Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol

BACKGROUND: There is little evidence on differences across health care systems in choice and outcome of the treatment of chronic low back pain (CLBP) with spinal surgery and conservative treatment as the main options. At least six randomised controlled trials comparing these two options have been performed; they show conflicting results without clear-cut evidence for superior effectiveness of any of the evaluated interventions and could not address whether treatment effect varied across patient subgroups. Cost-utility analyses display inconsistent results when comparing surgical and conservative treatment of CLBP. Due to its higher feasibility, we chose to conduct a prospective observational cohort study. METHODS: This study aims to examine if1. Differences across health care systems result in different treatment outcomes of surgical and conservative treatment of CLBP2. Patient characteristics (work-related, psychological factors, etc.) and co-interventions (physiotherapy, cognitive behavioural therapy, return-to-work programs, etc.) modify the outcome of treatment for CLBP3. Cost-utility in terms of quality-adjusted life years differs between surgical and conservative treatment of CLBP.This study will recruit 1000 patients from orthopaedic spine units, rehabilitation centres, and pain clinics in Switzerland and New Zealand. Effectiveness will be measured by the Oswestry Disability Index (ODI) at baseline and after six months. The change in ODI will be the primary endpoint of this study.Multiple linear regression models will be used, with the change in ODI from baseline to six months as the dependent variable and the type of health care system, type of treatment, patient characteristics, and co-interventions as independent variables. Interactions will be incorporated between type of treatment and different co-interventions and patient characteristics. Cost-utility will be measured with an index based on EQol-5D in combination with cost data. CONCLUSION: This study will provide evidence if differences across health care systems in the outcome of treatment of CLBP exist. It will classify patients with CLBP into different clinical subgroups and help to identify specific target groups who might benefit from specific surgical or conservative interventions. Furthermore, cost-utility differences will be identified for different groups of patients with CLBP. Main results of this study should be replicated in future studies on CLBP.

Influence of manure scrapers on dairy cows in cubicle housing systems

Manure scrapers are widely used in dairy cow loose-housing systems. In order to evaluate the effects of the scrapers on the cows, we assessed their impact on the animals' cardiac activity, feeding behaviour, and the behavioural reactions of cows confronted with different types of scrapers. In part I of the study, we measured cardiac activity (mean R–R interval and RMSSD, a parameter of heart-rate variability) whilst observing the behaviour of 29 focal cows on three farms during situations with and without active manure scrapers. Lower RMSSD values were observed during scraping events while cows were either lying, standing or walking in the alleyway, standing completely in the lying cubicle, or standing half in the lying cubicle (P=0.03), but only tended to differ while directly confronted with the scraper (P=0.06). This indicates that dairy cows experienced at least some mild stress during manure-scraping events. In part II, the feeding behaviour of 12 cows on each of two farms was recorded by means of a jaw-movement sensor and compared between situations with the manure-scraping event following forage provision either within or outside the main daily feeding period (i.e. within 1 or after 2 h from forage provisioning, respectively). The duration of night-time feeding (P=0.049) and the number of feeding bouts (P=0.036) were higher when a manure-scraping event took place within the main daily feeding period, indicating that the cows' feeding behaviour had been disturbed. In part III, we observed the cows' behaviour on 15 farms during eight manure scraping events per farm, where each of five farms had one of three different scraper types. We assessed the cows' immediate reactions when confronted with the scraper. In addition, we recorded the number of animals present in the alleyways before and after the manure-scraping events. The more cows that were present in the alleyways before the scraping event, the lower the proportion of cows showing direct behavioural reactions both with (P=0.017) and without (P=0.028) scraper contact, and the higher the number of cows that left the alleyways (P<0.001). Scraper type did not influence the proportion of cows showing behavioural reactions. In conclusion, our results show that dairy cows perceive the manure-scraping event negatively in some situations, that feeding behaviour may be disturbed when scrapers are active during the main feeding period, and that cows avoid the scraper during crowded situations.

Asthma and obesity in children: current evidence and potential systems biology approaches.

Both obesity and asthma are highly prevalent, complex diseases modified by multiple factors. Genetic, developmental, lung mechanical, immunological and behavioural factors have all been suggested as playing a causal role between the two entities; however, their complex mechanistic interactions are still poorly understood and evidence of causality in children remains scant. Equally lacking is evidence of effective treatment strategies, despite the fact that imbalances at vulnerable phases in childhood can impact long-term health. This review is targeted at both clinicians frequently faced with the dilemma of how to investigate and treat the obese asthmatic child and researchers interested in the topic. Highlighting the breadth of the spectrum of factors involved, this review collates evidence regarding the investigation and treatment of asthma in obese children, particularly in comparison with current approaches in 'difficult-to-treat' childhood asthma. Finally, the authors propose hypotheses for future research from a systems-based perspective.