Spinal manipulation epidemiology: Systematic review of cost effectiveness studies

BackgroundSpinal manipulative therapy (SMT) is frequently used by health professionals to manage spinal pain. With many treatments having comparable outcomes to SMT, determining the cost-effectiveness of these treatments has been identified as a high research priority.ObjectiveTo investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration.MethodsWe searched eight clinical and economic databases and the reference lists of relevant systematic reviews. Full economic evaluations conducted alongside randomised controlled trials with at least one SMT arm were eligible for inclusion. Two authors independently screened search results, extracted data and assessed risk of bias using the CHEC-list.ResultsSix cost-effectiveness and cost–utility analysis were included. All included studies had a low risk of bias scoring ?16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP care, exercise and physiotherapy.ConclusionsThis review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. However, as this conclusion is primarily based on single studies more high quality research is needed to identify whether these findings are applicable in other settings.     

Spinal manipulation and mobilisation for back and neck pain: a blinded review.

OBJECTIVE--To assess the efficacy of spinal manipulation for patients with back or neck pain. DESIGN--Computer aided search for published papers and blinded assessment of the methods of the studies. SUBJECTS--35 randomised clinical trials comparing spinal manipulation with other treatments. MAIN OUTCOME MEASURES--Score for quality of methods (based on four main categories: study population, interventions, measurement of effect, and data presentation and analysis) and main conclusion of author(s) with regard to spinal manipulation. RESULTS--No trial scored 60 or more points (maximum score 100) suggesting that most were of poor quality. Eighteen studies (51%) showed favourable results for manipulation. In addition, five studies (14%) reported positive results in one or more subgroups. Of the four studies with 50-60 points, one reported that manipulation was better, two reported that manipulation was better in only a subgroup, and one reported that manipulation was no better or worse than reference treatment. Eight trials attempted to compare manipulation with some placebo, with inconsistent results. CONCLUSIONS--Although some results are promising, the efficacy of manipulation has not been convincingly shown. Further trials are needed, but much more attention should be paid to the methods of study.     

An experimental manipulation of food and water: growth and time-space utilization of hatchling lizards (Sceloporus undulatus)

Summary At a site in western Nebraska, we studied the effects of supplemental food and water on growth, survival, and habitat utilization of hatchling iguanid lizards, Sceloporus undulatus. Hatchlings were randomly assigned to one of four experimental groups and received either (1) supplemental food only, (2) supplemental water only, (3) supplemental food and water, or (4) neither supplemental food nor water (control). Neither supplemental food nor supplemental water affected growth rate in length, growth rate in mass, or size-specific body mass (i.e. robustness) at the end of the treatment period. Over the 45 day treatment pierod, there were no significant differences among treatment groups in survival, home-range size, or habitat utilization. There were, however, significant differences in the index of activity. Hatchlings in the treatment groups receiving supplemental water were sighted more often than hatchlings in the control group. We conclude that, during our study, neither food nor water limited growth but that water limited activity.     

Epidemiology of Spinal Cord Injuries and Risk Factors for Complete Injuries in Guangdong,China: A Retrospective Study

Background

Spinal cord injuries are highly disabling and deadly injuries. Currently, few studies focus on non-traumatic spinal cord injuries, and there is little information regarding the risk factors for complete injuries. This study aims to describe the demographics and the injury characteristics for both traumatic and non-traumatic spinal cord injuries and to explore the risk factors for complete spinal cord injuries.

Methods

A retrospective study was performed by reviewing the medical records of 3,832 patients with spinal cord injuries who were first admitted to the sampled hospitals in Guangdong, China. The demographics and injury characteristics of the patients were described and compared between the different groups using the chi-square test. Logistic regression was conducted to analyze the risk factors for complete spinal cord injuries.

Results

The proportion of patients increased from 7.0% to 14.0% from 2003 to 2011. The male-to-female ratio was 3.0∶1. The major cause of spinal cord injuries was traffic accidents (21.7%). Many of the injured were workers (36.2%), peasants (22.8%), and unemployed people (13.9%); these occupations accounted for 72.9% of the total sample. A multivariate logistic regression model revealed that the OR (95% CI) for male gender compared to female gender was 1.25 (1.07–1.89), the OR (95%CI) for having a spinal fracture was 1.56 (1.35–2.60), the OR (95%CI) for having a thoracic injury was 1.23 (1.10–2.00), and the OR (95%CI) for having complications was 2.47 (1.96–3.13).

Conclusion

The proportion of males was higher than the proportion of females. Workers, peasants and the unemployed comprised the high-risk occupational categories. Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury. We recommend that preventive measures should focus on high-risk populations, such as young males.     

Rapporteur report: Epidemiology

Three talks were presented in the session on “Epidemiology”. The first talk was a review of prenatal studies. The second talk presented epidemiological evidence from prenatal studies. The third talk presented general issues regarding the planning of an epidemiological study. It was noted that epidemiological studies of prenatal exposures use data from the early 1980s when ultrasound was first introduced for foetal scans. These studies did not show associations between prenatal ultrasound scanning and childhood cancer, reduced birth weight, impaired childhood growth or neurological development in childhood. However, there was a possible association between prenatal ultrasound scanning and left-handedness in boys. The aetiology of this association remains uncertain.     

Antibiotics: opportunities for genetic manipulation

New antibiotics can still be discovered by the development of novel screening procedures. Notable successes over the last few years include the monobactams, beta-lactamase inhibitors (clavulanic acid) and new glycopeptides in the antibacterial field; antiparasitic agents such as avermectins; and herbicidal antibiotics like bialaphos. In the future we can expect the engineering of genes from 'difficult' pathogens, including mycobacteria and fungi, and cancer cells, to provide increasingly useful in vitro targets for the screening of antibiotics that can kill pathogens and tumours. There will also be a greater awareness of the need to reveal the full potential for antibiotic production on the part of microorganisms by the physiological and/or genetic awakening of 'silent' genes. Nevertheless, the supply of natural antibiotics for direct use or chemical modification is not infinite and there will be increasing scope for widening the range of available antibiotics by genetic engineering. 'Hybrid' antibiotics have been shown to be generated by the transfer of genes on suitable vectors between strains producing chemically related compounds. More exciting is the possibility of generating novelty by the genetic engineering of the synthases that determine the basic structure of antibiotics belonging to such classes as the beta-lactams and polyketides. Research in this area will certainly yield knowledge of considerable scientific interest and probably also of potential applicability. In the improvement of antibiotic titre in actinomycetes, protoplast fusion between divergent selection lines has taken a place alongside random mutation and screening. In some cases the cloning of genes controlling metabolic 'bottlenecks' in fungi and actinomycetes will give an immediate benefit in the conversion of accumulated biosynthetic intermediates to the desired end product. However, the main impact of genetic engineering in titre improvement will probably come only after a further use of this technology to understand and manipulate the regulation of antibiotic biosynthesis as a facet of the general challenge of understanding differential gene expression. Streptomyces offers a particularly fertile field for such research, following the isolation of DNA segments that carry groups of closely linked operons for the biosynthesis of and resistance to particular antibiotics, and of genes with pleiotropic effects on morphological differentiation and secondary metabolite formation.     

Feeling manipulated: cytomegalovirus immune manipulation

Background

ORF59 DNA polymerase processivity factor of the human rhadinovirus, Kaposi's sarcoma-associated herpesvirus (KSHV), is required for efficient copying of the genome during virus replication. KSHV ORF59 is antigenic in the infected host and is used as a marker for virus activation and replication.

Results

We cloned, sequenced and expressed the genes encoding related ORF59 proteins from the RV1 rhadinovirus homologs of KSHV from chimpanzee (PtrRV1) and three species of macaques (RFHVMm, RFHVMn and RFHVMf), and have compared them with ORF59 proteins obtained from members of the more distantly-related RV2 rhadinovirus lineage infecting the same non-human primate species (PtrRV2, RRV, MneRV2, and MfaRV2, respectively). We found that ORF59 homologs of the RV1 and RV2 Old World primate rhadinoviruses are highly conserved with distinct phylogenetic clustering of the two rhadinovirus lineages. RV1 and RV2 ORF59 C-terminal domains exhibit a strong lineage-specific conservation. Rabbit antiserum was developed against a C-terminal polypeptide that is highly conserved between the macaque RV2 ORF59 sequences. This anti-serum showed strong reactivity towards ORF59 encoded by the macaque RV2 rhadinoviruses, RRV (rhesus) and MneRV2 (pig-tail), with no cross reaction to human or macaque RV1 ORF59 proteins. Using this antiserum and RT-qPCR, we determined that RRV ORF59 is expressed early after permissive infection of both rhesus primary fetal fibroblasts and African green monkey kidney epithelial cells (Vero) in vitro. RRV- and MneRV2-infected foci showed strong nuclear expression of ORF59 that correlated with production of infectious progeny virus. Immunohistochemical studies of an MneRV2-infected macaque revealed strong nuclear expression of ORF59 in infected cells within the differentiating layer of epidermis corroborating previous observations that differentiated epithelial cells are permissive for replication of KSHV-like rhadinoviruses.

Conclusion

The ORF59 DNA polymerase processivity factor homologs of the Old World primate RV1 and RV2 rhadinovirus lineages are phylogenetically distinct yet demonstrate similar expression and localization characteristics that correlate with their use as lineage-specific markers for permissive infection and virus replication. These studies will aid in the characterization of virus activation from latency to the replicative state, an important step for understanding the biology and transmission of rhadinoviruses, such as KSHV.     

Epidemiology: a developing science

The story of French epidemiology dates back to Daniel Bernoulli (1760), with regard to mathematical epidemiology,and to Pierre-Charles Louis (1838), with regard to 'numerical medicine', the ancestor of the modern evidence-based medicine.This thematic issue samples some of the recent issues of modern epidemiology: biostatisticians have developed a series of specialized techniques to encover the risk factors and to measure the proportion of the disease frequency they can account for (one paper). Epidemiology of chronic diseases is now providing new insights into the tricky relationships between environmental, genetic factors, and diseases (four papers). Epidemiology is not just concerned with diseases. All aspects of human biology and physiology for which a population approach is necessary, are concerned: one paper deals with the case of fecundity and fertility, which are studied by both demographic and epidemiological approaches. One of the roles of epidemiology is to bring rational answers to disputed issues in public health, such as the hazards of postmenopausal hormonal therapy (one paper). Finally, the power of mathematics is increasingly used to understand better the dynamics of infectious diseases (two papers).