consultation and made 6 false-positive diagnoses. The status of a diagnostic prediction rule containing 4 features (female sex, age >70 years, significant trauma, and prolonged use of corticosteroids) was moderately associated with the presence of fracture (the area under the curve for the rule score was 0.834 [95% confidence interval 0.654–1.014]; P = 0.001). Conclusion In patients presenting to a primary care provider with back pain, previously undiagnosed serious pathology is rare. The most common serious pathology observed was vertebral fracture. Approximately half of the cases of serious pathology were identified at the initial consultation. Some red flags have very high false-positive rates, indicating that, when used in isolation, they have little diagnostic value in the primary care setting.

Objectives: This study aimed to provide a comprehensive profile of a representative sample of patients with acute low back pain drawn from the primary care setting. A secondary aim was to determine whether patient characteristics are associated with pain intensity or disability at the initial consultation. Methods: A total of 1172 consecutive patients with acute low back pain presenting to clinics of primary care practitioners (general practitioners, physiotherapists, and chiropractors) in Australia were recruited. Pain intensity and level of disability were measured at the first consultation, and a range of other variables were measured to describe the patient's characteristics. The characteristics were then grouped into 7 distinct factors: demographic, social, cultural, general health, psychologic, past low back pain history, and current low back pain history. Hierarchical linear regression models were used to determine each factor's independent relationship with pain intensity and disability. Results: The majority of patients reported having had a previous episode of low back pain (75.7%), and that the current episode was of sudden onset (76.7%). Only a small proportion (14.3%) had compensable back pain. Pain intensity and disability were associated with each other (P < 0.01), current low back pain history (P

Study Design. Inception cohort study. Objective. To provide the first reliable estimate of the 1-year incidence of recurrence in subjects recently recovered from acute nonspecific low back pain (LBP) and to determine factors predictive of recurrence in 1 year. Summary of Background Data. Previous studies provide potentially flawed estimates of recurrence of LBP because they do not restrict the cohort to those who have recovered and are therefore eligible for a recurrence. Methods. We identified 1334 consecutive patients who presented to primary care with acute LBP; of these 353 subjects recovered before 6 weeks and entered the current study. The primary outcome measure was recurrence of LBP in the next year. Specifically, an episode of recurrence was defined in 2 ways: recall of recurrence at the 12-month follow-up and report of pain at the 3- or 12-month follow-up. Risk factors for recurrence were assessed at baseline. Pain intensity was assessed at 6 weeks, 3 months, and 12 months and recurrence at 12 months. Factors that could plausibly affect recurrence were chosen a priori and evaluated using a multivariable regression analysis. Results. Recurrence of LBP was found to be much less common than previous estimates suggest, ranging from 24% (95% CI = 20%–28%) using “12-month recall” definition of recurrence, to 33% (95% CI = 28%–38%) using “pain at follow-up” definition of recurrence. However, only 1 factor, previous episode(s) of LBP, was consistently predictive of recurrence within the next 12 months (odds ratio = 1.8–2.0, P = 0.00–0.05). Conclusion. This study challenges the assumption that the majority of subjects will have a recurrence of LBP in a 1-year period. After the resolution of an episode of acute LBP, about 25% of subjects will have a recurrence in the next year. It is difficult to predict who will have a recurrence within the next year.

This article presents a systematic literature review on whether dietary intake influences the risk for perinatal depression, i.e. depression during pregnancy or post-partum. Such a link has been hypothesized given that certain nutrients are important in the neurotransmission system and pregnancy depletes essential nutrients. PubMed, EMBASE and CINAHL databases were searched for relevant articles until 30 May 2015. We included peer-reviewed studies of any design that evaluated whether perinatal depression is related to dietary intake, which was defined as adherence to certain diets, food-derived intake of essential nutrients or supplements. We identified 4808 studies, of which 35 fulfilled inclusion criteria: six randomized controlled trials, 12 cohort, one case-control and 16 cross-sectional studies, representing 88 051 distinct subjects. Studies were grouped into four main categories based on the analysis of dietary intake: adherence to dietary patterns (nine studies); full panel of essential nutrients (six studies); specific nutrients (including B vitamins, Vitamin D, calcium and zinc; eight studies); and intake of fish or polyunsaturated fatty acids (PUFAs; 12 studies). While 13 studies, including three PUFA supplementation trials, found no evidence of an association, 22 studies showed protective effects from healthy dietary patterns, multivitamin supplementation, fish and PUFA intake, calcium, Vitamin D, zinc and possibly selenium. Given the methodological limitations of existing studies and inconsistencies in findings across studies, the evidence on whether nutritional factors influence the risk of perinatal depression is still inconclusive. Further longitudinal studies are needed, with robust and consistent measurement of dietary intake and depressive symptoms, ideally starting before pregnancy.

To describe the accuracy of clinical features and tests used to screen for malignancy in patients with low back pain. A systematic review was performed on all available records on MEDLINE, EMBASE, and CINAHL electronic databases. Studies were considered eligible if they investigated a cohort of low back pain patients, used an appropriate reference standard, and reported sufficient data on the diagnostic accuracy of tests. Two authors independently assessed methodological quality and extracted data to calculate positive (LR+) and negative (LR-) likelihood ratios. Six studies evaluating 22 different clinical features and tests were identified. The prevalence of malignancy ranged from 0.1 to 3.5%. A previous history of cancer (LR+ = 23.7), elevated ESR (LR+ = 18.0), reduced hematocrit (LR+ = 18.2), and overall clinician judgement (LR+ = 12.1) increased the probability of malignancy when present. A combination of ageor =50 years, a previous history of cancer, unexplained weight loss, and failure to improve after 1 month had a reported sensitivity of 100%. Overall, there was poor reporting of methodological quality items, and very few studies were performed in community primary care settings. Malignancy is rare as a cause of low back pain. The most useful features and tests are a previous history of cancer, elevated ESR, reduced hematocrit, and clinician judgement.

Sarcopenia is the age-related loss of muscle mass and function that evolves into disability, loss of independence and death. In Brazil the number of older people is rapidly growing, resulting in an increased prevalence of chronic conditions associated with old age. As prevalence estimates provide essential information to policymakers when developing healthcare strategies, this systematic review and meta-analysis aimed to estimate the prevalence of sarcopenia in older Brazilians.Electronic database searches and hand-searching in relevant journals and reference lists were carried out without language restriction. Studies that reported the prevalence of sarcopenia in Brazilians aged 60 years or older were considered for inclusion. Sarcopenia was defined as low muscle mass, low muscle function or low muscle mass and function. Meta-analysis was carried out using a random-effects model.A total of 31 studies were included pooling 9416 participants. The overall prevalence of sarcopenia in older Brazilians was 17.0% (95% CI 13.0-22.0). Sensitivity analysis showed rates of 20.0% (95% CI 11.0-32.0) in women and 12.0% (95% CI 9.0-16.0) in men. Prevalence was 16.0% (95% CI 12.0-23.0) based on low muscle mass and function; and 17.0% (95% CI 9.0-31.0) based only on low muscle mass. The difference between these two criteria was not significant (P = 0.96).Sarcopenia is an emerging public health issue in Brazil. Attention should be paid to changes in prevalence rates over the next years because of the increase in the older population. Geriatr Gerontol Int 2017; 17: 5-16.

Purpose: To determine whether emotional distress reported at the initial consultation affects subsequent healthcare use either directly or indirectly via moderating the influence of symptoms. Methods: Longitudinal observational study of 2891 participants consulting primary care for low back pain. Negative binomial regression models were constructed to estimate independent effects of emotional distress on healthcare use. Potential confounders were identified using directed acyclic graphs. Results: After the initial consultation, participants had a mean (SD) of one (1.2) visit for back pain over 3 months, and nine (14) visits for back pain over 12 months. Higher reports of anxiety during the initial consultation led to increased short-term healthcare use (IRR 1.06, 95 % CI 1.01–1.11) and higher reports of depression led to increased long-term healthcare use (IRR 1.04, 95 % CI 1.02–1.07). The effect sizes suggest that a patient with a high anxiety score (8/10) would consult 50 % more frequently over 3 months, and a person with a high depression score (8/10) would consult 30 % more frequently over 12 months, compared to a patient with equivalent pain and disability and no reported anxiety or depression. Conclusions: Emotional distress in the acute stage of low back pain increased subsequent consultation rates. Interventions that target emotional distress during the initial consultation are likely to reduce costly and potentially inappropriate future healthcare use for patients with non-specific low back pain. Refereed/Peer-reviewed

Purpose:\ud Evidence supporting the use of therapeutic intra-articular facet joint injections for patients with suspected facet joint pain is sparse. A systematic review including a narrative synthesis was carried out to determine if intra-articular facet joint injections with active drug are more effective in reducing back pain and back pain-related disability than a sham procedure or a placebo/inactive injection. Secondly, to determine if intra-articular facet joint injections with active drug or placebo/inactive injection are more effective in reducing back pain and back pain-related disability than conservative treatment.\ud \ud Methods:\ud Medline, EMBASE, CINAHL, CENTRAL, Index to Chiropractic Literature and the Cochrane Central Register of Controlled Trials were searched from inception through April 2015. Data were screened and single extraction with independent verification and risk of bias assessment was performed.\ud \ud Results:\ud A total of 391 records were screened, and six trials were included. The trials included were small (range 18–109 participants) and overall in terms of pain and disability outcomes most were inconclusive. Only two of the trials report any significant between-group differences in pain (mean difference −1.0, 95 % CI −2.0 to −0.1) and (p = 0.032) or disability (mean difference −3.0, 95 % CI −6.2 to 0.2) and (p = 0.013) outcomes.\ud \ud Conclusions:\ud The studies found here were clinically diverse and precluded any meta-analysis. A number of methodological issues were identified. The positive results, whilst interpreted with caution, do suggest that there is a need for further high-quality work in this area.

Musculoskeletal disorders, such as knee pain, are common in children and adolescents, but there is a lack of high quality research that evaluates the clinical course of these conditions. The objective of this study was to evaluate the feasibility of conducting a prospective study of children and adolescents with knee pain using electronic methods of data collection.Children and adolescents with knee pain that presented to primary care physiotherapy clinics were enrolled and followed-up on a weekly basis via short messaging service (SMS) until their knee pain had recovered (i.e. two consecutive weeks of no pain). Feasibility was assessed in terms of recruitment, retention and response rates to SMS and an online questionnaire. Baseline and 6-month follow-up measures included pain, disability, physical function, physical activity and health related quality of life. Kaplan-Meier survival analysis was used to estimate the median time to knee pain recovery.Thirty participants (mean age 13.0 ± 2.2 years, 53% boys) were recruited over 26 months. The overall response rate to weekly SMS follow-up was 71.3% (809 received/1135 sent). One third of participants stopped responding to SMS prior to recovery, and these participants typically had a much lower response rate during the time they remained in the study. At 6-month follow-up, 80% of the cohort completed the final online questionnaire, and 29% of participants still reported current knee pain (≥1/10 VAS). The median time for knee pain recovery was 8 weeks (95%CI: 5, 10).Electronic data collection alone seems insufficient to track pain recovery in young people and may need to be supplemented with more traditional data collection methods. Researchers should consider further measures to address slow recruitment rates and high attrition when designing large prospective studies of children and adolescents in the future. Copyright © 2016 John WileySons, Ltd.

Objective To evaluate whether individual types of pain (headache, stomach-ache, and backache) or multiple pains affect the odds of young people achieving the recommended 60 minutes of moderate to vigorous physical activity (MVPA) per day in a large representative sample. Design Multicenter cross-sectional survey. Setting Twenty-eight countries across Europe and North America. Subjects Adolescents (N = 242,103). Methods An analysis of data collected in two waves (2001/02 and 2005/06) of the health behavior in school-aged children (HBSC) study was performed. Survey questions included the HBSC symptoms checklist and the amount of regular physical activity. Multilevel logistic regression was used to account for clustering effect of MVPA within countries. Models investigated the relationship between pain and physical activity, adjusted for the HBSC study year. Six models were conducted separately for gender and age-group (11, 13, and 15 years) strata. Results In general, the presence of pain was associated with reduced physical activity. Headache alone was associated with reduced physical activity in all six strata (odd ratios 0.77–0.84), stomach-ache alone in five strata (0.77–0.92), and backache alone in four strata (0.86–0.96). In 11- and 13-year-old girls, headache, stomach-ache, and backache, individually and in combination, were associated with decreased odds of being physically active (odds ratios ranging from 0.73 to 0.91). Within the other four age and gender strata, the relationship was less consistent. Conclusion Pain is associated with reduced physical activity in adolescents but this association varies according to gender, age, and the type of pain experienced.

Introduction Around 40% of people presenting to primary care with an episode of acute low back pain develop chronic low back pain. In order to reduce the risk of developing chronic low back pain, effective secondary prevention strategies are needed. Early identification of at-risk patients allows clinicians to make informed decisions based on prognostic profile, and researchers to select appropriate participants for secondary prevention trials. The aim of this study is to develop and validate a prognostic screening tool that identifies patients with acute low back pain in primary care who are at risk of developing chronic low back pain. This paper describes the methods and analysis plan for the development and validation of the tool. Methods/analysis The prognostic screening tool will be developed using methods recommended by the Prognosis Research Strategy (PROGRESS) Group and reported using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement. In the development stage, we will use data from 1248 patients recruited for a prospective cohort study of acute low back pain in primary care. We will construct 3 logistic regression models to predict chronic low back pain according to 3 definitions: any pain, high pain and disability at 3 months. In the validation stage, we will use data from a separate sample of 1643 patients with acute low back pain to assess the performance of each prognostic model. We will produce validation plots showing Nagelkerke R2 and Brier score (overall performance), area under the curve statistic (discrimination) and the calibration slope and intercept (calibration). Ethics and dissemination Ethical approval from the University of Sydney Ethics Committee was obtained for both of the original studies that we plan to analyse using the methods outlined in this protocol (Henschke et al, ref 11-2002/3/3144; Williams et al, ref 11638).

Background: Measurements of volume are taken in the clinical environment to determine the extent of swelling and to evaluate the effects of treatment interventions. In the research setting, volume measurements are taken to determine experimental outcomes. Water displacement and figure-of-eight methods are highly reliable for measuring foot and ankle volumes, but the responsiveness of the two methods has not been compared. This study was designed to investigate effects of manipulating hydrostatic and blood pressures on foot and ankle volume and responsiveness of the two methods to induced changes in foot and ankle volume. Methods: Intervention effects on volume were compared using water displacement and tape (figure-of-eight) methods. Foot and ankle volume was measured in each of the 30 participants while they were supine, sitting, and sitting with a sphygmomanometer cuff inflated around the lower thigh to occlude blood flow into the leg. These variations allowed manipulation of the hydrostatic and blood pressures acting on the foot and ankle. Results: Data from the water displacement method showed that a significant increase in volume of 31 mL ( p < 0.002) occurred with the cuff in place, but this was not detected using the figure-of-eight method. No significant difference ( p > 0.136) between the sitting and supine positions was detected using either method. Conclusions: Limb dependency while sitting or lying had no effect on measures from either method, but volumetry had a higher responsiveness to changes induced by application of the cuff. This effect was interpreted as arterial leakage past the cuff. Clinical Relevance: The figure-of-eight tape method and the water displacement technique for measuring ankle and foot volume may not be interchangeable. Changes in volume of the ankle and foot are better measured by the water displacement technique, but for measurements of ankle volume alone, the tape method is appropriate. The responsiveness of the tape method to changes in volume is yet to be determined.

Background Congenital lymphoedema is a lifelong condition that has detrimental physical and psychosocial outcomes for young patients and burdensome treatment responsibilities that may hamper patients’ motivation for self-management. There is limited research from the perspective of young people with primary lymphoedema. We aimed to describe the experiences and views of children and adolescents with lymphoedema to inform patient-centred practice. Methods Twenty patients (aged 8–21 years) with primary lymphoedema were purposively sampled from two paediatric clinics in Sydney, Australia, to participate in a semistructured interview. The transcripts were analysed thematically. Results We identified six themes: reinforcing abnormality (damaging self-esteem, self-consciousness, frustrating restrictions and isolation); negotiating uncertainties (fearing condition worsening, deprioritised and sidelined, questioning cause and permanence, widespread unawareness); vulnerability and caution (avoiding pain and discomfort, preventing severe and permanent consequences, depending on permission, limiting goals and aspirations); disruptive transition (resisting change, losing progress and support, avoiding treatment costs); developing resilience (focusing on the positives, embracing individuality, recalibrating normality, prioritising coping) and taking responsibility (individualising treatment, needing support, external pressure and motivation, sticking to a routine, seeking independence). Conclusion Children and adolescents learn to adjust to the daily demands of lymphoedema management by individualising and accepting their treatment, but many continue to struggle with their self-esteem and lifestyle restrictions. Strategies are needed to empower young patients to advocate for themselves during their transition to adult care. Treatment plans that minimise social restrictions, address emotional consequences and incorporate patients’ preferences could improve adherence, satisfaction and outcomes.