Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care

Short-term Patient-Reported Outcomes Following Bilateral Risk-Reducing Mastectomy for Patients at a High Risk for Breast Cancer: A Systematic Review

BACKGROUND

Bilateral risk-reducing mastectomies (RRMs) have been proven to decrease the risk of breast cancer in patients at high risk owing to family history or having pathogenic genetic mutations. However, few resources with consolidated data have detailed the patient experience following surgery. This systematic review features patient-reported outcomes for patients with no breast cancer history in the year after their bilateral RRM.

METHODS

The databases MEDLINE, Embase, and Scopus were used to identify studies. Studies were then evaluated by multiple authors, and their quality was assessed by using the Methodological Index for Non-Randomized Studies score.

RESULTS

Our search identified 1858 unique studies, of which 11 met our inclusion criteria. Only two of these studies included patients who did not receive postmastectomy reconstruction. The included studies were either retrospective cohort studies or prospective studies. General satisfaction with the outcome of RRM and the decision to undergo RRM was high across many of the studies, with low levels of regret. There was also a noticeable trend of improved psychosocial outcomes following RRM. For postoperative sexual well-being, body image, aesthetic satisfactions, and somatosensory function, there were a mix of positive and negative outcomes.

CONCLUSIONS

The patients who elected to manage their breast cancer risk with bilateral RRM (mostly with reconstruction) tend to be satisfied with their decision and the surgical outcomes. This may be related to decreased cancer-related anxiety. Postmastectomy psychosocial well-being tends to improve while physical health after surgery varies by patient.

The Role of Cytoreductive Surgery in Platinum-Resistant Ovarian Cancer (PROC): A Systematic Review

BACKGROUND/OBJECTIVE

Platinum-resistant ovarian cancer (PROC) has limited therapeutic options, and the role of cytoreductive surgery (CRS) in improving survival outcomes remains uncertain. We performed a systematic review to evaluate the oncological benefit of CRS on PROC patients and the associated surgical morbidity and mortality.

METHODS

We followed a prospective protocol according to PRISMA guidelines. We searched PubMed, Medline, and Embase till October 2024. We used a "Population Intervention Comparator Outcomes (PICO)" framework. Our population included women with epithelial PROC who underwent CRS with/without chemotherapy. Our outcomes included overall survival (OS), progression-free-survival (PFS), post-operative morbidity and mortality and Quality of Life.

RESULTS

Our search yielded 6590 citations; six studies (N = 155 patients) were included. There is limited evidence available on the role of CRS in PROC, with notable variation in reported outcomes and outcomes' measures; therefore, we were unable to perform quantitative synthesis. CRS demonstrated survival benefits in well-selected PROC patients, particularly those with limited, isolated recurrences, low tumour burden, and good performance status. Complete resection (R0) was associated with significantly longer OS/PFS compared to those who had suboptimal surgeries (R1/R2).

CONCLUSIONS

CRS seems to extend survival in carefully selected PROC patients, especially those with limited disease spread and favourable surgical profiles. Nevertheless, CRS carries substantial surgical risks, and its benefits appear contingent upon achieving R0. Further prospective trials with standardised patient selection criteria are needed to define CRS's role in PROC. At present, CRS in PROC should be considered within a multidisciplinary approach in specialised gynaecological oncology centres, with the careful assessment of patient-specific risk factors and potential for R0 resection.

Sexual dysfunction in lymphoma survivors: a scoping review

BACKGROUND

Lymphoma and cancer-related treatment can cause many complications, including sexual dysfunction, a common symptom experienced by lymphoma survivors during the disease trajectory and survivorship.

AIMS

A scoping review was performed to determine the current state of knowledge about sexual dysfunction in lymphoma survivors and identify knowledge gaps and implications for future research.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO were searched to identify all primary peer-reviewed research articles published in the English language that were pertinent to sexual dysfunction in lymphoma survivors. The framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist were used to assess and synthesize the available evidence on sexual dysfunction in lymphoma survivors.

OUTCOMES

This review provided supportive evidence that sexual function in lymphoma survivors is a major ongoing area of concern.

RESULTS

Thirty eligible articles published from 1979 to 2023 were appraised in this review. Most of the studies (73.33%) used a cross-sectional design. Using the Methodological Index for Non-Randomized Studies, more than half of the publications (53.33%) achieved a C quality ranking. The reviewed studies revealed that sexual dysfunction was a prevalent symptom experienced by lymphoma survivors, with predictors such as age, gender, sex hormones, stage of disease, and types of cancer treatment.

CLINICAL IMPLICATIONS

Healthcare providers need to consistently perform routine assessment of sexual function and provide adequate treatment options.

STRENGTHS AND LIMITATIONS

The reviewed studies document the problem of sexual dysfunction and offer potential areas of improvement for clinical practice. However, in the majority of the studies, longitudinal data were not obtained which could provide valuable insights on sexual functioning in lymphoma survivors.

CONCLUSION

Despite many years of research on sexual function in lymphoma survivors, substantial gaps in knowledge regarding sexual issues in this population remain.

IMPLICATIONS FOR PRACTICE

Healthcare providers should routinely assess sexual function of survivors and provide treatment options. Psychosexual interventions should be tailored for the needs of cancer survivors. Sexual function education is essential for all oncologists and should be included in the care pathway from diagnosis until survivorship.

'Provision of safety netting information during child health consultations; a systematic narrative review of caregivers' perspectives'

Safety netting (SN) provides specific information to caregivers identifying need to re-consult. SN is often used to bridge diagnostic uncertainty for first-contact healthcare professionals. This systematic narrative review investigated experiences of caregivers' regarding SN information received during acute child health consultations. Searches between April and December 2021 of six bibliographic databases (CINAHL, PsycINFO, BNI, EMCARE, MEDLINE and Web of Science) identified 3258 records. No studies were excluded based on quality and nine papers were included; the Mixed Methods Appraisal Tool was used to critically analyse papers and findings were summarised narratively. Four themes emerged: Importance of receiving Red-Flag-Symptom information, influences of specific mediums for information transfer to caregivers, key principles of SN as desired by caregivers and contextual influences of information transfer to caregivers. Quality of evidence was fair; review findings could provide underpinning principles to enable first-contact clinicians to enhance their person-centred approach to SN practice. There was a paucity of evidence generally, with a relatively small number of studies that captured specific SN activity during consultations. More research is also needed to capture the full-breadth of first-contact clinicians, particularly in non-clinical settings such as the home or school.

Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study

BACKGROUND

Safety-netting is intended to protect against harm from uncertainty in diagnosis/disease trajectory. Despite recommendations to communicate diagnostic uncertainty when safety-netting, this is not always done.

AIMS

To explore how and why doctors safety-netted in response to several clinical scenarios, within the broader context of exploring how doctors communicate diagnostic uncertainty.

METHODS

Doctors working in internal medical specialties (n=36) from five hospitals were given vignettes in a randomised order (all depicting different clinical scenarios involving diagnostic uncertainty). After reading each, they told an interviewer what they would tell a 'typical patient' in this situation. A follow-up semistructured interview explored reasons for their communication. Interviews were recorded, transcribed and coded. We examined how participants safety-netted using a content analysis approach, and why they safety-netting with thematic analysis of the semistructured follow-up interviews using thematic analysis.

RESULTS

We observed n=78 instances of safety-netting (across 108 vignette encounters). We found significant variation in how participants safety-netted. Safety-netting was common (although not universal), but clinicians differed in the detail provided about symptoms to be alert for, and the action advised. Although many viewed safety-netting as an important tool for managing diagnostic uncertainty, diagnostic uncertainty was infrequently explicitly discussed; most advised patients to return if symptoms worsened or new 'red flag' symptoms developed, but they rarely linked this directly to the possibility of diagnostic error. Some participants expressed concerns that communicating diagnostic uncertainty when safety-netting may cause anxiety for patients or could drive inappropriate reattendance/over-investigation.

CONCLUSIONS

Participants safety-netted variously, even when presented with identical clinical information. Although safety-netting was seen as important in avoiding diagnostic error, concerns about worrying patients may have limited discussion about diagnostic uncertainty. Research is needed to determine whether communicating diagnostic uncertainty makes safety-netting more effective at preventing harm associated with diagnostic error, and whether it causes significant patient anxiety.

Long COVID in Icelandic Children: A Matched Cohort Study of Nonspecific Symptoms Following SARS-CoV-2 Infection

PURPOSE

Pediatric severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections are usually mild and the mortality rates are low, but concerns have been raised about long-term symptoms that may resemble other postinfectious syndromes. Studies with robust control groups and high response rates have been few.

METHODS

We obtained identifiers for all 837 Icelandic children diagnosed with SARS-CoV-2 by PCR between March 2020 and June 2021 and contacted them by telephone. We asked about 10 physical and mental symptoms being present at least twice weekly for at least 2 months. Participants who reported symptoms were contacted again a year later. For each subject who completed the questionnaire, an age- and sex-matched comparator without SARS-CoV-2 infection was asked to complete the same questionnaire, and the risk difference was calculated.

RESULTS

Responses from 643 cases and 602 comparators were analyzed. Children who had been infected with SARS-CoV-2 were more likely to report one or more symptoms, except for anxiety/depression and sleep disturbances. Fatigue and loss of concentration were evidently more common in cases among teenagers (risk difference: 15%; 95% CI: 7-22% and 15%; 95% CI: 7-23%, respectively). At the second follow-up, close to a third of Long COVID cases had resolved but some participants had developed new persistent symptoms.

CONCLUSION

Symptoms of Long COVID in children are common and impact their quality of life. The importance of further unraveling the pathophysiology of acute and long-term symptoms following SARS-CoV-2 infection in children is vital as well as potential preventive measures.

Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review

AIM

To identify the most frequently reported non-instrumented measures of gait, activity, and participation in children with cerebral palsy (CP) after undergoing gait corrective orthopaedic surgery.

METHOD

Four databases were searched from database inception to the 9th December 2021 for studies that evaluated functional outcomes for children with CP under 18 years undergoing gait corrective orthopaedic surgery.

RESULTS

Of 547 citations, 44 publications (n = 3535 participants, n = 1789 males, mean age 10 years 5 months [SD = 3 years 3 months], Gross Motor Function Classification System levels I-III at the time of surgery) were eligible for inclusion. Fourteen different outcome measures were used: one measure of gait, 10 measures of activity, and three measures of participation. Gait was measured with the Edinburgh Visual Gait Scale (EVGS; 4 out of 44). The most common activity and participation measures were the Functional Mobility Scale (FMS; 15 out of 44) and Pediatric Outcomes Data Collection Instrument (11 out of 44) respectively. No studies reported a combination of gait, activity, and participation measures.

INTERPRETATION

The EVGS and FMS should be considered as core outcome measures in gait corrective orthopaedic surgery, while a measure of participation is unclear. Additional considerations for developing a comprehensive suite of outcomes include identifying a combination of clinical measures and performance-reflective questionnaires that are standardized for children with CP undergoing surgery and meaningful to clinicians and families.

Quality of life after risk-reducing surgery for breast and ovarian cancer prevention: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the impact of risk-reducing surgery for breast cancer and ovarian cancer prevention on quality of life. We considered risk-reducing mastectomy, risk-reducing salpingo-oophorectomy, and risk-reducing early salpingectomy and delayed oophorectomy.

DATA SOURCES

We followed a prospective protocol (International Prospective Register of Systematic Reviews: CRD42022319782) and searched MEDLINE, Embase, PubMed, and Cochrane Library from inception to February 2023.

STUDY ELIGIBILITY CRITERIA

We followed a PICOS (population, intervention, comparison, outcome, and study design) framework. The population included women at increased risk of breast cancer or ovarian cancer. We focused on studies reporting quality of life outcomes (health-related quality of life, sexual function, menopause symptoms, body image, cancer-related distress or worry, anxiety, or depression) after risk-reducing surgery, including risk-reducing mastectomy for breast cancer and risk-reducing salpingo-oophorectomy or risk-reducing early salpingectomy and delayed oophorectomy for ovarian cancer.

METHODS

We used the Methodological Index for Non-Randomized Studies (MINORS) for study appraisal. Qualitative synthesis and fixed-effects meta-analysis were performed.

RESULTS

A total of 34 studies were included (risk-reducing mastectomy: 16 studies; risk-reducing salpingo-oophorectomy: 19 studies; risk-reducing early salpingectomy and delayed oophorectomy: 2 studies). Health-related quality of life was unchanged or improved in 13 of 15 studies after risk-reducing mastectomy (N=986) and 10 of 16 studies after risk-reducing salpingo-oophorectomy (N=1617), despite short-term deficits (N=96 after risk-reducing mastectomy and N=459 after risk-reducing salpingo-oophorectomy). Sexual function (using the Sexual Activity Questionnaire) was affected in 13 of 16 studies (N=1400) after risk-reducing salpingo-oophorectomy in terms of decreased sexual pleasure (-1.21 [-1.53 to -0.89]; N=3070) and increased sexual discomfort (1.12 [0.93-1.31]; N=1400). Hormone replacement therapy after premenopausal risk-reducing salpingo-oophorectomy was associated with an increase (1.16 [0.17-2.15]; N=291) in sexual pleasure and a decrease (-1.20 [-1.75 to -0.65]; N=157) in sexual discomfort. Sexual function was affected in 4 of 13 studies (N=147) after risk-reducing mastectomy, but stable in 9 of 13 studies (N=799). Body image was unaffected in 7 of 13 studies (N=605) after risk-reducing mastectomy, whereas 6 of 13 studies (N=391) reported worsening. Increased menopause symptoms were reported in 12 of 13 studies (N=1759) after risk-reducing salpingo-oophorectomy with a reduction (-1.96 [-2.81 to -1.10]; N=1745) in the Functional Assessment of Cancer Therapy - Endocrine Symptoms. Cancer-related distress was unchanged or decreased in 5 of 5 studies after risk-reducing mastectomy (N=365) and 8 of 10 studies after risk-reducing salpingo-oophorectomy (N=1223). Risk-reducing early salpingectomy and delayed oophorectomy (2 studies, N=413) led to better sexual function and menopause-specific quality of life.

CONCLUSION

Risk-reducing surgery may be associated with quality of life outcomes. Risk-reducing mastectomy and risk-reducing salpingo-oophorectomy reduce cancer-related distress, and do not affect health-related quality of life. Women and clinicians should be aware of body image problems after risk-reducing mastectomy, and of sexual dysfunction and menopause symptoms after risk-reducing salpingo-oophorectomy. Risk-reducing early salpingectomy and delayed oophorectomy may be a promising alternative to mitigate quality of life-related risks of risk-reducing salpingo-oophorectomy.

Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos

BACKGROUND

General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns.

OBJECTIVES

To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record.

METHODS

We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium.

RESULTS

Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic.

CONCLUSION

We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.

Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure: A Systematic Review and Meta-Analysis

To compare the outcomes of modified-Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) techniques with those of conventional-ALPPS.

Background

ALPPS is an established technique for treating advanced liver tumors.

Methods

PubMed, Web of Science, and Cochrane databases were searched. The outcomes were assessed by single-arm and 2-arm analyses.

Results

Seventeen studies containing 335 modified-ALPPS patients were included in single-arm meta-analysis. The estimated blood loss was 267 ± 29 mL (95% confidence interval [CI], 210-324 mL) during the first and 662 ± 51 mL (95% CI, 562-762 mL) during the second stage. The operation time was 166 ± 18 minutes (95% CI, 131-202 minutes) during the first and 225 ± 19 minutes (95% CI, 188-263 minutes) during the second stage. The major morbidity rate was 14% (95% CI, 9%-22%) after the first stage. The future liver remnant hypertrophy rate was 65.2% ± 5% (95% CI, 55%-75%) and the interstage interval was 16 ± 1 days (95% CI, 14-17 days). The dropout rate was 9% (95% CI, 5%-15%). The overall complication rate was 46% (95% CI, 37%-56%) and the major complication rate was 20% (95% CI, 14%-26%). The postoperative mortality rate was 7% (95% CI, 4%-11%). Seven studies containing 215 patients were included in comparative analysis. The hypertrophy rate was not different between 2 methods (mean difference [MD], -5.01; 95% CI, -19.16 to 9.14; P = 0.49). The interstage interval was shorter for partial-ALPPS (MD, 9.43; 95% CI, 3.29-15.58; P = 0.003). The overall complication rate (odds ratio [OR], 10.10; 95% CI, 2.11-48.35; P = 0.004) and mortality rate (OR, 3.74; 95% CI, 1.36-10.26; P = 0.01) were higher in the conventional-ALPPS.

Conclusions

The hypertrophy rate in partial-ALPPS was similar to conventional-ALPPS. This shows that minimizing the first stage of the operation does not affect hypertrophy. Moreover, the postoperative overall morbidity and mortality rates were lower following partial-ALPPS.

Early reattenders to the paediatric emergency department: A prospective cohort study and multivariate analysis

AIMS

The rate of unplanned reattendances is used as an indicator of the quality of care delivered in a paediatric emergency department (PED). With early reattendance in the UK well above the national target of 1-5%, we aimed to identify the factors which predict unplanned early reattendance to the PED.

METHODS

This is a prospective, single-centre cohort study undertaken over 12 months. Data were collected on all patients who reattended the PED within 7 days of their initial visit as well as for a comparative cohort of patients with no visit in the preceding or subsequent 7 days. Multiple patient and departmental variables were recorded and analysed using a multivariate regression model.

RESULTS

There were a total of 19 420 index visits to the PED, of which 1461 patients had an unscheduled reattendance within 7 days - a rate of 7.5%. Factors associated with unplanned but related reattendance include young age and diagnosis with a respiratory or other medical illness. Interestingly, the grade of clinician appeared to be relevant with patients seen by junior members of the medical team less likely to reattend. Acuity of illness was not a significant factor. A substantial number of unplanned early reattenders (36.3%) would have been missed had a time period of 72 h been used rather than 7 days.

CONCLUSIONS

This study identifies the typical patient who will have an unplanned, related early reattendance to a PED. This study also supports the use of a 7-day time period when using early reattendance as a performance indicator.

Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care

BACKGROUND

Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.

OBJECTIVE

To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.

METHODS

Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.

RESULTS

95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.

CONCLUSIONS

We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

Effectiveness and Acceptability of Low-intensity Psychological Interventions on the Well-being of Older Adults: A Systematic Review

Objectives: Growth in the older adult population and healthcare inequities mean there is a global need to increase access to early intervention in mental healthcare for older adults. This systematic review synthesized the evidence for the efficacy and acceptability of low-intensity psychological interventions (self-help, psychoeducation, bibliotherapy, internet cognitive-behavioral therapy: iCBT) for older adults with mild-to-moderate mental health problems.Methods: Ovid, EBSCOhost and ProQuest were searched for articles describing low-intensity psychological interventions. Pre and post outcome measures and a mean age of at least 50 (age range ≥40) were required for inclusion.Results: 26 articles (23 studies) described various interventions. Most studies were good quality and reported improvements in participant's mental health scores post intervention. Participants were more likely to be female, aged 60-70 and to be highly educated. Eight studies reported obtaining participant satisfaction ratings. Three studies included participants from rural areas.Conclusions: Low-intensity psychological interventions can be effective for older adults with mild-to-moderate mental health problems, but generalizability is constrained.Clinical Implications: Guided iCBT and bibliotherapy may be beneficial for adults in their 60s and 70s experiencing mild-to-moderate levels of depression. CBT may also be beneficial for reducing symptoms of mild-to-moderate anxiety. Providing the option of low-intensity psychological intervention, particularly iCBT, may help increase engagement with treatment.

Cementless unicompartmental knee replacement achieves better ten-year clinical outcomes than cemented: a systematic review

PURPOSE

The aim of this study was to report and compare the long-term revision rate, revision indications and patient reported outcome measures of cemented and cementless unicompartmental knee replacements (UKR).

METHODS

Databases Medline, Embase and Cochrane Central of Controlled Trials were searched to identify all UKR studies reporting the ≥ 10 year clinical outcomes. Revision rates per 100 component years [% per annum (% pa)] were calculated by fixation type and then, subgroup analyses for fixed and mobile bearing UKRs were performed. Mechanisms of failure and patient reported outcome measures are reported.

RESULTS

25 studies were eligible for inclusion with a total of 10,736 UKRs, in which there were 8790 cemented and 1946 cementless knee replacements. The revision rate was 0.73% pa (CI 0.66-0.80) and 0.45% pa (CI 0.34-0.58) per 100 component years, respectively, with the cementless having a significantly (p < 0.001) lower overall revision rate. Therefore, based on these studies, the expected 10-year survival of cementless UKR would be 95.5% and cemented 92.7%. Subgroup analysis revealed this difference remained significant for the Oxford UKR (0.37% pa vs 0.77% pa, p < 0.001), but for non-Oxford UKRs there were no significant differences in revision rates of cemented and cementless UKRs (0.57% pa vs 0.69% pa, p = 0.41). Mobile bearing UKRs had significantly lower revision rates than fixed bearing UKRs in cementless (p = 0.001), but not cemented groups (p = 0.13). Overall the revision rates for aseptic loosening and disease progression were significantly lower (p = 0.02 and p = 0.009 respectively) in the cementless group compared to the cemented group (0.06 vs 0.13% pa and 0.10 vs 0.21% pa respectively).

CONCLUSIONS

Cementless fixation had reduced long-term revision rates compared to cemented for the Oxford UKR. For the non-Oxford UKRs, the revision rates of cementless and cemented fixation types were equivalent. Therefore, cementless UKRs offer at least equivalent if not lower revision rates compared to cemented UKRs.

LEVEL OF EVIDENCE

III.

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

BACKGROUND

To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.

METHODS AND FINDINGS

A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit ('index' visit), in 2012-2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7-2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65-0.74) and summary calibration slope of 0.83 (95% CI 0.67-0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87-5.01) and specificity 0.96 (95% CI 0.95-0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25-0.35), sensitivity 0.88 (95% CI 0.86-0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68-0.75) and summary calibration slope of 0.84 (95% CI 0.71-0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.

CONCLUSION

We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Systematic review of prospective studies focused on regionalization of care in surgical oncology

To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization.

Non-invasive neuromodulation effects on painful diabetic peripheral neuropathy: a systematic review and meta-analysis

Diabetic Peripheral Neuropathy (DPN) typically is accompanied by painful symptoms. Several therapeutic agents have been tried for symptomatic relief, but with varying results. The use of non-invasive neuromodulation (NINM) is a potential treatment option for DPN. The objective of our study is to evaluate NINM effects on pain rating and nerve conduction velocity in DPN patients. The search was carried out in seven databases until Aug 30th, 2019. Finally, twenty studies met the inclusion criteria. We found a significant reduction of pain scores by central NINMs (effect size [ES] =  - 0.75, 95% CI =  - 1.35 to - 0.14), but not by the overall peripheral techniques (electrical and electromagnetic) (ES =  - 0.58, 95% CI =  - 1.23 to 0.07). However, the subgroup of peripheral electrical NINMs reported a significant higher effect (ES =  - 0.84, 95% CI =  - 1.57 to - 0.11) compared to electromagnetic techniques (ES = 0.21; 95% CI =  - 1.00 to 1.42, I2 = 95.3%) . Other subgroup analysis results show that NINMs effects are higher with intensive protocols and in populations with resistant symptoms or intolerance to analgesic medications. Besides, NINMs can increase motor nerves velocity (ES = 1.82; 95% CI = 1.47 to 2.17), and there were no effects on sensory nerves velocity (ES = 0.01, 95% CI =  - 0.79 to 0.80). The results suggest that central and peripheral electrical NINMs could reduce neuropathic pain among DPN patients, without reported adverse events. Well-powered studies are needed to confirm that NINM techniques as an alternative effective and safe treatment option.

Development of a tool for coding safety-netting behaviours in primary care: a mixed-methods study using existing UK consultation recordings

BACKGROUND

Safety netting is recommended in a variety of clinical settings, yet there are no tools to record clinician safety-netting communication behaviours.

AIM

To develop and assess the inter-rater reliability (IRR) of a coding tool designed to assess safety-netting communication behaviours in primary care consultations.

DESIGN AND SETTING

A mixed-methods study using an existing dataset of video-and audio-recorded UK primary care consultations.

METHOD

Key components that should be assessed in a coding tool were identified using the published literature and relevant guidelines. An iterative approach was utilised to continuously refine and generate new codes based on the application to real-life consultations. After the codebook had been generated, it was applied to 35 problems in 24 consultations independently by two coders. IRR scores were then calculated.

RESULTS

The tool allows for the identification and quantification of the key elements of safety-netting advice including: who initiates the advice and at which stage of the consultation; the number of symptoms or conditions the patient is advised to look out for; what action patients should take and how urgently; as well as capturing how patients respond to such advice plus important contextual codes such as the communication of diagnostic uncertainty, the expected time course of an illness, and any follow-up plans. The final tool had substantial levels of IRR with the mean average agreement for the final tool being 88% (κ = 0.66).

CONCLUSION

The authors have developed a novel tool that can reliably code the extent of clinician safety-netting communication behaviours.

Effects of dog-assisted therapy in adults with dementia: a systematic review and meta-analysis

BACKGROUND

Dog-assisted therapy (DAT) is a non-pharmacological intervention based on the interaction between patients and dogs, which has been proposed to help adults with dementia. However, evidence to support it is lacking. Thus, we aim to evaluate the effects of DAT on this population and to assess the certainty of the evidence of the RCTs estimates.

METHODS

A systematic search was performed. We included randomized controlled trials (RCTs) and quasi-experimental (QE) controlled studies published up to March 2018, which evaluated the beneficial and deleterious effects of DAT in adults with dementia. Mean differences (MD) or standardized mean differences (SMD) and their 95% confidence intervals (95% CI) were calculated and random effects meta-analyses were performed. Certainty of evidence was assessed for RCTs estimates using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The study protocol has been registered in PROSPERO (CRD42018090434).

RESULTS

Ten studies (six RCTs and four QE controlled studies) were eligible for inclusion. Meta-analysis of RCTs showed no effect of DAT in daily life activities (SMD: 0.16; 95% CI: -0.80 to 1.12), depression (SMD: -0.45; 95% CI: -2.81 to 1.91), agitation (SDM: -1.12; 95% CI: -2.67 to 0.43), quality of life (SDM: 0.16; 95% CI: -0.41 to 0.73), and cognitive impairment (SDM: -0.52; 95% CI: -1.33 to 0.30), but it found a beneficial effect in apathy (1 study, n = 37, MD: 1.81; 95% CI: 1.26 to 2.36). All outcomes had a very low certainty of evidence according to GRADE methodology.

CONCLUSIONS

RCTs evidence of very low certainty suggests that, in adults with dementia, DAT has no effect in daily life activities, depression, agitation, quality of life, and cognitive impairment, although one small study found an apparent beneficial effect in apathy. More well-designed and correctly reported studies are needed in order to provide a conclusion.

TRIAL REGISTRATION

CRD42018090434 (PROSPERO).

Safety netting for primary care: evidence from a literature review

BACKGROUND

Ensuring patient safety is vital in primary care. One mechanism to increase patient safety is through a practice known as safety netting. Safety netting is widely recommended in national guidelines; however, a variety of definitions exist with no consensus on when safety netting should be used and what advice or actions it should contain.

AIM

This study aimed to identify different definitions of safety netting to provide conceptual clarity and propose a common approach to safety netting in primary care.

DESIGN AND SETTING

Literature review and evidence synthesis of international articles relating to safety netting in primary care.

METHOD

An electronic database and grey-literature search was conducted using terms around the theme of safety netting with broad inclusion criteria.

RESULTS

A total of 47 studies were included in the review. Safety netting was defined as a consultation technique to communicate uncertainty, provide patient information on red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient's condition. Safety-netting advice may include information on the natural history of the illness, advice on worrying symptoms to look out for, and specific information on how and when to seek help. In addition to advice within the consultation, safety netting includes follow-up of investigations and hospital referrals. Safety netting was considered to be particularly important when consulting with children, the acutely unwell, patients with multimorbidity, and those with mental health problems.

CONCLUSION

Safety netting is more than solely the communication of uncertainty within a consultation. It should include plans for follow-up as well as important administrative aspects, such as the communication of test results and management of hospital letters.

Antibiotic Use in Febrile Children Presenting to the Emergency Department: A Systematic Review

Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.

Long-term outcomes of over 8,000 medial Oxford Phase 3 Unicompartmental Knees-a systematic review

Background and purpose - There is debate as to the relative merits of unicompartmental and total knee arthroplasty (UKA, TKA). Although the designer surgeons have achieved good results with the Oxford UKA there is concern over the reproducibility of these outcomes. Therefore, we evaluated published long-term outcomes of the Oxford Phase 3 UKA. Patients and methods - We searched databases to identify studies reporting ≥10 year outcomes of the medial Oxford Phase 3 UKA. Revision, non-revision, and re-operation rates were calculated per 100 component years (% pa). Results - 15 studies with 8,658 knees were included. The annual revision rate was 0.74% pa (95% CI 0.67-0.81, n = 8,406) corresponding to a 10-year survival of 93% and 15-year survival of 89%. The non-revision re-operation rate was 0.19% pa (95% CI 0.13-0.25, n = 3,482). The re-operation rate was 0.89% pa (95% CI 0.77-1.02, n = 3,482). The most common causes of revision were lateral disease progression (1.42%), aseptic loosening (1.25%), bearing dislocation (0.58%), and pain (0.57%) (n = 8,658). Average OKS scores were 40 at 10 years (n = 3,417). The incidence of medical complications was 0.83% (n = 1,443). Interpretation - Very good outcomes were achieved by both designer and non-designer surgeons. The PROMs, medical complication rate, and non-revision re-operation rate were better than those found in meta-analyses and publications for TKA but the revision rate was higher. However, if failure is considered to be all re-operations and not just revisions, then the failure rate of UKA was less than that of TKA.

Characteristics of revisits of children at risk for serious infections in pediatric emergency care

In this study, we aimed to identify characteristics of (unscheduled) revisits and its optimal time frame after Emergency Department (ED) discharge. Children with fever, dyspnea, or vomiting/diarrhea (1 month-16 years) who attended the ED of Erasmus MC-Sophia, Rotterdam (2010-2013), the Netherlands, were prospectively included. Three days after ED discharge, we applied standardized telephonic questionnaires on disease course and revisits. Multivariable logistic regression analysis was used to identify independent characteristics of revisits. Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with revisits (n = 527) in children at risk for serious infections discharged from the ED (n = 1765). Children revisited the ED within a median of 2 days (IQR 1.0-3.0), but this was proven to be shorter in children with vomiting/diarrhea (1.0 day (IQR 1.0-2.0)) compared to children with fever or dyspnea (2.0 (IQR 1.0-3.0)).

CONCLUSION

Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with emergency health care revisits in children with fever, dyspnea, and vomiting/diarrhea. These characteristics could help to define targeted review of children during post-discharge period. We observed a disease specific and differential timing of control revisits after ED discharge. What is Known • Fever, dyspnea, and vomiting/diarrhea are major causes of emergency care attendance in children. • As uncertainty remains on uneventful recovery, patients at risk need to be identified on order to improve safety netting after discharge from the ED. What is New • In children with fever, dyspnea, and vomiting/diarrhea, young age, parental concern and chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea help to define targeted review of children during the post-discharge period. • A revisit after ED discharge is disease-specific and seems to be shorter for children with vomiting/diarrhea than others.

Fever in Children: Pearls and Pitfalls

Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children. We review the epidemiology and measurement of fever, the meaning of fever and associated clinical signs in children of different ages and under special conditions, including fever in children with cognitive impairment, recurrent fevers, and fever of unknown origin. While the majority of febrile children have mild, self-resolving viral illness, a minority may be at risk of life-threatening infections. Clinical assessment differs markedly from adult patients. Hands-off evaluation is paramount for a correct evaluation of breathing, circulation and level of interaction. Laboratory markers and clinical prediction rules provide limited help in identifying children at risk for serious infections; however, clinical examination, prudent utilization of laboratory tests, and post-discharge guidance ("safety netting") remain the cornerstone of safe management of febrile children.

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

INTRODUCTION

Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits.

METHODS

Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances.

RESULTS

Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions.

CONCLUSION

We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.

Cementless fixation in medial unicompartmental knee arthroplasty: a systematic review

PURPOSE

The aim of this study was to evaluate clinical outcome, failures, implant survival, and complications encountered with cementless fixation in unicompartmental knee arthroplasty (UKA).

METHODS

A systematic review of the literature on cementless fixation in UKA was performed according to the PRISMA guidelines. The following database was comprehensively searched: PubMed, Cochrane, Medline, CINAHL, Embase, and Google Scholar. The keywords "unicompartmental", "unicondylar", "partial knee arthroplasty", and "UKA" were combined with each of the keyword "uncemented", "cementless" and "survival", "complications", and "outcome". The following data were extracted: demographics, clinical outcome, details of failures and revisions, cumulative survival, and complications encountered. The risk of bias of each study was estimated with the MINORS score and a further scoring system based on the presence of the primary outcomes.

RESULTS

From a cohort of 63 studies identified using the above methodology, 10 papers (1199 knees) were included in the final review. The mean follow-up ranged from 2 to 11 years (median 5 years). The 5-year survival ranged from 90 to 99 % and the 10-year survival from 92 to 97 %. There were 48 revisions with an overall revision rate of 0.8 per 100 observed component-years. The most common cause of failure was progression of osteoarthritis in the retained compartment (0.9 %). The cumulative incidence of complications and revisions was comparable to that reported in similar studies on cemented UKAs. The advantages of cementless fixation include faster surgical time, avoidance of cementation errors, and lower incidence of radiolucent lines.

CONCLUSIONS

Cementless fixation is a safe and effective alternative to cementation in medial UKA. Clinical outcome, failures, reoperation rate, and survival are similar to those reported for cemented implants with lower incidence of radiolucent lines.

LEVEL OF EVIDENCE

IV.

Implications of a negative abdominal CT in the management of pediatric blunt abdominal trauma

BACKGROUND

No consensus exists on management of children with a negative trauma CT following blunt abdominal trauma (BAT). Asymptomatic children are frequently "admitted for observation" following negative CT owing to concerns about missing an intraabdominal injury (IAI) without evidence for this practice. We aimed to investigate the feasibility of discharge following a negative CT scan in children sustaining blunt abdominal trauma.

METHODS

Retrospective audit at a UK paediatric major trauma center and review of the literature.

RESULTS

108 patients were included (median age 11y; 60% male). Commonest mechanisms of injury: road traffic collisions (61 patients; 56%) and falls from a height (37; 34%). 40 (37%) had a normal CT scan, of whom 6 (15%) were discharged from ED. The remaining 34 patients were admitted, of whom 14 (41%) were discharged within 24h. The other 20 children were admitted for other specialty input. None of the 108 children had a missed IAI or reattended with suspicion of IAI. The NPV for CT to detect IAI was 100% (95% CI: 96%-100%). The literature search identified 3 observational cohort studies and 2 patient groups contained in a systematic review (total of 9149 patients with normal CT abdomen after BAT). Only 9 (<0.1%) patients required operative intervention for missed IAI. The NPV for CT to detect IAI was 99.6%-99.8% (95% CI 99%-100%).

CONCLUSION

Our study and literature review demonstrate that asymptomatic children with a normal abdominal CT scan in the ED are very unlikely to have IAI and that the NPV of CT is very high (96%-100%). Direct discharge from the ED is possible for asymptomatic children with a negative CT following blunt abdominal trauma, as long as no other reasons for admission exist and should be accompanied by safety-net advice.

LEVEL OF EVIDENCE STATEMENT

This is a level II evidence study. In itself it is a retrospective study, with the literature review including one large, high-quality prospective cohort study, and further prospective cohort studies of ordinary quality.