Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion.
Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature.
All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists.
Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively.
The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the ‘meso’ level of a whole systems approach.
It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways.
Although substantial progress in the treatment of stable angina pectoris (sAP) has been made, little is known about the functional status and quality of life (QoL) of patients in different healthcare systems.
We undertook a survey using the Seattle Angina Questionnaire (SAQ) (five domains scored form 0—worst assessment to 100—best assessment) to assess symptoms, QoL (including limitation of activities), demographics, geographic distribution and individual disease data in patients with stable coronary artery disease in Austrian cardiology practices.
A total of 660 patients with sAP with a mean age of 69.2 years were included. SAQ scores were 67.5±24.4 for physical limitation, 65.5±26.6 for angina stability, 79.3±23.2 for angina frequency, 86.3±16.2 for treatment satisfaction and 63.7±24.2 for overall QoL. Multiple regression identified male gender, but also female gender, Eastern Austrian residence and high body mass index as predictive factors for SAQ scoring. A total of 35.6% of the patients reported at least one desirable activity that was limited through AP symptoms.
Activity and QoL assessments are in accordance with published literature: The number and the diversity of desired activities indicate the need to focus on patient’s individual activity level to improve symptom management.
Immunological factors play important roles in the occurrence of hypertrophic scars. Imiquimod can be used as an immunosuppressive agent to regulate the function of T‐helper (Th) cell subsets Th1 and Th2. In this article, we explored the impact of imiquimod on scar hyperplasia through Th cells. A rabbit ear hypertrophic scar model was built. Four round wounds were cut in each rabbit's ears ventrally with a diameter of 1 cm and bilateral symmetry. All the right ear wounds were treated with 5% imiquimod cream. The blank control group contained all the left ear wounds, which were treated with Vaseline ointment at the same time. Haematoxylin and eosin and Masson staining showed that imiquimod collagen deposition was significantly reduced compared with the control group, scar index (SEI) showed that the proliferative degree reached its peak on the 28th day after operation in blank group, and the degree of hyperplasia was significantly higher than that of the imiquimod group (P < .05). Real‐time Polymerase chain reaction results showed that the imiquimod induced the expression of Th2 cell‐related chemokines CCL2, CCL3, CCL5, CCL7, and CCL13 at each time point, which were significantly lower than that of the blank control group, and the expressions of Th1 cell‐associated chemokines CXCL10 and CXCL12 at each time point was significantly higher than the blank control group (P < .05). Imiquimod can be used to regulate the expression of Th1 and Th2 cell‐associated chemokines to control scar hyperplasia.
To investigate the relationship between gay app use and HIV testing among men who have sex with men (MSM).
Serial cross-sectional study.
A newly well-developed city in China.
4935 MSM were recruited through offline sampling methods from 2015 to 2017.
The primary outcome is the difference in HIV testing between app and non-app users.
2872 (58.2%) and 2159 (43.7%) participated MSM had been tested for HIV within lifetime and the past year, respectively. Compared with non-app-using MSM, app-using MSM had a significantly higher prevalence of HIV testing within lifetime (adjusted OR (AOR): 1.48, 95% CI 1.27 to 1.72) and the past year (AOR: 1.36, 95% CI 1.18 to 1.57). App-using MSM were more likely to take an HIV test at the Centers for Disease Control and Prevention (AOR: 1.48, 95% CI 1.24 to 1.76) and community-based organisations (AOR: 1.71, 95% CI 1.44 to 2.03), but less often at gay venues (AOR: 0.49, 95% CI 0.37 to 0.63). Meanwhile, app-using MSM were more likely to take self-testing (AOR: 1.61, 95% CI 1.21 to 2.14). Predictors of HIV testing in the past year were: having an education level of college or higher (AOR: 1.29, 95% CI 1.01 to 1.65), being self-identified as a homosexual (AOR: 1.23, 95% CI 1.02 to 1.46), being recruited through clinic-based sampling (AOR: 1.30, 95% CI 1.06 to 1.60), using gay app (AOR: 1.49, 95% CI 1.21 to 1.83), engaging in group sex (AOR: 1.64, 95% CI 1.23 to 2.19), having received HIV-related service (AOR: 5.49, 95% CI 4.57 to 6.60), having a high level of HIV-related knowledge (AOR: 1.33, 95% CI 1.10 to 1.61) and high-risk perception (AOR: 2.95, 95% CI 1.40 to 6.23).
Gay app use was significantly associated with increased HIV testing among MSM hard to reach by traditional outreach. Therefore, it is imperative to expand HIV testing among non-app-using MSM. Continued efforts, innovative strategies and increased resource are highly needed to realise the first ‘90’ target.
To assess the prevalence and factors associated with fatigue in the general population.
Population-based, cross-sectional survey performed between May 2014 and April 2017.
General population of the city of Lausanne, Switzerland.
2848 participants (53.2% women, age range 45–86 years).
Prevalence of fatigue the previous week, defined as a score of ≥4 using the Fatigue Severity Scale.
The prevalence of fatigue was 21.9% (95% CI 20.4% to 23.4%) in the total sample. On bivariate analysis, participants with fatigue were younger, had a higher body mass index, a lower handgrip strength and lower ferritin levels. Participants with fatigue were more frequently women, had a lower educational level, presented more frequently with clinical insomnia, diabetes, anaemia, depression and low thyroid stimulating hormone (TSH) values, had a higher consumption of antihistamines, antidepressants and hypnotics, and rated more frequently their health as bad or very bad. Multivariable analysis showed that obesity (OR 1.40 (95% CI 1.03 to 1.91)), insomnia categories (p value for trend
In a population-based sample aged 45–86, fatigue was present in one out of five subjects. Regarding clinical factors, sleep disturbances such as insomnia and sleep apnoea should be assessed first, followed by depression. Regarding biological factors, anaemia should be ruled out, while screening for hypothyroidism is not recommended as a first step. Sleep complaints and fatigue in older subjects are not due to ageing and should prompt identification of the underlying cause.
Walking exercise is a recommended but underused treatment for intermittent claudication caused by peripheral arterial disease (PAD). Addressing the factors that influence walking exercise may increase patient uptake of and adherence to recommended walking. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of a physiotherapist-led behavioural change intervention on walking ability in adults with intermittent claudication (MOtivating Structured walking Activity in people with Intermittent Claudication (MOSAIC)) in comparison with usual care.
The MOSAIC trial is a two-arm, parallel-group, single-blind RCT. 192 adults will be recruited from six National Health Service Hospital Trusts. Inclusion criteria are: aged ≥50 years, PAD (Ankle Brachial Pressure Index ≤0.90, radiographic evidence or clinician report) and intermittent claudication (San Diego Claudication Questionnaire), being able and willing to participate and provide informed consent. The primary outcome is walking ability (6 min walking distance) at 3 months. Outcomes will be obtained at baseline, 3 and 6 months by an assessor blind to group allocation. Participants will be individually randomised (n=96/group, stratified by centre) to receive either MOSAIC or usual care by an independent randomisation service. Estimates of treatment effects will use an intention-to-treat framework implemented using multiple regression adjusted for baseline values and centre.
This trial has full ethical approval (London—Bloomsbury Research Ethics Committee (17/LO/0568)). It will be disseminated via patient forums, peer-reviewed publications and conference presentations.
The aim of this study was to conduct New Zealand-specific research to inform the design of a pulse oximetry screening strategy that ensures equity of access for the New Zealand maternity population. Equity is an important consideration as the test has the potential to benefit some populations and socioeconomic groups more than others.
New Zealand has an ethnically diverse population and a midwifery-led maternity service. One quaternary hospital and urban primary birthing unit (Region A), two regional hospitals (Region B) and three regional primary birthing units (Region C) from three Health Boards in New Zealand’s North Island participated in a feasibility study of pulse oximetry screening. Home births in these regions were also included.
There were 27 172 infants that satisfied the inclusion criteria; 16 644 (61%) were screened. The following data were collected for all well newborn infants with a gestation age ≥35 weeks: date of birth, ethnicity, type of maternity care provider, deprivation index and screening status (yes/no). The study was conducted over a 2-year period from May 2016 to April 2018.
Screening rates improved over time. Infants born in Region B (adjusted OR=0.75; 95% CI 0.67 to 0.83) and C (adjusted OR=0.29; 95% CI 0.27 to 0.32) were less likely to receive screening compared with those born in Region A. There were significant associations between screening rates and deprivation, ethnicity and maternity care provider. Lack of human and material resources prohibited universal access to screening.
A pulse oximetry screening programme that is sector-led is likely to perpetuate inequity. Screening programmes need to be designed so that resources are distributed in the way most likely to optimise health outcomes for infants born with cardiac anomalies.
This study was approved by the Health and Disability Ethics Committees of New Zealand (15/NTA/168).
Mother-to-child transmission (MTCT) is one of the main transmission routes of HIV, and the probability of MTCT can be dramatically reduced with comprehensive interventions. In southwest and western regions in China, the level of development in rural areas is relatively backwards and retains some original features, which also increases the difficulty of controlling infectious diseases. The Liangshan Prefecture started the prevention of MTCT programme in 2009. However, the implementation of the programme is not ideal, and the coverage of HIV testing is still low. Many Yi (local major ethnicity) women did not take antenatal care (ANC) and just gave birth to their babies at home for a variety of reasons.
Women with pregnancy history in the last 5 years were recruited from two townships based on cluster sampling. Face-to-face interviews were conducted to collect data. Descriptive analysis was performed to describe demographic characteristics, history of pregnancy and ANC uptake, knowledge of and attitudes towards ANC. Multivariable analysis was used to identify factors associated with uptake of ANC.
Among 538 women who completed the questionnaires, 77.9% knew that ANC was necessary during and after pregnancy. However, only 24.2% actually accessed ANC. Almost all women (94.6%) expressed their willingness to receive ANC for pregnancy but barriers towards actual uptake of ANC existed including shyness, lack of independence and unavoidable cost. Multivariate analysis showed that no experience of living outside of Zhaojue for more than 6 months, higher number of births, not knowing the necessity of ANC during pregnancy and not knowing the government’s promotion policies for ANC were associated with lack of ANC uptake.
Although ethnic minority women in rural Liangshan expressed strong intention to use ANC, actual uptake of ANC was low. Knowledge of ANC and HIV prevention for MTCT should be improved among this population, and efforts should be made to help them overcome barriers to accessing ANC.
To assess the efficacy and safety of dexmedetomidine (DEX) as an adjuvant to local wound infiltration anaesthesia in abdominal surgery, we conducted this meta‐analysis. First, the systematic search strategy was performed on PubMed, Embase, and Cochrane Library and five randomised controlled trials (RCTs) involving 294 patients were included. Then, the outcome data were extracted from the studies and their effect sizes were calculated using Review Manager 5. As a result, the addition of DEX significantly reduced visual analogy scores at 6 hours after surgery (mean difference = −0.53[−0.82, −0.25], P < .001), 12 hours after surgery (mean difference = −0.39 [−0.73, −0.05]; P = .03), and 24 hours after surgery (mean difference = −0.20 [−0.29, −0.11], P < .001) and reduced total analgesic consumption within 24 hours after surgery (mean difference = −4.92 [−9.00, −0.84]; P = .02) compared with placebo groups. However, there was no difference in the incidence of postoperative nausea and vomiting (risk ratio = 0.68 [0.41, 1.14]; P = .14). In summary, DEX as a local anaesthetic adjuvant added for local wound infiltration anaesthesia in abdominal surgery could reduce visual analogy scores and postoperative analgesic consumption without changing incidence of postoperative nausea and vomiting.
We demonstrate sodium pyruvate (NaPy) pre‐treatment as a successful approach for pressure ulcer (PU) prevention by averting their aetiological origin—cell‐level damage and death by large, sustained mechanical loads. We evaluated the NaPy pre‐treatment effect on permeability changes in the cell's plasma membrane (PM) following application of in vitro damaging‐level strains. Fibroblasts or myoblasts, respectively, models for superficial or deep‐tissue damage were grown in 0 or 1 mM NaPy, emulating typical physiological or cell culture conditions. Cells were pre‐treated for 4 hours with 0 to 5 mM NaPy prior to 3‐hour sustained, damaging‐level loads (12% strain). PM permeability was quantified by the cell uptake of small (4 kDa), fluorescent dextran compared with unstrained control using fluorescence‐activated cell sorting (FACS). Pre‐treatment with 1 mM, and especially 5 mM, NaPy significantly reduces damage to PM integrity. Long‐term NaPy pre‐exposure can improve protective treatment, affecting fibroblasts and myoblasts differently. Pre‐treating with NaPy, a natural cell metabolite, allows cells under damaging‐level mechanical loads to maintain their PM integrity, that is, to avoid loss of homeostasis and inevitable, eventual cell death, by preventing initial, microscale stages of PU formation. This pre‐treatment may be applied prior to planned periods of immobility, for example, planned surgery or transport, to prolong safe time in a position by preventing initial cell damage that can cascade and lead to PU formation.
by Jonas Bochem, Henning Zelba, Teresa Amaral, Janine Spreuer, Daniel Soffel, Thomas Eigentler, Nikolaus Benjamin Wagner, Ugur Uslu, Patrick Terheyden, Friedegund Meier, Claus Garbe, Graham Pawelec, Benjamin Weide, Kilian Wistuba-HamprechtImmune checkpoint blockade with anti-PD-1 antibodies is showing great promise for patients with metastatic melanoma and other malignancies, but despite good responses by some patients who achieve partial or complete regression, many others still do not respond. Here, we sought peripheral blood T-cell biomarker candidates predicting treatment outcome in 75 stage IV melanoma patients treated with anti-PD-1 antibodies. We investigated associations with clinical response, progression-free survival (PFS) and overall survival (OS). Univariate analysis of potential biological confounders and known biomarkers, and a multivariate model, was used to determine statistical independence of associations between candidate biomarkers and clinical outcomes. We found that a lower than median frequency of peripheral PD-1+CD56+ T-cells was associated with longer OS (p = 0.004), PFS (p = 0.041) and superior clinical benefit (p = 0.009). However, neither frequencies of CD56-CD4+ nor CD56-CD8+ T-cells, nor of the PD-1+ fraction within the CD4 or CD8 subsets was associated with clinical outcome. In a multivariate model with known confounders and biomarkers only the M-category (HR, 3.11; p = 0.007) and the frequency of PD-1+CD56+ T-cells (HR, 2.39; p = 0.028) were identified as independent predictive factors for clinical outcome under PD-1 blockade. Thus, a lower than median frequency of peripheral blood PD-1+CD56+ T-cells prior to starting anti-PD-1 checkpoint blockade is associated with superior clinical response, longer PFS and OS of stage IV melanoma patients.
To clarify gender differences in the demographic variables and infertility problems associated with depression among men and women undergoing infertility treatment.
A cross‐sectional study.
We surveyed 380 women and 360 men undergoing infertility treatment at the reproductive medicine center of a hospital in China's Ningxia Province from March ‐ September 2016.
For women, ethnicity, the number of clinic visits, social concern and sexual concern were factors linked with depression symptoms. For men, treatment cost pressure and social concern were significantly associated with depression symptoms.
Psychological counseling and intervention programs should be integrated into in‐vitro fertilization treatments and interventions should be targeted based on gender differences.
This article is protected by copyright. All rights reserved.
To explore whether the risk of peripheral venous catheters failure remained constant throughout catheter use in adult patients.
Peripheral venous catheters, widely used in adult patients, may have a critical threshold dwell time associated with increased risk of catheter failure.
Prospective, observational study. We have complied with the STROBE Checklist of items.
This study was conducted from July to October 2018 in Hunan, China. Data on patient factors, catheter factors, and catheter failure events were collected. Poisson regression was used to assess the effect of catheter dwell time on catheter failure while adjusting for other variables.
A total of 1477 patients were included in the analysis. There were 854 cases (57.8%) of catheter failure. The median dwell time to catheter failure was 52 h (interquartile range: 36–73 h). The incidence rate of catheter failure significantly increased by 1.1%/h in the first 38 h after catheter insertion. From 39–149 h, the incidence rate significantly decreased, and at >149 h, there was no significant change in the incidence rate. Meanwhile, factors like vascular quality and infused drugs showed having an impact on catheter failure events.
The risk of catheter failure may not remain constant throughout the dwell time. The results suggest that nurses should assess the insertion site frequently in the first 38 h.
The significant increase in the risk of catheter failure per hour may warrant close and frequent inspection of insertion site during the first 38 hours.
To establish an index system for evaluation of undergraduate nursing student innovation ability.
An index system for evaluation of undergraduate nursing student innovation ability has not been established.
A three‐round Delphi survey sought opinions from experts about the index system for evaluation of undergraduate nursing student innovation ability.
A Delphi survey was used for the study of 19 experts from nursing education, clinical nursing and health management. The consistency of consultation results formed the basis for determining the rounds of consultation. With the importance of consulting experts in the last round, we established the judgment matrix using yaahp7.5 software and the analytic hierarchy process, and determined the weight coefficient of each index. A modified recommendation for the Conducting and Reporting of Delphi studies (CREDES) was used to guide this study.
Nineteen experts from 10 nursing colleges and nine third‐level first‐class hospitals in seven domestic provinces/municipalities were included in this study. The index system was divided into primary, secondary and tertiary levels. Consensus was reached on three primary indicators (“spirit”, “ability” and “achievement”), nine secondary indicators and 28 tertiary indicators.
A unified and hierarchical quality assessment index framework for nursing undergraduate creative ability was established. The framework should be further tested and improved in practice.
Nursing students are the main force behind clinical nursing in the future. An innovative approach to skill acquisition and application could enhance the student nurse experience. The innovative ability of nursing students is important for identification of education strategies that be implemented to better support those individuals. Furthermore, the construction of the index system is helpful for evaluation of the innovation ability of nursing students that are required to better meet the needs of clinical nursing work in the future.
by Zoe White, Nadia Milad, Arash Y. Tehrani, William Wei-Han Chen, Graham Donen, Stephanie L. Sellers, Pascal BernatchezThere is no cure or beneficial management option for Limb-Girdle muscular dystrophy (MD) type 2B (LGMD2B). Losartan, a blood pressure (BP) lowering angiotensin II (AngII) receptor type 1 (ATR1) blocker (ARB) with unique anti-transforming growth factor-β (TGF-β) properties, can protect muscles in various types of MD such as Duchenne MD, suggesting a potential benefit for LGMD2B patients. Herein, we show in a mild, dysferlin-null mouse model of LGMD2B that losartan increased quadriceps muscle fibrosis (142%; P
Evidence-based clinical resources (EBCRs) have the potential to improve diagnostic and therapeutic accuracy. The majority of US teaching medical institutions have incorporated them into clinical training. Many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries. We sought to determine the utility of EBCRs in an East African medical school.
The University of Rwanda (UR), a medical school located in East Africa.
Medical students and faculty members at UR.
We offered medical students and faculty at UR free access to UpToDate, a leading EBCR and conducted a cohort study to assess its uptake and usage. Students completed two surveys on their study habits and gave us permission to access their activity on UpToDate and their grades.
Of the 980 medical students invited to enrol over 2 years, 547 did (56%). Of eligible final year students, 88% enrolled. At baseline, 92% of students reported ownership of an internet-capable device, and the majority indicated using free online resources frequently for medical education. Enrolled final year students viewed, on average, 1.24 topics per day and continued to use UpToDate frequently after graduation from medical school. Graduating class exam performance was better after introduction of UpToDate than in previous years.
Removal of the cost barrier was sufficient to generate high uptake of a leading EBCR by senior medical students and habituate them to continued usage after graduation.
Liver kinase B1 (LKB1) is considered a tumour suppressor that can control cell growth and metabolism. Whether LKB1 expression levels are related to clinicopathology and prognosis is controversial. This review aimed to quantitatively examine the latest evidence on this question.
An updated systematic review and meta-analysis on the association between LKB1 expression and prognosis of patients with solid tumours were performed.
Eligible studies were identified through literature searches from database establishment until 15 June 2018 in the following databases: Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure and Wan Fang databases.
The association between LKB1 expression and clinicopathological characteristics, overall survival (OS), disease-free survival (DFS) and relapse-free survival (RFS) of patients with solid tumours were reported. Sufficient data were available to calculate the OR or HR and 95% CI.
Relevant data were meta-analysed for OS, DFS, RFS and various clinical parameters.
The systematic review included 25 studies containing 6012 patients with solid tumours. Compared with patients with high LKB1 expression, patients with low expression showed significantly shorter OS in univariate analysis (HR=1.63, 95% CI 1.35 to 1.97, p
Low LKB1 expression predicts shorter OS, worse tumour differentiation, larger tumours, earlier lymph node metastasis and more advanced TNM stage. Low LKB1 expression may be a useful biomarker of poor clinicopathology and prognosis.
by Christian Rominger, Ilona Papousek, Andreas Fink, Corinna M. Perchtold, Helmut K. Lackner, Elisabeth M. Weiss, Andreas R. SchwerdtfegerCoping with mental challenges is vital to everyday functioning. In accordance with prominent theories, the adaptive and flexible adjustment of the organism to daily demands is well expressed in task-related changes of cardiac vagal control. While many mental challenges are associated with increased effort and associated decreased task-related heart rate variability (HRV), some cognitive challenges go along with HRV increases. Especially creativity represents a cognitive process, which not only results from mental effort but also from spontaneous modes of thinking. Critically, creativity and HRV are associated with regular exercising and fitness. Furthermore, the cross-stressor adaptation theory suggests that changes in cardiac reactions to physical challenges may generalize to mental challenges. In line with this idea the amount of regular exercising was hypothesized to moderate the association between HRV changes and creativity. A sample of 97 participants was investigated. They reported the amount of regular exercise and their ECG was measured at baseline and during a creativity task. An association between task-related HRV changes and originality as a function of participants’ amount of regular exercise was found. Participants reporting more regular exercising produced more original ideas when they had higher HRV increases during the task, while more sedentary participants showed the opposite association. Results suggest that individuals with a higher amount of regular exercise achieve higher originality probably via the engagement in more spontaneous modes of thinking, while more sedentary people may primarily benefit from increased mental effort. This supports the conclusion that higher creativity can be achieved by different strategies.