Biomechanical strength of triceps tendon repairs: systematic review and meta-regression analysis of human cadaveric studies

PURPOSE

It is unclear which triceps tendon repair constructs and techniques produce the strongest biomechanical performance while minimizing the risk of gap formation and repair failure. We aimed to determine associations of construct and technique variables with the biomechanical strength of triceps tendon repairs. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov were systematically searched for peer-reviewed studies on biomechanical strength of triceps tendon repairs in human cadavers. 6 articles met the search criteria. Meta-regression was performed on the pooled dataset (123 specimens). Outcomes of interest included gap formation, failure mode, and ultimate failure load. Covariates were fixation type; number of implants; and number of sutures. Stratification by covariates was performed. We found no association between fixation type and ultimate failure load; however, suture anchor fixation was associated with less gap formation compared with transosseous direct repair (β =  - 1.1; 95% confidence interval [CI]:- 2.2, - 0.04). A greater number of implants was associated with smaller gap formation (β = - 0.77; 95% CI: - 1.3, - 0.28) while a greater number of sutures was associated with higher ultimate failure load ( β= 3; 95% CI: 21, 125). In human cadaveric models, the number of sutures used in triceps tendon repairs may be more important than the fixation type or number of implants for overall strength. If using a transosseous direct repair approach to repair triceps tendon tears, surgeons may choose to use more sutures in their repair in order to balance the risk of larger gap formation when compared to indirect repair techniques.

LEVEL OF EVIDENCE

Level III.

PSVII-6 Effects of Hydroponically Sprouted Cereal Grains on Feedlot Performance, Blood Serum Chemistry, and Apparent Nutrient Digestibility in Beef Cattle

Recent technological advancements in the local chain agricultural technology sector have produced automated systems that overcome pitfalls of traditional forage production. With significantly altered nutrient composition when compared with typical forages, research investigating the effects of hydroponically sprouted grain (HG) on feedlot growth and performance is needed. Angus steers (n = 40) averaging 274 kilograms body weight were randomly assigned to one of four pens in replicated pen experimental feedlot setting. Treatment pens were balanced for incoming weight, age, and genetic background to ensure uniformity throughout the experiment. Dietary treatments were randomly assigned and delivered continuously for an eight-week comparison period; diets were balanced for metabolizable energy, fiber, and crude protein content with 15% inclusion of HG administered in the treatment group. Nutrient digestibility was assessed through weekly manure sampling. Daily rate of gain, feed conversion ratio, and cost of gain was assessed through monthly replicated (n = 3) weight evaluations. Blood serum chemistry was evaluated through individual animal blood serum samples collected from the lateral tail vein. Multiple variables measured indicated positive and statistically significantly (p < 0.05) changes resulting from the inclusion of HG (Table 1). On a percentage basis, daily rate of gain and dry matter intake improved 12% and 11%, respectively. Marginal trends (p < 0.20) in nutrient digestibility were noted and blood serum metrics associated with nutrient bioavailability and rumen health were positive. Results highlight the potential feeding value of HG and automated production systems as a novel agricultural technology solution.

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The quality of reporting in cardiac MRI artificial intelligence segmentation studies - a systematic review

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by an NIHR AI Award, AI_AWARD01706. This research was also funded in part, by the Wellcome Trust [Grant number 205188/Z/16/Z ].

Background

There has been a rapid increase in the number of Artificial Intelligence (AI) studies of cardiac MRI (CMR) segmentation. AI has huge potential to improve image analysis assessments. However, advancement and clinical translation in this field depend on researchers presenting their work in a transparent and reproducible manner.

Purpose

This systematic review aimed to evaluate the quality of reporting in AI studies involving CMR segmentation.

Methods

MEDLINE and EMBASE databases were searched for AI CMR segmentation studies on 18/11/2021. The flow of study inclusion is shown in Figure 1. Any AI method to segment any cardiac structure on CMR was eligible for inclusion. Each study was assessed for compliance with the Checklist for Artificial Intelligence in Medical Imaging (CLAIM).

Results

70 studies were included in the qualitative analysis. Studies were published between 2015 to 2021, with the majority (71%) published in 2020 and 2021. Most studies were performed in Europe (33%), China (27%) and the USA (26%). Short-axis sections were segmented in 70% of studies and most commonly included both ventricles (51%) or the left ventricle alone (30%). 20 different architecture implementations were represented. Figure 2 summarises the most relevant CLAIM domains to AI segmentation. The training sample eligibility criteria, demographics and clinical characteristics were not reported in 47% and 81% of studies, respectively. Ground truth annotations, source of the annotations and annotation tool were absent in 31%, 36% and 51% of studies respectively. Preprocessing steps and software libraries and packages used in training were not included in 27% and 24%. Details on the training approach including the number of models trained and method of selecting the final model were missing in 20% and 17% of the studies. Methods of validation or testing on external data, inter- and intra- rater variability and failure analysis were unreported in 57%, 63% and 74%, respectively.

Conclusion

This systematic review highlights important gaps in the AI literature of CMR studies. We identified key items missing in the dataset description, model development, validation and testing that limit the transparency, reproducibility and hence validity of published AI studies. This review may support closer adherence to established frameworks for reporting standards.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

1643 Quality Assessment of Intra-Oral Radiography Within Two Hospitals in South Wales, UK: A Two-Cycle Audit and Introduction to The Updated 2020 Public Health England Quality Grading System

Aim

To evaluate the quality of intra-oral radiographs taken within two hospitals in South Wales, United Kingdom, and assess the impact of radiographer training, with the aim of reducing the percentage of undiagnostic radiographs to 10% or less in accordance with national performance targets.

Method

Details of intra-oral periapical and occlusal radiographs taken in the two hospitals between the 1st July 2015 and the 30th June 2016 were retrieved. 100 radiographs were randomly selected and assessed. Change was then implemented in the delivery of radiographer training workshops, which involved two hours of both didactic teaching and hands-on skills training. There were 10 workshops and 52 attendees. A second audit cycle was completed, with a further 100 radiographs randomly selected from the 1st December 2018 and 30th April 2019.

Results

There was a 33.2% reduction of undiagnostic radiographs, bringing the total down to 6.3%, meeting the standards of the audit. Feedback from the workshops were also extremely positive; 50% of radiographers grading the quality of the workshops at 10/10.

Conclusions

The workshops were successful in improving the quality of intra-oral radiographs, therefore improving the quality of this service. This blueprint can be shared amongst other hospitals, to sustainably improve the overall quality of dental radiography in the hospital setting. Recent updated guidance in 2020 introduced a new two-point scale radiograph grading system: ‘Acceptable’ and, ‘not acceptable’. Radiographs graded as, ‘not acceptable’, should account for no more than 5% of radiographs. Future audit cycles will follow this new grading system and standard.

Treatment Effect of Niaspan, a Controlled-release Niacin, in Patients with Hypercholesterolemia: A Placebo-controlled Trial

Background

The present study was designed to determine the efficacy and safety of Niaspan (Kos Pharmaceuticals, Inc, Hollywood, FL), a new controlled-release formulation of niacin, in the treatment of primary hyperlipidemia, the occurrence and severity of flushing events, and potential adverse effects, particularly hepatotoxicity.

Methods and Results

The study was conducted as a multicenter, randomized, double-blind, placebo-controlled, parallel comparison of Niaspan in doses of 1000 mg/day and 2000 mg/day, administered once a day at bedtime. One hundred twenty-two patients with low-density lipoprotein cholesterol levels > 4.14 mM/L (160 mg/dL) with dietary intervention and high-density lipoprotein cholesterol ≤ 1.81 mM/L (70 mg/dL) were randomized to one of three treatment groups: placebo, and 1000 mg/day or 2000 mg/day of Niaspan. Safety and efficacy measures included 12-hour serum fasting lipid and lipoprotein concentrations, serum analyte levels for major organ function, flushing diaries, and adverse event records. The placebo group demonstrated no significant changes in serum lipoprotein concentrations over the treatment period of 12 weeks, except for a slight 4% increase in high-density lipoprotein cholesterol. Niaspan significantly lowered low-density lipoprotein cholesterol levels by 6% and 14% for the 1000 mg/day and 2000 mg/day doses, respectively. High-density lipoprotein cholesterol levels rose significantly, with a 17% increase occurring at the 1000 mg/day dose and a 23% increase occurring at the 2000 mg/day dose. Niaspan (2000 mg/day) produced significant decreases of 27% and 29%, respectively, for serum lipoprotein(a) and triglyceride concentration. Although the incidence of flushing was significant, these episodes were generally well tolerated.

Conclusion

Niaspan administered in doses of 1000 mg/day and 2000 mg/day at bedtime were well tolerated with few side effects and produced favorable effects on the major circulating lipoproteins of patients with primary dyslipidemias as specified by the enrollment criteria.

Early Prediction of Soybean Traits through Color and Texture Features of Canopy RGB Imagery

Global crop production is facing the challenge of a high projected demand, while the yields of major crops are not increasing at sufficient speeds. Crop breeding is an important way to boost crop productivity, however its improvement rate is partially hindered by the long crop generation cycles. If end-season crop traits such as yield can be predicted through early-season phenotypic measurements, crop selection can potentially be made before a full crop generation cycle finishes. This study explored the possibility of predicting soybean end-season traits through the color and texture features of early-season canopy images. Six thousand three hundred and eighty-three images were captured at V4/V5 growth stage over 6039 soybean plots growing at four locations. One hundred and forty color features and 315 gray-level co-occurrence matrix-based texture features were derived from each image. Another two variables were also introduced to account for location and timing differences between the images. Five regression and five classification techniques were explored. Best results were obtained using all 457 predictor variables, with Cubist as the regression technique and Random Forests as the classification technique. Yield (RMSE = 9.82, R2 = 0.68), Maturity (RMSE = 3.70, R2 = 0.76) and Seed Size (RMSE = 1.63, R2 = 0.53) were identified as potential soybean traits that might be early predictable.

Dual β-Lactam Combinations Highly Active against Mycobacterium abscessus Complex In Vitro

As a consequence of a growing population of immunocompromised individuals, including transplant recipients and cystic fibrosis patients, there has been a dramatic increase in chronic infections caused by Mycobacterium abscessus complex (MABC) strains that are usually recalcitrant to effective antibiotic therapy. The recent rise of macrolide resistance in MABC has further complicated this clinical dilemma, dramatizing the need for novel agents. The repurposing of current antibiotics is one rapid path from discovery to patient care. In this study, we have discovered that dual β-lactams, and specifically the combination of ceftazidime with either ceftaroline or imipenem, are synergistic and have clinically relevant activities, with MIC50s of 0.25 (ceftaroline with 100 µg/ml ceftazidime) and 0.5 µg/ml (imipenem with 100 µg/ml ceftazidime) against clinical MABC isolates. Similar synergy was observed in time-kill studies against the M. abscessus ATCC 19977 strain using clinically achievable concentrations of either imipenem (4 µg/ml) or ceftaroline (2 µg/ml), as the addition of ceftazidime at concentrations of ≥50 µg/ml showed a persistent bactericidal effect over 5 days. Treatment of THP-1 human macrophages infected with three different M. abscessus clinical isolates supported the in vitro findings, as the combination of 100 µg/ml ceftazidime and 0.125 µg/ml ceftaroline or 100 µg/ml ceftazidime and 0.25 µg/ml imipenem dramatically reduced the CFU counts to near baseline levels of infection. This study's finding that there is synergy between certain β-lactam combinations against M. abscessus infection provides optimism toward identifying an optimum dual β-lactam treatment regimen.IMPORTANCE The emergence of chronic MABC infections among immunocompromised populations and their inherent and acquired resistance to effective antibiotic therapy have created clinical challenges in advancing patients for transplant surgery and treating those with disease. There is an urgent need for new treatment regimens, and the repurposing of existing antibiotics provides a rapid strategy to advance a laboratory finding to patient care. Our recent discoveries that dual β-lactams, specifically the combination of ceftazidime with ceftaroline or ceftazidime with imipenem, have significant in vitro MIC values and kill curve activities and are effective against infected THP-1 human macrophages provide optimism for a dual β-lactam treatment strategy against MABC infections. The unexpected synergistic activities reported in this study create a new path of discovery to repurpose the large family of β-lactam drugs.

Insertion of an intrathecal catheter following a recognised accidental dural puncture reduces the need for an epidural blood patch in parturients: an Australian retrospective study

BACKGROUND

There is no clear consensus about how best to prevent post-dural puncture headache (PDPH) following an accidental dural puncture in parturients. Our primary objective was to investigate whether the insertion of an intrathecal catheter following accidental dural puncture reduces the incidence of PDPH and therapeutic epidural blood patch.

METHODS

Anaesthetic records from January 2009 to December 2015 were reviewed retrospectively and parturients who had an accidental dural puncture and/or PDPH were identified. Data from those with a recognised dural puncture in whom an intrathecal catheter was inserted at the time of accidental dural puncture (ITC group) were compared to those without an intrathecal catheter (non-ITC group), as were outcomes of patients with an intrathecal catheter for ≥24 hours compared to <24 hours.

RESULTS

Of 94 recognised accidental dural punctures, 66 were in the ITC group (37 for ≥24 h) and 28 in the non-ITC group. In the ITC group, 22 (33.3%) required an epidural blood patch in comparison to 19 (67.9%) in the non-ITC group (P <0.01, 95% CI 12.5 to 52.0). In the ITC group, 62 (93.9%) developed PDPH in comparison to 28 (100%) in the non-ITC group (P=0.186, 95% CI -6.55 to 14.57). Intrathecal catheter insertion for ≥24 h obviated the need for an epidural blood patch in 28 (75.7%) parturients, compared to 13 (59.1%) if <24 h (P=0.184, 95% CI -7.08 to 39.72).

CONCLUSION

Inserting an intrathecal catheter after a recognised accidental dural puncture significantly reduced the need for an epidural blood patch.

Field-Based Scoring of Soybean Iron Deficiency Chlorosis Using RGB Imaging and Statistical Learning

Iron deficiency chlorosis (IDC) is an abiotic stress in soybean that can cause significant biomass and yield reduction. IDC is characterized by stunted growth and yellowing and interveinal chlorosis of early trifoliate leaves. Scoring IDC severity in the field is conventionally done by visual assessment. The goal of this study was to investigate the usefulness of Red Green Blue (RGB) images of soybean plots captured under the field condition for IDC scoring. A total of 64 soybean lines with four replicates were planted in 6 fields over 2 years. Visual scoring (referred to as Field Score, or FS) was conducted at V3-V4 growth stage; and concurrently RGB images of the field plots were recorded with a high-throughput field phenotyping platform. A second set of IDC scores was done on the plot images (displayed on a computer screen) consistently by one person in the office (referred to as Office Score, or OS). Plot images were then processed to remove weeds and extract six color features, which were used to train computer-based IDC scoring models (referred to as Computer Score, or CS) using linear discriminant analysis (LDA) and support vector machine (SVM). The results showed that, in the fields where severe IDC symptoms were present, FS and OS were strongly positively correlated with each other, and both of them were strongly negatively correlated with yield. CS could satisfactorily predict IDC scores when evaluated using FS and OS as the reference (overall classification accuracy > 81%). SVM models appeared to outperform LDA models; and the SVM model trained to predict IDC OS gave the highest prediction accuracy. It was anticipated that coupling RGB imaging from the high-throughput field phenotyping platform with real-time image processing and IDC CS models would lead to a more rapid, cost-effective, and objective scoring pipeline for soybean IDC field screening and breeding.

Report on a proving of pulsatilla 3x

We report a proving of Pulsatilla 3x conducted during three months of 1978 with 52 volunteers in North West England.

The study included a double blind cross-over administration of placebo or medicated tablets in a manner intended to provide control as well as test phases.

Two important findings are reported. First, that the results obtained failed to give statistically significant evidence for the effects of Pulsatilla 3x. Second, that the reported effects clearly indicated a “trial response”. That is, a response to the process of the trial rather than to the agent being proved.

The significance and implications of these findings are discussed.

Type 3 VWD and an inhibitor to VWF: Challenges in diagnosis

Developing an inhibitor to von Willebrand factor (VWF) is extremely uncommon. Consequently, patients with von Willebrand disease (VWD) tend not to be routinely evaluated for inhibitors, leading to the possibility of delay in inhibitor diagnosis. We present such an occurrence to raise awareness, with a view to avoiding such delays. A 1-year-old male with no family history of bleeding disorders or parental consanguinity presented with a tongue bleed lasting three days. Investigations confirmed a diagnosis of Type 3 VWD. Over the next few months, the patient received seven exposures to Humate-P (a plasma derived FVIII containing von Willebrand factor concentrate), but developed an anaphylactic reaction necessitating adrenalin and Benadryl (diphenhydramine). The reaction quickly abated and did not recur with further exposure to Humate-P. In 2013, due to recurrent epistaxis and tonsillar bleeding, the patient was commenced on prophylaxis receiving Humate-P 50 RCo U/kg twice weekly. Despite this regimen, he continued to experience recurrent epistaxis, leading to escalation of prophylaxis to 3/week. In November 2014, he showed persistent tonsillar bleeding, despite having received two doses of Humate-P (each 40 RCo U/kg) in the previous 12 hours. Testing revealed reduced VWF:Ag, VWF:RCo and FVIII:C recoveries. Further testing revealed an anti-VWF antibody (2.6 BU) of unspecified Ig type. Since diagnosis of the inhibitor, he has received 100 RCo U/kg daily for prophylaxis and immune tolerance. He is now bleed-free; however, monthly inhibitor testing shows that his inhibitor persists. Given the limited experience and literature on inhibitors in VWD, the prognosis for such cases is unknown.

The Overseas Registration Examination of the General Dental Council

The Overseas Registration Examination is a route to entry to the UK Dentists Register for dentists who have qualified outside the European Economic Area. The role of the examination is to protect the public by ensuring that such dentists meet minimum standards of competence. Candidates invest considerable time and resource in attempting the examination. For these reasons it is essential that the examination is both robust and fair. This paper describes the fundamental principles of assessment underpinning the design of the examination and the steps taken by the General Dental Council's ORE Advisory Group to assure its ongoing quality.

Efficacy of Minocycline in Naturally Occurring Nonacute Ehrlichia canis Infection in Dogs

BACKGROUND

Minocycline has been used in the treatment of Ehrlichia canis infection in dogs as an alternative to doxycycline, the recommended treatment. However, efficacy of this alternative therapy is unknown.

OBJECTIVE

To assess the efficacy of minocycline in the treatment of natural occurring E. canis infection in dogs.

ANIMALS

Ten privately owned dogs of mixed breed positive for E. canis by blood PCR.

METHODS

Prospective, randomized clinical study. Dogs positive for E. canis by PCR were housed in a kennel environment and randomly allocated to receive doxycycline 10 mg/kg bodyweight PO once daily ("gold standard" control group) or minocycline (extralabel) 10 mg/kg bodyweight PO twice daily (treatment test group) for 28 days. Blood, analyzed by PCR to determine the presence or absence of E. canisDNA, was collected weekly during treatment starting on the first day of treatment and including through day 35, 7 days after the last treatment.

RESULTS

In both groups, one dog tested negative after 7 days of treatment. For the doxycycline group, the latest time to a negative PCR test was after 3 weeks of treatment. For the minocycline group, the latest time was on day 28 of treatment. All dogs tested negative 7 days after the end of treatment.

CONCLUSION AND CLINICAL IMPORTANCE

Minocycline can be an effective alternative to doxycycline for clearing E. canis from the blood in nonacute infections.

A stress tensor and QTAIM perspective on the substituent effects of biphenyl subjected to torsion

The Quantum Theory of Atoms in Molecules (QTAIM) defines quantities in 3D space that can be easily obtained from routine quantum chemical calculations. The present investigation shows that local properties can be related quantitatively to measures traditionally connected to experimental data, such as Hammett constants. We consider the specific case of substituted biphenyl to quantify the effects of a torsion φ, 0.0° ≤ φ ≤ 180.0°, of the C-C bond linking the two phenyl rings for C12 H9 -x, where x = N(CH3 )2 , NH2 , CH3 , CHO, CN, NO2, on the entire molecule. QTAIM interpreted Hammett constants, aΔH(rb ) are introduced and constructed using the difference between the H(rb ) value of C12 H9 -x and the C12 H9 -H, biphenyl which is the reference molecule, with a constant of proportionality a. This investigation unexpectedly yields very good or good agreement for the x groups with the Hammett para-, meta-, and ortho-substituent constants and is checked against para-substituted benzene. We then proceed to present the interpreted substituent constants of seven new biphenyl substituent groups, where tabulated Hammett substituent constant values are not available; y = SiH3 , ZnCl, COOCH3 , SO2 NH2 , SO2 OH, COCl, CB3 . Consistency is found for the QTAIM interpreted biphenyl substituent constants of the seven new groups y independently using the stress tensor polarizability Pσ . In addition, a selection of future applications is discussed that highlight the usefulness of this approach. © 2016 Wiley Periodicals, Inc.

Promotion of Influenza Prevention Beliefs and Behaviors through Primary School Science Education

BACKGROUND

School-based campaigns to improve student health have demonstrated short-term success across various health topics. However, evidence of the effectiveness of programs in promoting healthy beliefs and behaviors is limited. We hypothesized that educational curricula teaching the science behind health promotion would increase student knowledge, beliefs and adherence to healthy behaviors, in this case related to influenza.

METHODS

Integrated Science Education Outreach is a successful education intervention in Rochester, Minnesota public schools that has demonstrated improvements in student learning. Within this program, we designed novel curricula and assessments to determine if gains in knowledge extended to influenza prevention. Further, we coupled InSciEd Out programming with a clinical intervention, Influenza Prevention Prescription Education (IPPE), to compare students' attitudes, intentions and healthy behaviors utilizing surveys and hand hygiene monitoring equipment.

RESULTS

95 students participated in (IPPE) in the intervention school. Talking drawings captured improvement in influenza prevention understanding related to hand washing [pre n=17(43%); post n=30(77%)] and vaccination [pre n=2(5%); post n=15(38%)]. Findings from 1024 surveys from 566 students revealed strong baseline understanding and attitudes related to hand washing and cough etiquette (74% or greater positive responses). Automated hand hygiene monitoring in school bathrooms and classrooms estimated compliance for both soap (overall median 63%, IQR 38% to 100%) and hand sanitizer use (0.04 to 0.24 uses per student per day) but did not show significant pre/ post IPPE differences.

CONCLUSIONS

Student understanding of principles of influenza prevention was reasonably high. Even with this baseline, InSciEd Out and IPPE improved students' unprompted knowledge of behaviors to prevent influenza, as reflected by talking drawings. This novel metric may be more sensitive in capturing knowledge among students than traditional assessment methods. However, IPPE did not produce further significant differences in student attitudes and behaviors regarding the flu.

Study protocol for an evaluation of the effectiveness of 'care bundles' as a means of improving hospital care and reducing hospital readmission for patients with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic Obstructive Pulmonary Disease is one of the commonest respiratory diseases in the United Kingdom, accounting for 10% of unplanned hospital admissions each year. Nearly a third of these admitted patients are re-admitted to hospital within 28 days of discharge. Whilst there is a move within the NHS to ensure that people with long-term conditions receive more co-ordinated care, there is little research evidence to support an optimum approach to this in COPD. This study aims to evaluate the effectiveness of introducing standardised packages of care i.e. care bundles, for patients with acute exacerbations of COPD as a means of improving hospital care and reducing re-admissions.

METHODS / DESIGN

This mixed-methods evaluation will use a controlled before-and-after design to examine the effect of, and costs associated with, implementing care bundles for patients admitted to hospital with an acute exacerbation of COPD, compared with usual care. It will quantitatively measure a range of patient and organisational outcomes for two groups of hospitals - those who deliver care using COPD care bundles, and those who deliver care without the use of COPD care bundles. These care bundles may be provided for patients with COPD following admission, prior to discharge or at both points in the care pathway. The primary outcome will be re-admission to hospital within 28 days of discharge, although the study will additionally investigate a number of secondary outcomes including length of stay, total bed days, in-hospital mortality, costs of care and patient / carer experience. A series of nested qualitative case studies will explore in detail the context and process of care as well as the impact of COPD bundles on staff, patients and carers.

DISCUSSION

The results of the study will provide information about the effectiveness of care bundles as a way of managing in-hospital care for patients with an acute exacerbation of COPD. Given the number of unplanned hospital admissions for this patient group and their rate of subsequent re-admission, it is hoped that this evaluation will make a timely contribution to the evidence on care provision, to the benefit of patients, clinicians, managers and policy-makers.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials - ISRCTN13022442 - 11 February 2015.

The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review

BACKGROUND

Having a visual, hearing or physical impairment (defined as problems in body function or structure) may adversely influence the mental well-being of military personnel. This paper reviews the existing literature regarding the prevalence of mental health problems among (ex-)military personnel who have a permanent, predominantly, physical impairment.

METHOD

Multiple electronic literature databases were searched for relevant studies (EMBASE (1980-January 2014), MEDLINE (1946-January 2014), PsycINFO (2002-January 2014), Web of Science (1975-January 2014)).

RESULTS

25 papers were included in the review, representing 17 studies. Studies conducted among US military personnel (n=8) were most represented. A range of mental health disorders were investigated; predominately post-traumatic stress disorder (PTSD), but also depression, anxiety disorder (excluding PTSD), psychological distress and alcohol misuse. The findings indicate that mental health disorders including PTSD (range 2-59%), anxiety (range 16.1-35.5%), depression (range 9.7-46.4%) and psychological distress (range 13.4-36%) are frequently found whereby alcohol misuse was least common (range 2.2-26.2%).

CONCLUSIONS

Common mental health disorders were frequently identified among (ex-)military personnel with a physical impairment. Adequate care and support is necessary during the impairment adaptation process to facilitate the psychosocial challenges (ex-)military personnel with an impairment face. Future research should be directed into factors impacting on the mental well-being of (ex-)military personnel with an impairment, how prevalence rates vary across impairment types and to identify and act on specific needs for care and support.

Minimal important difference in field walking tests in non-cystic fibrosis bronchiectasis following exercise training

BACKGROUND

The 6-min walk distance (6MWD) and incremental shuttle walk distance (ISWD) are clinically meaningful measures of exercise capacity in people with non-cystic fibrosis (CF) bronchiectasis, but the change in walking distance which constitutes clinical benefit is undefined. This study aimed to determine the minimal important difference for the 6MWD and ISWD in non-CF bronchiectasis.

METHODS

Thirty-seven participants with mean FEV1 70% predicted completed both field walking tests before and after an 8-week exercise program. The minimal important difference was calculated using a distribution-based and anchor-based method, with the global rating of change scale used.

RESULTS

The mean change in 6MWD in participants who reported themselves to be unchanged was 10 m, compared to 36 m (small change) and 45 m (substantial change) (p = 0.01). For the ISWD, the mean change in participants who reported themselves to be unchanged was 33 m, compared to 54 m (small change) and 73 m (substantial change) (p = 0.04). The anchor-based method defined the minimal important difference for 6MWD as 24.5 m (AUC 0.76, 95% CI 0.61-0.91) and for ISWD as 35 m (AUC 0.88, 95% CI 0.73-0.99), based on participant's global rating of change. The distribution-based method indicated a value of 22.3 m for the 6MWD and 37 m for the ISWD. There was excellent agreement between the two methods for the 6MWD (kappa = 0.91) and the ISWD (kappa = 0.92).

CONCLUSIONS

Small changes in 6MWD and ISWD may represent clinically important benefits in people with non-CF bronchiectasis. These data are likely to assist in the interpretation of change in exercise capacity following intervention.

Day-case minimally invasive excision of a giant mediastinal parathyroid adenoma

Inferior parathyroid adenomas in the mediastinum can be a troublesome cause for hypercalcaemia, requiring a full collar incision or, occasionally, a sternotomy. We report a case of a giant parathyroid adenoma in a 61-year-old woman on warfarin, which we excised via a minimally invasive transcervical approach after radiological localisation. The procedure was performed as a day case and, at six weeks, the patient had recovered fully with biochemical resolution of hypercalcaemia. This case demonstrates that focused transcervical excision of giant parathyroid adenomas is a viable option and should be considered prior to neck exploration or sternotomy.

Physiotherapy practice patterns for patients undergoing surgery for lung cancer: a survey of hospitals in Australia and New Zealand

BACKGROUND

There has been a recent increase in the research available to guide physiotherapy management of patients who require surgical resection for lung cancer. It is unclear whether this evidence has influenced clinical practice.

AIM

To describe physiotherapy practice patterns in the preoperative and postoperative management of patients who undergo surgical resection for lung cancer.

METHODS

Physiotherapists involved in the management of patients who require surgical resection for lung cancer at hospitals across Australia and New Zealand were mailed a purpose-designed questionnaire.

RESULTS

The response rate was 91% (43/47). Prior to surgery, 40% (n = 17) of the respondents indicated that patients were not assessed by a physiotherapist. In most hospitals (n = 39; 91%), patients did not participate in supervised exercise training before surgery. Most commonly, physiotherapy was commenced on the day following surgery (n = 39; 91%), with walking-based exercise being the treatment that was most frequently implemented in all patients (n = 40; 93%). Seventy-two per cent of respondents referred less than 25% of patients to pulmonary rehabilitation on discharge from hospital. Physiotherapy assessment and treatment choices were influenced predominantly by established practice in the hospital and personal experience rather than research findings.

CONCLUSION

In people who undergo surgical resection for lung cancer, physiotherapy services focused on reducing or preventing postoperative pulmonary complications. Despite recent data suggesting that exercise training is beneficial in this population, our data indicate that referral to pulmonary rehabilitation was uncommon.

Insulin and extremity muscle mass in overweight and obese women

Obesity disproportionately affects women, especially those of African descent, and is associated with increases in both fat and muscle masses. Although increased extremity muscle mass may be compensatory to fat mass load, we propose that elevated insulin levels resulting from diminished insulin sensitivity may additionally contribute to extremity muscle mass in overweight or obese women. The following measurements were performed in 197 non-diabetic women (57% black, 35% white; age 46±11 years [mean±SD], BMI range 25.0 to 57.7 kg/m²): dual-energy X-ray absorptiometry for fat and extremity muscle masses; exercise performance by duration and peak oxygen consumption (VO₂ peak) during graded treadmill exercise; fasting insulin and in 183 subjects insulin sensitivity index (S_I) calculated from the minimal model. S_I (range 0.5 to 14.1 liter/mU⁻¹•min⁻¹) was negatively, and fasting insulin (range 1.9 to 35.6 μU/mL) positively, associated with extremity muscle mass (both P<0.001), independent of age and height. Sixty-seven percent of women completed 6 months of participation in a weight loss and exercise program: We found a significant association between reduction in fasting insulin and a decrease in extremity muscle mass (P=0.038), independent of reduction in fat mass or improvement in exercise performance by VO₂ peak and exercise duration, and without association with change in S_I or interaction by race. Thus, hyperinsulinemia in overweight or obese women is associated with increased extremity muscle mass, which is partially reversible with reduction in fasting insulin concentration, consistent with stimulatory effects of insulin on skeletal muscle.