Inger B. Scheel

The political origins of health inequity: prospects for change

Ole Petter Ottersen, Jashodhara Dasgupta, Chantal Blouin, Paulo Buss, Virasakdi Chongsuvivatwong, Julio Frenk, Sakiko Fukuda-Parr, Bience P Gawanas, Rita Giacaman, John Gyapong, Jennifer Leaning, Michael Marmot, Desmond McNeill, Gertrude I Mongella, Nkosana Moyo, Sigrun Møgedal, Ayanda Ntsaluba, Gorik Ooms, Espen Bjertness, Ann Louise Lie, Suerie Moon, Sidsel Roalkvam, Kristin I Sandberg, Inger B Scheel

Effect of Glucosamine on Pain-Related Disability in Patients With Chronic Low Back Pain and Degenerative Lumbar Osteoarthritis: A Randomized Controlled Trial

CONTEXT Chronic low back pain (LBP) with degenerative lumbar osteoarthritis (OA) is widespread in the adult population. Although glucosamine is increasingly used by patients with chronic LBP, little is known about its effect in this setting. OBJECTIVE To investigate the effect of glucosamine in patients with chronic LBP and degenerative lumbar OA. DESIGN, SETTING, AND PARTICIPANTS A double-blind, randomized, placebo-controlled trial conducted at Oslo University Hospital Outpatient Clinic, Oslo, Norway, with 250 patients older than 25 years of age with chronic LBP (>6 months) and degenerative lumbar OA. INTERVENTIONS Daily intake of 1500 mg of oral glucosamine (n = 125) or placebo (n = 125) for 6 months, with assessment of effect after the 6-month intervention period and at 1 year (6 months postintervention). MAIN OUTCOME MEASURES The primary outcome was pain-related disability measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity, and the quality-of-life EuroQol-5 Dimensions (EQ-5D) instrument. Data collection occurred during the intervention period at baseline, 6 weeks, 3 and 6 months, and again 6 months following the intervention at 1 year. Group differences were analyzed using linear mixed models analysis. RESULTS At baseline, mean RMDQ scores were 9.2 (95% confidence interval [CI], 8.4-10.0) for glucosamine and 9.7 (95% CI, 8.9-10.5) for the placebo group (P = .37). At 6 months, the mean RMDQ score was the same for the glucosamine and placebo groups (5.0; 95% CI, 4.2-5.8). At 1 year, the mean RMDQ scores were 4.8 (95% CI, 3.9-5.6) for glucosamine and 5.5 (95% CI, 4.7-6.4) for the placebo group. No statistically significant difference in change between groups was found when assessed after the 6-month intervention period and at 1 year: RMDQ (P = .72), LBP at rest (P = .91), LBP during activity (P = .97), and quality-of-life EQ-5D (P = .20). Mild adverse events were reported in 40 patients in the glucosamine group and 46 in the placebo group (P = .48). CONCLUSIONS Among patients with chronic LBP and degenerative lumbar OA, 6-month treatment with oral glucosamine compared with placebo did not result in reduced pain-related disability after the 6-month intervention and after 1-year follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00404079.

Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology.

Objectives  Lay health workers (LHWs) are used in many settings to increase immunisation uptake among children. However, little is known about the effectiveness of these interventions. The objective of this review was to assess the effects of LHW interventions on childhood immunisation uptake.

Prognostic Factors of Prolonged Disability in Patients With Chronic Low Back Pain and Lumbar Degeneration in Primary Care: A Cohort Study

Study Design. A cohort study with 1-year follow-up. Objective. To identify prognostic factors in patients with chronic nonspecific low back pain (LBP). Summary of Background Data. The factors (e.g., sociodemographical, low back–related, radiological, and biological) associated with persistent pain and disability for patients with chronic nonspecific LBP are uncertain. Furthermore, sparse information exists about the relationship between biological factors like impaired fasting glucose tolerance and chronic nonspecific LBP. Methods. The participants consisted of 250 patients with nonspecific LBP of more than 6 months duration and degenerative lumbar osteoarthritis. The patients were originally recruited for a randomized controlled trial from the clinics of general practitioners, physiotherapists, and chiropractors. Potential predictors were evaluated at baseline. The outcome was absolute level of pain-related disability (Roland-Morris Disability Questionnaire [RMDQ]) at 1 year. The association between potential prognostic factors and the outcome was analyzed with multivariate linear backward regression. Results. At baseline and 1 year, the RMDQ scores were 9.5 and 5.1 points, respectively. Mean (SD) baseline values for body mass index (BMI), EuroQol (EQ)-index, EQ–visual analogue scale were 25.4 (4.3), 0.60 (0.3), and 61.2 (20.8), respectively. Higher pain-related disability levels (1-year RMDQ score) were associated with 6.1 mmol/L or more fasting glucose level at baseline (&bgr;, 3.7; 95% confidence interval [CI], 1.2–6.1; P = 0.00), baseline pain-related disability (&bgr; 0.2; 95% CI, 0.1–0.4; P = 0.00), BMI (&bgr;, 0.2; 95% CI, 0.1–0.3; P < 0.03), EQ-index (&bgr;, −4.5; 95% CI, 6.9 to 2.1; P = 0.00), and EQ–visual analogue scale (&bgr;, 0.3; 95% CI, −0.6 to −0.0; P = 0.03). However, a limited number of patients had 6.1 mmol/L or more of fasting glucose level at baseline (13/250 patients). The imaging findings, modic changes, and high intensity zones had no predictive ability. Conclusion. Increased pain-related disability at 1 year was seen in patients with impaired fasting glucose tolerance, greater pain-related disability, higher BMI, and lower quality of life at baseline.

Nonrandomized studies are not always found even when selection criteria for health systems intervention reviews include them: a methodological study

OBJECTIVE Systematic reviews within the Cochrane Effective Practice and Organisation of Care Group (EPOC) can include both randomized and nonrandomized study designs. We explored how many EPOC reviews consider and identify nonrandomized studies, and whether the proportion of nonrandomized studies identified is linked to the review topic. STUDY DESIGN AND SETTING We recorded the study designs considered in 65 EPOC reviews. For reviews that considered nonrandomized studies, we calculated the proportion of identified studies that were nonrandomized and explored whether there were differences in the proportion of nonrandomized studies according to the review topic. RESULTS Fifty-one (78.5%) reviews considered nonrandomized studies. Forty-six of these reviews found nonrandomized studies, but the proportion varied a great deal (median, 33%; interquartile range, 25--50%). Reviews of health care delivery interventions had lower proportions of nonrandomized studies than those of financial and governance interventions. CONCLUSION Most EPOC reviews consider nonrandomized studies, but the degree to which they find them varies. As nonrandomized studies are believed to be at higher risk of bias and their inclusion entails a considerable effort, review authors should consider whether the benefits justify the inclusion of these designs. Research should explore whether it is more useful to consider nonrandomized studies in reviews of some intervention types than others.

WHICH ROLAND-MORRIS DISABILITy QUESTIONNAIRE? RASCH ANALySIS Of fOUR DIffERENT vERSIONS TESTED IN A NORWEGIAN POPULATION

BACKGROUND The Roland-Morris Disability Questionnaire (RDQ) is one of the most frequently used and recommended outcome measures for patients with low back pain. OBJECTIVE To examine the fit of data from 4 different versions of the RDQ to a Rasch model in a Norwegian sample of patients with chronic low back pain and degenerative lumbar osteoarthritis. METHODS Patients with chronic low back pain and degenerative lumbar osteoarthritis completed the RDQ prior to treatment in a secondary healthcare clinic. Data were analysed using a dichotomous Rasch model. RESULTS Of 250 included patients, 243 patients with a mean age of 48.5 years completed all 24 items of the RDQ. None of the 4 RDQ versions (the original 24-item, the 18-item versions of Williams and Stratford, and the 11-item of Stroud) were a unidimensional measure of disability due to low back pain. Items 3 and 23 were redundant and items 13 and 18 did not fit the Rasch model. Several items showed differential item functioning, indicating that the items performed differently in subgroups of the sample. CONCLUSION In the absence of consistent findings across studies that have evaluated the RDQ by Rasch analysis, caution should be exercised in the development and application of alternative versions of the RDQ.

No effect of 6-month intake of glucosamine sulfate on Modic changes or high intensity zones in the lumbar spine: sub-group analysis of a randomized controlled trial

BackgroundThe underlying pathology and natural course of Modic changes (MC) in the vertebral body marrow and high intensity zones (HIZs) in the annulus fibrosus is not completely clarified. These findings on magnetic resonance imaging (MRI) have initiated different treatments with little or unclear effect. In a randomized trial (n = 250), glucosamine sulfate (GS) had no effect on low back pain related disability. GS could still have an effect on MC and HIZ. In this sub-study, 45 patients from the trial who had MC and/or HIZ at pre-treatment underwent follow-up MRI. The aim was to examine the course of MC and HIZ and to compare this course between groups treated with 6-month intake of oral GS versus placebo.ResultsOf 141 pre-treatment MC in 42 (of 45) patients, 29 (20.6%) MC in 18 patients had altered type and 14 MC in 9 patients had altered size (decreased for 1 MC) 6-18 months later: odds ratio (OR) for type vs. size alterations 4.0; 95% confidence interval (CI) 1.2-17.7. No MC resolved. HIZ vanished from 3 of 23 discs in 3 of 21 patients with pre-treatment HIZ. Ten new MC (all type I or I/II) occurred in 8 patients and 2 new HIZs in 2 patients. The GS group (n = 19) and placebo group (n = 26) did not differ in proportions of MC with decreased (OR 1.6; 95% CI 0.4-6.1) or increased type I dominance at follow-up (OR placebo:GS 2.4; 95% CI 0.6-9.7), or with increased size (OR 1.0; 95% CI 0.2-4.7). HIZ vanished from 1 of 8 discs in 1 of 8 patients in the GS group vs. 2 of 15 discs in 2 of 13 patients in the placebo group (OR 0.8; 95% CI 0.02-12.2).ConclusionsIn this sub-group analysis of a placebo-controlled trial, the effect of GS on MC and HIZs was no different from the effect of the placebo intervention. MC and HIZs remained mostly unchanged during the 6-18 months study period. Some short term changes did occur and MC more often altered type than size.Trial registrationNCT00404079 at http://www.clinicaltrial.gov.

Commission on Global Governance for Health: just another report? – Authors' reply

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Effect of Oral Glucosamine on Pain-Related Disability in Patients With Chronic Low Back Pain

Financial Disclosures:Dr Cooper-DeHoff reported receiving research funding from Abbott Laboratories during the conduct of INVEST and currently receiving funding from the National Institutes of Health. Dr Pepine reported receiving research grants from the National Heart, Lung, and Blood Institute (NHLBI), Abbott Laboratories, Baxter, Pfizer, GlaxoSmithKline, and Bioheart Inc; serving as consultant for Abbott Laboratories, Forest Laboratories, Novartis/Cleveland Clinic, NicOx, Angloblast, Sanofi-Aventis, NHLBI, National Institutes of Health, Medtelligence, and SLACK Inc; and receiving unrestricted educational grants from AstraZeneca, AtCor Medical Inc, Daiichi Sankyo Inc, Eli Lilly, Pfizer Inc, Sanofi-Aventis, and Schering-Plough. No other disclosures were reported.