Intermediate care pathways for musculoskeletal conditions--are they working? A systematic review

BACKGROUND

Musculoskeletal condition assessment and management is increasingly delivered at the primary to secondary care interface, by inter-disciplinary triage and treat services.

OBJECTIVES

This review aimed to describe Intermediate Care pathways, evaluate effectiveness, describe outcomes and identify gaps in the evidence.

DATA SOURCES

PubMed, ISI Web of Science, EMBASE, Ovid Medline, PEDro, Google Scholar to October 2013.

STUDY SELECTION/ELIGIBILITY CRITERIA

Studies in English that evaluated relevant services were considered for inclusion. Studies evaluating paediatric or emergency medicine and self-referral were excluded.

RESULTS

Twenty-three studies were identified. Between 72% and 97% of patients could be managed entirely within Intermediate Care with a 20% to 60% resultant reduction in orthopaedic referral rate. Patient reported outcome measures typically showed significant symptom improvements. Knee conditions were most commonly referred on to secondary care (35% to 56%), with plain films (5% to 23%) and MRI (10% to 18%) the commonest investigations. Physiotherapists' clinical decision making and referral accuracy were comparable to medical doctors in 68% to 96% of cases. Intermediate Care consistently leads to significantly reduced orthopaedic waiting times and high patient satisfaction.

LIMITATIONS

These findings are not based on strong evidence and there is an urgent need for high-quality, prospective, comprehensive evaluation of Intermediate Care provision, including cost-effectiveness and impact on other services.

FUNDING

Part funded by EPSRC and AXA-PPP.

CONCLUSION

Intermediate Care consistently improves patient outcome, typically results in appropriate referral and management, reduces waiting times and increases patient satisfaction. There is a case for wider provision of Intermediate Care services to effectively manage non-surgical musculoskeletal patients.

Tropical infection after a case of total hip arthroplasty

In non-endemic areas, malaria is mainly an imported disease. This article reports a case of transfusion-related Plasmodium falciparum malaria in a non-endemic area. Despite initial clinical signs consistent with malaria, the diagnosis was not elicited because of the absence of any identified epidemiological risk factors. The case indicates that transfusion-transmitted malaria still occurs in non-endemic countries. The role of laboratory testing to prevent and diagnose transfusion-transmitted malaria in non-endemic malaria countries is crucial.

Provision of health promotion programmes to people with serious mental illness: a mapping exercise of four South London boroughs

BACKGROUND

People with serious mental illness (SMI) are at increased risk of developing various physical health diseases, contributing to significantly reduced life expectancies compared with the general population. In light of this, the Department of Health have set the physical health of people with mental health problems as a priority for improvement. Additionally, the UK government encourages the NHS and local authorities to develop health promotion programmes (HPPs) for people with SMI.

AIMS

To document how many and what types of HPPs were available to people with SMI across four South London boroughs, UK.

RESULTS

We found 145 HPPs were available to people with SMI across the four boroughs, but with an inequitable distribution. We also found that certain HPPs set admission criteria that were likely to act as a barrier to improving health.

CONCLUSIONS

A more integrated approach of documenting and providing information regarding the provision of HPPs for or inclusive of people with SMI is needed.

ABSTRACT

People with serious mental illness (SMI) such as schizophrenia, schizoaffective disorders and bipolar disorder are at increased risk of developing diabetes, cardiovascular disease and respiratory disease, contributing to significantly reduced life expectancies. As a result, emphasis has been placed on developing Health Promotion Programmes (HPPs) to modify the risk of poor physical health in SMI. We examined how many and what types of HPPs are available for or inclusive of people with SMI across four borough in South London, UK. A cross-sectional mapping study was carried out to identify the number of HPPs available to people with SMI. We found 145 HPPs available to people with SMI existed across the four boroughs but with an inequitable distribution, which in some boroughs we anticipate may not meet need. In some cases, HPPs set admission conditions which were likely to further impede access. We recommend that accurate and readily available information on the provision of HPPs for or inclusive of people with SMI is needed.

Activity limitations and factors influencing functional outcome of patients with stroke following rehabilitation at a specialised facility in the Western Cape

BACKGROUND

Determining the functional abilities and factors influencing outcome of patients with stroke following rehabilitation are essential for the planning of future interventions and services in order to optimise recovery.

OBJECTIVES

To determine the activity limitations and factors influencing functional outcome of patients with stroke managed at a specialised rehabilitation centre.

METHODOLOGY

A longitudinal study design was used to determine the functional outcomes of patients admitted to the centre on admission and discharge. A data gathering sheet was developed to collect information pertaining to the demographicand medical profile and process of rehabilitation, whereas the Barthel Index was used to collect data relating to functional abilities. For analysis, descriptive statistics as well as inferential statistics (Student t test) were utilised to determine the paired differences. Six prognostic factors influencing functional outcome were selected and tested using linear (bivariate) regression.

RESULTS

The mean Barthel Index scores on admission and at discharge were 58.85 and 81.59 respectively. A significant improvement was noted in the execution of functional task of patients with stroke (p< 0.01) between the data collection points. Despite the significant overall improvement, results show a high prevalence of dependence with walking and stair climbing at discharge. Only functional ability on admission (r=0.49) predicted a favourable functional outcome at discharge.

CONCLUSION

This study highlights the limitations of younger stroke survivors and the need for continued rehabilitation following in-patient care. It further underscores the administration of a functional rating scale on admission in order to aggressively manage activity limitations.

Cnages in activity limitations and predictors of functional outcome of patients with spinal cord injury following in patient rehabilitation

The purpose of this study was to investigate the changes in the activity limitations of patients following in-patient rehabilitation and the factors influencing functional ability as measured by the Spinal Cord independence measure III (SCIM III). A longitudinal study design was utilised to study the change in functional abilities of patients with spinal cord injury between admission and discharge. A convenient sampling strategy was employed, in which every consecutive patient admitted to the rehabilitation centre within a three-month period was eligible for the study. Demographic-, medical, and process of rehabilitation data were collected and collated from the patients’ medical records using a data gathering sheet that was validated and tested for reliability. functional abilities were measured by the SCIM III. Seventy-six patients met the inclusion criteria, consisting of 58 paraplegics and 18 tetraplegics. The mean age of this cohort was 34.14 years. A significant difference (p<0.001) in functional ability was detected for the total sample, with only 12.5% of patients independent in walking ability and 28.12% in stair management. four (4) factors were found to be predictors of functional outcomes on bivariate analysis, but when considered together in a multiple regression model, only functional status on admission remained correlated to functional outcomes. Conclusion and implication for practice: Significant improvement in functional abilities of persons with spinal cord injury following in-patient rehabilitation was observed. however, mobility and stair-management limitations were the most prevalent at discharge. lastly, a lower functional status should be better targeted to optimise functional ability in the future. future research should be directed towards illuminating whether personal factors or rehabilitation inefficiencies are responsible for the limitations observed at discharge.

Highlights and conclusions from the technical consultative meeting on novel coronavirus infection, Cairo, Egypt, 14-16 January 2013

The emergence of a novel strain of coronavirus in the Arabian Peninsula raised a global health concern in 2012, partly because the majority of human infections were fatal and partly due to its presumed animal origin. An urgent meeting of scientific and public health experts was convened by WHO in January 2013 in view of the limited knowledge available on the epidemiological and natural history of infection with this novel virus. The meeting reviewed current evidence and identified critical knowledge gaps to improve better understanding of the public health risk associated with the virus so as to improve preparedness and to safeguard and protect global health.

Evaluation of a new clinical performance assessment tool : A reliability study

Clinical practice is an essential requirement of any graduatephysiotherapy programme. For this purpose, valid and reliable assessment toolsare paramount for the measurement of key competencies in the real-worldsetting. This study aims to determine the internal consistency and inter-raterreliability of a newly developed and validated clinical performance assessmentform. A cross-sectional quantitative research design was used, which includedpaired evaluations of 32 (17 treatment and 15 assessment) student examinationsperformed by two independent clinical educators. Chronbachs alpha was computedto assess internal consistency and intraclass correlation coefficient (ICC’s) withconfidence intervals of 95% were computed to determine the percentage agreement between paired examiners. Thedegree of internal consistency was substantial for all key performance areas of both examinations, except for timeand organisational management (0.21) and professionalism (0.42) in the treatment and evaluation examinationsrespectively. The overall internal consistency was 0.89 and 0.73 for both treatment and assessment examinations,indicating substantial agreement. With regard to agreement between raters, the ICC’s for the overall marks were0.90 and 0.97 for both treatment and assessment examinations. Clinical educators demonstrated a high level ofreliability in the assessment of students’ competence using the newly developed clinical performance assessment form.These findings greatly underscore the reliability of results obtained through observation of student examinations, andadd another tool to the basket of ensuring quality assurance in physiotherapy clinical practice assessment.

Overcoming the learning curve in hand-assisted laparoscopic live donor nephrectomy - a study in the animal model

The demand for kidneys in South Africa is staggering. Only 38% of the kidney transplants done in 2008 were from related living donors. Laparoscopic living donor nephrectomy has been shown to have the advantages of decreased postoperative pain, better cosmesis and a quicker return to work when compared with the open technique. With limited surgical expertise, a realistic model was needed to overcome the learning curve. Methods. A total of 21 nephrectomies were performed on 12 pigs. The transperitoneal hand-assisted laparoscopic technique was used. Results. The median operative time was 75 minutes and the median warm ischaemic time 88 seconds. Three cases were aborted owing to major vascular injuries. Discussion. The advent of laparoscopic techniques has been associated with an increase in morbidity and complications in donor and recipient during the initial learning curve. We found that with our porcine model, 21 nephrectomies were adequate in overcoming the learning curve. After 15 nephrectomies no complications were noted.

Hand-assisted laparoscopic live donor nephrectomy - initial experience

INTRODUCTION

The advantages of minimally invasive live donor nephrectomy have been well documented, with no adverse effect on graft function. Minimal access nephrectomy has now become the standard of care in many units. We have adopted the hand-assisted laparoscopic live donor (HALLDN) technique, and present our initial experience with the first 24 cases.

MATERIAL AND METHODS

HALLDNs were performed trans-peritoneally. Primary outcomes included total operative time, warm ischaemic time, time to discharge, and post-operative complications. Warm ischaemic time was measured from the time of clamping the renal artery to the time of perfusing the kidney on the back table.

RESULTS

Mean total operative time was 143 minutes and mean warm ischaemic time was 188 seconds. A downward trend was displayed for operative times. Mean time to discharge was 60 hours. A right nephrectomy was performed in 2 cases. No surgical morbidity is reported. We describe 1 donor mortality.

DISCUSSION

Our results compare favourably with those documented in the literature. Aberrant renal vascular anatomy had no adverse effect on operative or warm ischaemic times. HALLDN proved beneficial in patients with a high BMI.

CONCLUSION

Surgical experience is vital when performing HALLDN. Overcoming the learning curve with an animal model is beneficial.

Exploring the key performance areas and assessment criteria for the evaluation of students’ clinical performance: a delphi study

Background: evaluating  students’ clinical  performance  is  an integral part of the quality assurance in a physiotherapy curriculum, however, the objectivity during clinical examination have been questioned on numerous occasions.  The  aim  of  this  study  was  to  explore  the  essential  key  clinical performance areas and the associated assessment criteria in order to develop a reliable clinical assessment form.Methods: A Delphi study was used to obtain consensus on the development of a reliable clinical performance assessment tool. The study population consisted of  purposively  selected  academic  physiotherapy  staff  from  the  University  of Western Cape as well as supervisors and clinicians involved in the examination of  physiotherapy  students  from  the  three  Universities  in  the  Western Cape.  Findings  from  the  Delphi  rounds  were analysed  descriptively. Fifty  percent  or  higher  agreement  on  an  element  was  interpreted  as  an  acceptable  level of consensus.Results: Eight key performance areas were identified with five assessment criteria per key performance area as well as the weighting per area. It was evident that evaluators differed on the expectations of physiotherapy students as well as the criteria used to assess them.Conclusions: The Delphi panel contributed to the formulation of a clinical assessment form through the identification of  relevant  key  performance  areas  and  assessment  criteria  as  they  relate  to undergraduate  physiotherapy  training. Consensus on both aspects was reached following discussion and calculation of mean ranking sores.Implications: This process of reaching consensus in determining clear criteria for measuring key performance areas contributes to the objectivity of the process of examinations.

Periodontal conditions in Williams Beuren syndrome: a series of 8 cases

BACKGROUND

Williams Beuren syndrome (WBS) is an unusual hereditary connective tissue disease caused by a microdeletion at position 7q11-23 and a haploinsufficiency at the elastin gene. The most frequent specific features are elf-like face, alteration of cognitive functions and cardiovascular diseases including isolated supravalvular aortic stenosis. A number of clinical findings have been reported, but none of the studies evaluating this syndrome consider the oral cavity. It is equally surprising that the gingival tissue, which carries a perfectly structured elastic fibre network, has not yet been investigated. It is important to verify whether subjects affected by WBS are more susceptible to periodontal disease than healthy subjects who are not that much affected, for periodontal disease may have deleterious effects on the cardiovascular system.

METHODS

In an attempt to address this issue, the oral manifestations of 8 patients (ages from 5 to 12 years) with WBS have been investigated: dental examination, periodontal examination (gingival phenotype, plaque control record, gingival index, bone quality).

RESULTS

All patients had oral parafunction, tooth number abnormalities and malocclusions. Average gingival height and width were greater than normal. Plaque index was always very high except for one patient, but the gingival inflammation was not linked to the quantity of clinical plaque index. There was no obvious loss of attachment.

CONCLUSION

As with collagen, elastin is a structural macromolecule of the gingiva. These components play an important role in gingival function and in the resistance of the periodontium to daily aggressions. Unlike genetic diseases characterized by impairment of collagen macrofibrils, it is suggested that the hemizygous gene encoding elastin does not result in periodontal disease. In addition there is an existence of a possible concordance between the elastin gene haploinsufficiency and the periodontal phenotype. There might be some adaptive process to this deficiency.

Survey on legislation regarding wet cooling systems in European countries

Wet cooling systems are often associated with large outbreaks of Legionnaires' disease. Several European countries have legislation for registering such systems. The authors aimed to obtain an overview of the situation in Europe. A questionnaire survey was sent to 35 of the countries that collaborate in the European Working Group for Legionella Infections. In two countries it was passed to a regional level (to three regions in both Belgium and the United Kingdom), so that 39 countries or regions were sent the survey; 37 responded. Nine countries stated having legislation for the registration of wet cooling systems. Separate legislation exists at a regional level for two regions in Belgium and all three regions in the UK, giving a total of twelve countries/regions with legislation. In nine of these countries/regions, the legislation has been introduced since 2001. All of these countries/regions require periodic microbiological monitoring between twice a year and weekly; in nine, the legislation requires periodic inspection of the systems. Regulations for the registration of wet cooling systems should be required by public health authorities. During an outbreak of legionellosis, a register of wet cooling systems can speed up the investigation process considerably. The authors believe that the European Centre for Disease Prevention and Control (ECDC) should take the initiative to propose European Community (EC) regulations for all Member States.

Survey on legislation regarding wet cooling systems in European countries

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