A course of psychotherapy for low back pain remains effective for at least three years, finds trial

A type of psychotherapy called cognitive functional therapy (CFT) is the first treatment for chronic disabling low back pain with good evidence that it can effectively reduce disability due to the pain for more than a year, finds a randomized controlled trial (RCT) published in The Lancet Rheumatology.

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A course of psychotherapy for low back pain remains effective for at least three years, finds trial

A type of psychotherapy called cognitive functional therapy (CFT) is the first treatment for chronic disabling low back pain with good evidence that it can effectively reduce disability due to the pain for more than a year, finds a randomized controlled trial (RCT) published in The Lancet Rheumatology.

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‘Healthocide’ coined to describe deliberate attacks on health care as acts of war

The deliberate destruction of health services and systems as an act of war should be termed “healthocide” and medical practitioners should call out and stand firm against this weaponization of health care, insists a thought-provoking commentary published in the open-access journal BMJ Global Health.

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‘Healthocide’ coined to describe deliberate attacks on health care as acts of war

The deliberate destruction of health services and systems as an act of war should be termed “healthocide” and medical practitioners should call out and stand firm against this weaponization of health care, insists a thought-provoking commentary published in the open-access journal BMJ Global Health.

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Childhood verbal abuse shows similar impact on adult mental health as physical abuse

Experiencing childhood verbal abuse shows a similar impact on adult mental health as physical abuse, suggests a large intergenerational study, published in the open access journal BMJ Open.

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Older, White Male Smokers at Higher Risk for Diabetic Foot Ulcers: Study

Researchers have identified that some subgroups of patients with diabetes, older males, smokers, and White ethnicity, are at significantly increased risk of developing diabetic foot ulcer disease (DFUD), a severe condition with a poorer five-year survival rate than most cancers. The study was published in Diabetes, Obesity & Metabolism by Safoora G. and colleagues. The research found that those with higher systolic blood pressure and a higher baseline HbA1c level were more likely to develop DFUD.

DFUD is a long-standing, life-changing diabetic complication that is frequently under-diagnosed with regard to its catastrophizing effects. Previously, almost all risk factor information was derived from small, clinic-based surveys that tended to be cross-sectional in design. The current study sought to address the deficit through the utilization of two large and independent English and Scottish diabetic cohorts, providing one of the largest analyses to date.

The research evaluated a combined total of 391,790 individuals with diabetes—131,042 from England via the Clinical Practice Research Datalink (CPRD), and 260,748 from Scotland via the Scottish Diabetes Research Network-National Diabetes Dataset (SDRN-NDS). The English cohort included primary and secondary care data, whereas the Scottish cohort utilized secondary care and foot clinic data.

Key Findings

Incidence of DFUD:

• In the English cohort, 4.7% of patients developed DFUD during a median follow-up of 4.3 years, representing an incidence rate of 9.0 per 1,000 person-years (95% CI: 8.8–9.2).

• In the Scottish cohort, 2.9% of patients developed DFUD during a median follow-up of 6.3 years, with an incidence rate of 4.4 per 1,000 person-years (95% CI: 4.3–4.5).

Common Risk Factors Identified in Both Populations:

• Age: The older patients had higher chances of developing DFUD.

• Sex: Males were more vulnerable.

• Ethnicity: Individuals of White ethnicity were having greater incidence rates.

• Lifestyle: Smokers were much more likely to develop DFUD.

• Clinical indicators: Greater systolic blood pressure and baseline HbA1c levels were strongly related with subsequent DFUD.

This study provides strong evidence to support the targeting of these high-risk groups in diabetes care programs. These findings can provide the impetus for more effective prevention strategies, lowering the life-changing costs of diabetic foot ulcer disease.

Reference:

Gharibzadeh S, Lee J, Highton P, Greenlaw N, Gillies C, Zaccardi F, Brennan A, Pollard DJ, Valabhji J, Game F, Stanley B, Leese G, Gray L, Tesfaye S, Webb D, Wild S, Shabnam S, Davies M, Khunti K, Petrie J, Gregg E. Risk factors for development of diabetic foot ulcer disease in two large contemporary UK cohorts. Diabetes Obes Metab. 2025 Jun 24. doi: 10.1111/dom.16519. Epub ahead of print. PMID: 40555701.

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One in Three Hospitalised Adult Tetanus Patients Die: Meta-Analysis Finds

China: A systematic review and meta-analysis published in BMJ Open has highlighted the alarming mortality rate among hospitalised adult patients with tetanus and identified key factors that significantly influence survival outcomes.

The study, conducted by Zhenlin Chen and colleagues from the Department of Emergency, Zhangzhou Affiliated Hospital of Fujian Medical University, analysed data from 22 observational studies comprising 1,618 adult patients admitted with tetanus between January 2000 and February 2024.

The study revealed the following findings:

  • The pooled analysis showed an overall mortality rate of 32% among hospitalised adult tetanus patients, highlighting the persistent threat of this preventable disease despite medical advancements.
  • The findings emphasize the need for enhanced preventive strategies, including better adult vaccination coverage and timely wound care education, particularly for individuals over 40 years of age.
  • Age ≥40 years was identified as a significant risk factor for mortality (RR = 1.89).
  • An incubation period of less than seven days was linked to higher mortality risk (RR = 2.10).
  • The onset of symptoms within two days increased the likelihood of death (RR = 2.06).
  • Severe disease, indicated by the Ablett classification ≥III, was strongly associated with mortality (RR = 3.40).
  • The presence of autonomic dysfunction was a major predictor of poor outcomes (RR = 4.84).
  • The need for mechanical ventilation significantly increased the mortality risk (RR = 2.46).
  • These identified factors can help clinicians in early risk assessment and implementing targeted management strategies to improve survival in hospitalised tetanus patients.

According to the authors, the meta-analysis is the first of its kind to systematically evaluate mortality and associated risk factors in hospitalised adults with tetanus. Data were extracted independently by two reviewers from four major databases—PubMed, Web of Science, The Cochrane Library, and Embase. Statistical heterogeneity was assessed using the I² statistic, with subgroup and meta-regression analyses performed to explore potential sources of variation among the studies.

While the study provides valuable insights, the authors acknowledged certain limitations. Only four databases were searched, which may have resulted in the exclusion of relevant studies. Additionally, both univariate and multivariate analyses were considered for risk factor extraction, and the small sample size for certain variables may have affected the robustness of the results. Differences in statistical methodologies across studies were also noted as a factor warranting cautious interpretation.

Despite these constraints, the findings carry significant clinical and public health implications. The high mortality rate reinforces the urgent need to strengthen tetanus control measures, particularly focusing on adult immunisation and early intervention for high-risk patients. The identification of specific risk factors provides a framework for targeted care, potentially reducing fatalities in hospitalised cases.

The researchers stress that further large-scale, multicentre prospective studies are necessary to validate these findings and provide more detailed clinical insights. Until then, prioritising vaccination coverage, improving awareness of wound care, and promptly identifying patients at elevated risk could serve as key strategies in reducing tetanus-related deaths among adults.

Reference:

Chen Z, Lin Z, Zhang W, et alMortality and risk factors in hospitalised adult patients with tetanus: a systematic review and meta-analysis. BMJ Open 2025;15:e101782. doi: 10.1136/bmjopen-2025-101782

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Improved Ejection Fraction in Heart Failure Tied to Better Outcomes, But Clinical Risks Remain: Study Finds

USA: A substantial portion of patients diagnosed with heart failure with reduced ejection fraction (HFrEF) go on to experience meaningful improvement in cardiac function, but they remain at notable clinical risk—emphasizing the continued need for guideline-directed medical therapy (GDMT). The findings stem from a large, retrospective cohort study published in JACC by Dr. Kyung H. Min and colleagues from Kaiser Permanente San Francisco Medical Center.

Analyzing electronic health data from 28,292 patients with newly diagnosed HFrEF between 2013 and 2022, the study revealed the following:

  • Around 31% of patients experienced significant improvement in left ventricular ejection fraction (LVEF), meeting the criteria for heart failure with improved ejection fraction (HFimpEF).
  • This improvement was defined as an absolute increase in LVEF of more than 10%, reaching above 40% within one year of diagnosis.
  • Patients with HFimpEF had lower rates of worsening heart failure events (17.4 per 100 person-years) compared to those with persistent HFrEF (34.1 per 100 person-years).
  • All-cause mortality was also lower in the HFimpEF group, at 5.7 versus 11.0 per 100 person-years.
  • Despite clinical improvements, HFimpEF did not equate to complete recovery, and the risk of adverse events remained.
  • Reducing or discontinuing guideline-directed medical therapy (GDMT) after improvement was associated with increased clinical risk.
  • A slight decline in the use of evidence-based therapies such as beta-blockers, RAAS inhibitors, and MRAs was observed after patients transitioned to HFimpEF.
  • Researchers cautioned that this drop in therapy use could negatively affect long-term outcomes if not carefully managed.

Accompanying the study, an editorial by Drs. Andrew S. Perry and Lynne W. Stevenson from Vanderbilt University Medical Center emphasized the evolving landscape of heart failure treatment. They noted that while many patients benefit from GDMT, the heterogeneity of heart failure means that standard therapies may not be adequate for all. “The improvement journey will hopefully include new lanes as GDMT continues to evolve beyond traditional triple therapy,” they wrote.

Perry and Stevenson also highlighted the limitations of focusing solely on ejection fraction as a measure of heart failure progression. “The imminent era of broad population data will hopefully guide integration of primary and secondary causes, therapeutic responses, and multidimensional surveillance beyond EF, to personalize regimens and improve prognosis along all journeys with HF,” they suggested.

Ultimately, the study highlights both the encouraging potential for heart function recovery and the persistent vulnerability of patients even after improvement. Continued adherence to and optimization of GDMT remains crucial in managing HFimpEF, as personalized approaches based on emerging data may shape the future of care.

Reference:

Min KH, Go AS, Lee K, et al. Guideline-directed medical therapy and outcomes among patients with heart failure with improved ejection fraction. JACC. 2025;86:338-350.

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Surgical Serenity: How to Help Kids Cope with Anesthesia Anxiety?

Anxiety during anesthesia induction in children is a significant concern, associated with various adverse outcomes, including behavioral issues and prolonged induction times. Approximately 50-67% of pediatric patients experience this anxiety, highlighting the necessity for effective management strategies. Nonpharmacological interventions, such as parental presence, psychological therapy, and virtual reality, have been proposed as alternatives to pharmacological methods like midazolam, which can have undesirable effects. However, the specific impacts of various nonpharmacological interventions remain ambiguous due to a scarcity of direct comparative studies.

Recent systematic review analyzed 34 randomized controlled trials (RCTs) involving 3,040 participants to compare the efficacy of different nonpharmacological interventions. A Bayesian network meta-analysis approach facilitated both direct and indirect comparisons, crucial given the lack of head-to-head trials. The primary outcomes measured included anxiety levels during induction, assessed using standardized scales such as the modified Yale Preoperative Anxiety Scale (mYPAS).

Results of Nonpharmacological Interventions

Results indicated that interventions combining parental presence with interactive distraction techniques (PDI-PPIA and IDI-PPIA) showed the highest efficacy in reducing anxiety during anesthesia induction, achieving statistical significance with standardized mean differences (SMD) of -1.94 and -1.83, respectively. In contrast, traditional parental presence interventions alone (PPIA) and other passive or interactive distractions were less effective, with SMDs ranging from -0.91 to -1.18. Notably, no interventions demonstrated a significant reduction in parental anxiety levels.

Quality Assessment of Studies

The meticulous quality assessment revealed a predominantly low to moderate risk of bias across studies, although some concerns were raised regarding outcome measurement, primarily due to observer blinding issues. Sensitivity analyses confirmed the primary findings, reinforcing the conclusion that specific nonpharmacological strategies provide effective means to mitigate preoperative anxiety in children. The analysis underscores the pressing need for future head-to-head trials to further delineate the comparative effectiveness of these strategies, particularly in diverse populations and settings. Subgroup analyses were constrained by limited data on intravenous versus inhalation induction methods, suggesting a vital area for future exploration. The findings advocate for the integration of tailored, family-centered interventions into clinical practice to enhance the overall perioperative experience for pediatric patients.

Key Points

– Anxiety prevalence during anesthesia induction in pediatric patients is significant, with 50-67% experiencing anxiety, leading to behavioral issues and prolonged induction times, necessitating effective management strategies.

– A systematic review of 34 randomized controlled trials (RCTs) involving 3,040 participants was conducted to evaluate the efficacy of various nonpharmacological interventions compared to traditional pharmacological methods.

– Bayesian network meta-analysis was utilized to facilitate both direct and indirect comparisons of interventions, with the primary outcome being anxiety levels during induction measured by standardized scales like the modified Yale Preoperative Anxiety Scale (mYPAS).

– Interventions combining parental presence with interactive distraction techniques (PDI-PPIA and IDI-PPIA) demonstrated the highest efficacy in reducing anxiety with significant standardized mean differences (SMDs) of -1.94 and -1.83, whereas traditional parental presence alone (PPIA) and other distraction methods showed lower efficacy (SMDs range from -0.91 to -1.18).

– Quality assessment of the included studies revealed a low to moderate risk of bias, with concerns primarily related to outcome measurement and observer blinding, though sensitivity analyses confirmed the robustness of the primary findings.

– The findings emphasize the necessity for future head-to-head trials to better understand the comparative effectiveness of nonpharmacological interventions, particularly in diverse populations, while advocating for family-centered strategies to improve the perioperative experience for pediatric patients.

Reference –

Yuanyuan Li et al. (2025). Nonpharmacological Interventions For Decreasing Anxiety During Anesthesia Induction In Children: A Systematic Review And Bayesian Network Meta-Analysis. *BMC Anesthesiology*, 25. https://doi.org/10.1186/s12871-025-03077-z.

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Even Mild CKD Elevates Infection Risk, Study Finds

Researchers have determined in a new study published in EClinicalMedicine that patients with chronic kidney disease (CKD), even at its earliest stages, have a substantially elevated risk of requiring hospitalization for serious infection. The results concluded that reduced kidney function and increased excretion of albumin in the urine are independently and stepwise related to increased risk of infection, even in individuals with only mildly decreased kidney function. The study was conducted by Junichi I. and colleagues.

In this large, meta-analysis, one of the Chronic Kidney Disease Prognosis Consortium (CKD-PC), data from 47 international cohorts with 1,246,912 participants were combined. The investigators compared estimated glomerular filtration rate using serum creatinine (eGFRcr) and urinary albumin-to-creatinine ratio (ACR) to determine the association of these biomarkers with infection-related hospitalization. Infections were infections of the respiratory, urinary, skin, gastrointestinal, genital, nervous, and cardiovascular tracts, and sepsis. Follow-up information was collected through December 31, 2019.

This analysis employed individual participant data from 1.2 million people in 47 cohorts worldwide, for which their eGFRcr and ACR were measured. Both the markers were analyzed as continuous and categorical markers. Acute infection hospitalization was monitored through discharge diagnostic codes, with follow-up censored in December 2019 or at cohort closure. Cox models of proportional hazards were employed to calculate the hazard ratios (HRs) for risk of infection associated with kidney function and with levels of albuminuria.

Key Findings

• Of more than 1.2 million participants, 170,864 persons (13.7%) were hospitalized for infections in follow-up.

• The overall rate of incidence (IR) was 22.0 per 1000 person-years (interquartile interval: 16.2–31.0).

• Relative to those with eGFRcr 90–104 ml/min/1.73 m² and ACR <10 mg/g:

• Patients with eGFRcr 60–89 had an HR of 1.09 (95% CI: 1.06–1.13)

• Individuals with eGFRcr 45–59 had an HR of 1.39 (95% CI: 1.34–1.45)

• ACR 10–29 mg/g was correlated with an HR of 1.40 (95% CI: 1.33–1.47)

• ACR 30–299 mg/g had an HR of 1.82 (95% CI: 1.72–1.92)

• Individuals with extremely high eGFRcr ≥105 ml/min/1.73 m² also had higher infection risk (HR: 1.22; 95% CI: 1.17–1.26)—a surprising result indicating non-linear relations at extreme levels.

• The highest risk was seen in those with both extremely low eGFRcr (<30 ml/min/1.73 m²) and elevated ACR (≥300 mg/g), with combined HR of 6.27 (95% CI: 5.70–6.90)—more than six times as high as the reference group.

• These trends were consistent regardless of the type of infection. For instance, HR of lower respiratory tract infections was 1.26 (95% CI: 1.22–1.30) per 15 ml/min/1.73 m² reduction in eGFRcr, and 1.48 (95% CI: 1.44–1.53) per 8-fold rise in ACR.

Risk of infection in CKD patients is significant, and this risk starts early in the progression of kidney impairment. The authors of the study concluded that both worsening kidney function and rising albuminuria are independent, additive predictors of hospitalization with infection. These results necessitate specific infection prevention measures not only in those with severe CKD but also in people in preceding stages of kidney disease.

Reference:

Ishigami, J., Surapaneni, A., Matsushita, K., Coresh, J., Grams, M. E., Ballew, S. H., Sang, Y., Stengel, B., Ärnlöv, J., Bell, S., Carrero, J.-J., Chang, A. R., Ciemins, E. L., Haynes, R., Ix, J., Kotsis, F., Lees, J. S., Pandit, K., Rao, P., … Surapaneni, A. (2025). Estimated glomerular filtration rate, albuminuria, and risk of infection: a collaborative meta-analysis of individual participant data. EClinicalMedicine, 86(103372), 103372.https://doi.org/10.1016/j.eclinm.2025.103372•

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