The prognosis of acute and persistent low-back pain: a meta-analysis

Background:

Although low-back pain is a highly prevalent condition, its clinical course remains uncertain. Our main objective was to systematically review the literature on the clinical course of pain and disability in patients with acute and persistent low-back pain. Our secondary objective was to investigate whether pain and disability have similar courses.

Methods:

We performed a meta-analysis of inception cohort studies. We identified eligible studies by searching MEDLINE, Embase and CINAHL. We included prospective studies that enrolled an episode-inception cohort of patients with acute or persistent low-back pain and that measured pain, disability or recovery. Two independent reviewers extracted data and assessed methodologic quality. We used mixed models to determine pooled estimates of pain and disability over time.

Results:

Data from 33 discrete cohorts (11 166 participants) were included in the review. The variance-weighted mean pain score (out of a maximum score of 100) was 52 (95% CI 48–57) at baseline, 23 (95% CI 21–25) at 6 weeks, 12 (95% CI 9–15) at 26 weeks and 6 (95% CI 3–10) at 52 weeks after the onset of pain for cohorts with acute pain. Among cohorts with persistent pain, the variance-weighted mean pain score (out of 100) was 51 (95% CI 44–59) at baseline, 33 (95% CI 29–38) at 6 weeks, 26 (95% CI 20–33) at 26 weeks and 23 (95% CI 16–30) at 52 weeks after the onset of pain. The course of disability outcomes was similar to the time course of pain outcomes in the acute pain cohorts, but the pain outcomes were slightly worse than disability outcomes in the persistent pain cohorts.

Interpretation:

Patients who presented with acute or persistent low-back pain improved markedly in the first six weeks. After that time improvement slowed. Low to moderate levels of pain and disability were still present at one year, especially in the cohorts with persistent pain.Low-back pain is a highly prevalent condition associated with work absenteeism, disability and large health care costs; however, there is still disagreement about prognosis. For example, the European guidelines for the management of low-back pain states that 90% of patients with acute low-back pain recover in six weeks.¹ In contrast, some well-conducted cohort studies show a less optimistic picture, providing short-term estimates of recovery ranging from 39% to 76%.^2,3 This wide range of estimates of prognosis is likely explained by differences in cohorts and definitions used to define the onset or conclusion of an episode of low-back pain. Because very different definitions of recovery are often used, it is difficult to obtain pooled estimates of recovery rates. Instead, it might be more useful to describe the clinical course of low-back pain in terms of expected changes in pain or disability over time.A recent systematic review⁴ summarized the prognostic factors for persistent disabling low-back pain but did not describe the clinical course. The only meta-analysis to investigate the clinical course of acute low-back pain was published in 2003.⁵ This review concluded that both pain and disability improve rapidly within weeks (mean reduction of 58% of initial scores in the first month) and recurrences are common. A limitation of this review was that, although it retrieved 15 studies, only 5 were cohort studies; the remaining 10 were randomized controlled trials. Randomized trials often have narrow inclusion criteria and low rates of participation, which make them less suitable for inferring prognosis. The best design to describe the prognosis of a condition is a cohort study enrolling a representative sample of incident cases (i.e., by including patients at a similar early point in their condition).^6,7 Such studies are known as inception cohort studies. To the best of our knowledge, no review has yet investigated the clinical course of pain and disability among people with persistent low-back pain (subacute and chronic). Thus, the prognosis for people with persistent low-back pain is still uncertain.The aim of our study was to systematically review the clinical course of pain and disability in patients with acute and persistent low-back pain. We included only inception cohort studies. Our second aim was to investigate whether pain and disability have similar courses.     

<Emphasis Type="Italic">Cabruca</Emphasis> agroforests in southern Bahia,Brazil: tree component,management practices and tree species conservation

In southern Bahia, Brazil, cabrucas are the traditional agroforests in which cacao trees are planted under thinned-out native forests. To analyze the role of cabrucas in tree species conservation, we inventoried the non-cocoa trees in 1.0 ha plots of cabruca in 16 cocoa farms and compared our results with a similar survey undertaken in the early 1960s in the same region to analyze the long term changes. We also interviewed 160 cocoa farmers to investigate their preferences for species and the main practices used in managing shade trees. The cabrucas showed high levels of tree diversity for an agroforestry system (Shannon index ranging from 2.21 to 3.52) and also high variation in structure and composition among the different farms. Forest specialist trees accounted for most species (63.9%) in the survey and were among the species most preferred by the farmers, although we found evidence that some of these trees are gradually being replaced by other species. Our results indicate that cabrucas are poor substitutes for undisturbed forests in terms of tree species richness, but their presence in human-altered landscapes is of utmost importance to the conservation of forest tree species as they increase overall heterogeneity and may serve as ecological corridors, additional habitats, and buffer zones.     

Interaction between IRF6 and TGFA Genes Contribute to the Risk of Nonsyndromic Cleft Lip/Palate

Previous evidence from tooth agenesis studies suggested IRF6 and TGFA interact. Since tooth agenesis is commonly found in individuals with cleft lip/palate (CL/P), we used four large cohorts to evaluate if IRF6 and TGFA interaction contributes to CL/P. Markers within and flanking IRF6 and TGFA genes were tested using Taqman or SYBR green chemistries for case-control analyses in 1,000 Brazilian individuals. We looked for evidence of gene-gene interaction between IRF6 and TGFA by testing if markers associated with CL/P were overtransmitted together in the case-control Brazilian dataset and in the additional family datasets. Genotypes for an additional 142 case-parent trios from South America drawn from the Latin American Collaborative Study of Congenital Malformations (ECLAMC), 154 cases from Latvia, and 8,717 individuals from several cohorts were available for replication of tests for interaction. Tgfa and Irf6 expression at critical stages during palatogenesis was analyzed in wild type and Irf6 knockout mice. Markers in and near IRF6 and TGFA were associated with CL/P in the Brazilian cohort (p<10⁻⁶). IRF6 was also associated with cleft palate (CP) with impaction of permanent teeth (p<10⁻⁶). Statistical evidence of interaction between IRF6 and TGFA was found in all data sets (p = 0.013 for Brazilians; p = 0.046 for ECLAMC; p = 10⁻⁶ for Latvians, and p = 0.003 for the 8,717 individuals). Tgfa was not expressed in the palatal tissues of Irf6 knockout mice. IRF6 and TGFA contribute to subsets of CL/P with specific dental anomalies. Moreover, this potential IRF6-TGFA interaction may account for as much as 1% to 10% of CL/P cases. The Irf6-knockout model further supports the evidence of IRF6-TGFA interaction found in humans.     

Simultaneous determination of sulfamethoxazole and trimethoprim in biological fluids for high-throughput analysis: comparison of HPLC with ultraviolet and tandem mass spectrometric detection

The comparison of two methods based on online solid phase extraction-liquid chromatography with UV (SPE-LC-UV) or mass spectrometry detection (SPE-LC-MS/MS) for the simultaneous quantification of sulfamethoxazole (SMZ) and trimethoprim (TMP) is presented. The methods were validated and proved to be accurate. The analysis of standard samples for SMZ at concentrations of 0.5, 1.5, 25 and 50microg/mL demonstrated a relative standard deviation of less than 6% for both methods (n=18), while TMP samples at concentrations of 0.05, 0.15, 1.5 and 5.0microg/mL were analyzed with R.S.D. of less than 4% (n=18). The method with mass spectrometric detection was approximately six times more sensitive than the method with ultraviolet detection. The total run time for the SPE-LC-MS/MS was 2.5min per sample as opposed to 18.0min for the SPE-LC-UV method. The method with MS detection in comparison with UV detection proved to be more rugged and was successfully applied to pharmacokinetics studies.     

Effect of trypsin inhibitor from Crotalaria pallida seeds on Callosobruchus maculatus (cowpea weevil) and Ceratitis capitata (fruit fly)

A proteinaceous trypsin inhibitor was purified from Crotalaria pallida seeds by ammonium sulfate precipitation, affinity chromatography on immobilized trypsin-Sepharose and TCA precipitation. The trypsin inhibitor, named CpaTI, had M(r) of 32.5 kDa as determined by SDS-PAGE and was composed of two subunits with 27.7 and 5.6 kDa linked by disulfide bridges. CpaTI was stable at 50 degrees C and lost 40% of activity at 100 degrees C. CpaTI was also stable from pH 2 to 12 at 37 degrees C. CpaTI weakly inhibited chymotrypsin and elastase and its inhibition of papain, a cysteine proteinase, were indicative of its bi-functionality. CpaTI inhibited, in different degrees, digestive enzymes from Spodoptera frugiperda, Alabama argillacea, Plodiainterpunctella, Anthonomus grandis and Zabrotes subfasciatus guts. In vitro and in vivo susceptibility of Callosobruchus maculatus and Ceratitis capitata to CpaTI was evaluated. C. maculatus and C. capitata enzymes were strongly susceptible, 74.4+/-15.8% and 100.0+/-7.3%, respectively, to CpaTI. When CpaTI was added to artificial diets and offered to both insect larvae, the results showed that C. maculatus was more susceptible to CpaTI with an LD(50) of 3.0 and ED(50) of 2.17%. C. capitata larvae were more resistant to CpaTI, in disagreement with the in vitro effects. The larvae were more affected at lower concentrations, causing 27% mortality and 44.4% mass decrease. The action was constant at 2-4% (w/w) with 15% mortality and 38% mass decrease.     

Effects of preculture variability on clavulanic acid fermentation.

The production profile of clavulanic acid by Streptomyces clavuligerus was shown to be strongly dependent on inoculum activity. Two sets of fermentations (A and B) were investigated at industrial pilot-plant scale using complex media. Type A fermentations were inoculated using late exponential growth phase mycelia. Type B fermentations were inoculated using mycelia harvested at stationary phase. Productivities throughout type A fermentations were consistently higher than type B, reaching a maximum at about 70 h and then decaying to the same final productivities at 140 h of type B runs. Several scheduling alternatives, based on combinations of the two inocula types and different fermentation lengths, were compared in terms of the overall process economics (fermentation and downstream). An increase of ca. 22% on the overall process profit is predicted using late exponential growth phase inocula and a fermentation duration of only 96 h. A new operating strategy was thus proposed for inoculum production based on the control of preculture activity using off-gas analysis. This method ensures higher productivity and better batch-to-batch reproducibility of clavulanic acid fermentations than traditional methods based on constant age inocula.     

Peripheral glucose metabolism in patients with essential hypertension.

The present study was designed to determine the effect of essential hypertension on peripheral glucose metabolism during the postabsorptive state and after an oral glucose challenge. Ten normal subjects and nine patients with essential hypertension were studied after an overnight fast (12-14 h) and for 3 h after the ingestion of 75 g of glucose. Peripheral glucose metabolism was analyzed by the forearm technique to estimate muscle exchange of substrate combined with indirect calorimetry. Decreased forearm glucose uptake was observed in hypertensive patients compared to normal subjects (4.9+/-0.6 vs. 8.6+/-0.5 mmol x 100 ml forearm(-1) x 3 h(-1)) with diminished nonoxidative glucose metabolism (2.7+/-0.5 vs. 6.9+/-0.6 mmol x 100 ml forearm(-1) x 3 h(-1)). Muscle glucose oxidation did not differ significantly between groups. Both serum free fatty acid levels and lipid oxidation rates were similar in the normal subjects and the hypertensive patients, and declined in a similar fashion after glucose ingestion. Basal serum insulin levels did not differ significantly between normal and hypertensive patients, whereas the insulinemic response to glucose load was greater among the patients with essential hypertension. These data show that insulin resistance occurring in patients with essential hypertension is accompanied by impaired muscle glucose uptake and nonoxidative metabolism.