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ObjectivesChronic diseases, including back pain, result in significant patient morbidity and societal burden. Overall improvement in physical fitness is recommended for prevention and treatment. Walking is a convenient modality for achieving initial gains. Our objective was to determine whether neighbourhood walkability, acting as a surrogate measure of physical fitness, was associated with the presence of chronic disease.MethodsWe conducted a cross-sectional study of prospectively collected data from a prior randomized cohort study of 227 patients referred for tertiary assessment of chronic back pain in Ottawa, ON, Canada. The Charlson Comorbidity Index (CCI) was calculated from patient-completed questionnaires and medical record review. Using patients’ postal codes, neighbourhood walkability was determined using the Walk Score, which awards points based on the distance to the closest amenities, yielding a score from 0 to 100 (0-50: car-dependent; 50-100: walkable).ResultsBased on the Walk Score, 134 patients lived in car-dependent neighborhoods and 93 lived in walkable neighborhoods. A multivariate logistic regression model, adjusted for age, gender, rural postal code, body mass index, smoking, median household income, percent employment, pain, and disability, demonstrated an adjusted odds ratio of 2.75 (95% confidence interval, 1.16 to 6.53) times higher prevalence for having a chronic disease for patients living in a car-dependent neighborhood. There was also a significant dose-related association (p=0.01; Mantel-Haenszel chi-square=6.4) between living in car-dependent neighbourhoods and more severe CCI scores.ConclusionsOur findings suggest that advocating for improved neighbourhood planning to permit greater walkability may help offset the burden of chronic disease.

BACKGROUND Psychogenic purpura (PP) is an idiopathic psychodermatologic condition of recurrent, painful purpura precipitated by psychological stress predominantly affecting young females. Little consensus on the diagnostic guidelines for this rare condition exists, often resulting in costly, unnecessary, and stressful investigations as well as prolonged hospital admissions. OBJECTIVE With this first up-to-date systematic review of 134 cases of PP in over a decade, we aim to thoroughly investigate the diagnostic strategy and treatment regimens used in the last decade. With a prompter diagnosis, patient stress and nosocomial ecchymoses can be minimized and treatment can be expedited. METHODS A literature review of four databases (PubMed, OVID Embase, OVID Medline and Web of Science databases) yielded 46 full-text articles, which were reviewed and extracted by two independent reviewers. RESULTS We analyzed a total of 134 cases, consisting largely of females (N=125) with purpura on the upper (76.9%, N=103) or lower limbs (83.6%, N=112). Apart from a paresthesia prodrome, patients commonly experienced headache, malaise, and arthralgia or myalgia. 70.1% of patients (N=95) reported a physiological or psychological stressor or psychiatric diagnosis prior to the development of the purpura. Laboratory testing almost always revealed unremarkable results. The intradermal washed autoerythrocyte sensitization test was positive in 97.7% (N=42) of cases. Histopathology biopsy findings commonly revealed dermal erythrodiapedesis or hemorrhage (N=34) and perivascular inflammatory infiltrates (N=17). 41.8% of patients (N=56) received a novel psychiatric diagnosis, with depression being the most common (56%, N=40). In both patients with or without a novel psychiatric diagnosing, observation, counselling or support, treatment with antidepressants (i.e., SSRIs), and psychotherapy (i.e., cognitive behaviour therapy) prevailed in resolution of the purpura. CONCLUSIONS Due to the unclear etiology and infrequent presentation of this condition, it remains a diagnosis of exclusion based on clinical suspicion evaluating presence of stressors or psychiatric co-morbidities and exclusion of systemic conditions. Clinical confirmation can be sought through a positive autoerythrocyte sedimentation test, characteristic histopathology findings and remission of purpura following psychiatric treatment.

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