Showing papers in "British Medical Bulletin in 2019"
TL;DR: This scoping review investigated: what is known about current nurse workforces and shortages and what can be done to forestall such shortages?
Abstract: Introduction Nurses comprise half the global health workforce. A nine million shortage estimated in 2014 is predicted to decrease by two million by 2030 but disproportionality effect regions such as Africa. This scoping review investigated: what is known about current nurse workforces and shortages and what can be done to forestall such shortages? Sources of data Published documents from international organisations with remits for nursing workforces, published reviews with forward citation and key author searches. Areas of agreement Addressing nurse shortages requires a data informed, country specific model of the routes of supply and demand. It requires evidence informed policy and resource allocation at national, subnational and organisation levels. Areas of controversy The definition in law, type of education, levels and scope of practice of nurses varies between countries raising questions of factors and evidence underpinning such variation. Most policy solutions proposed by international bodies draws on data and research about the medical workforce and applies that to nurses, despite the different demographic profile, the work, the career options, the remuneration and the status. Growing points Demand for nurses is increasing in all countries. Better workforce planning in nursing is crucial to reduce health inequalities and ensure sustainable health systems. Areas timely for developing research Research is needed on: the nursing workforce in low income countries and in rural and remote areas; on the impact of scope of practice and task-shifting changes; on the impact over time of implementing system wide policies as well as raising the profile of nursing.
181 citations
TL;DR: A systematic search of articles assessing the role of microRNA in physiopathology, diagnosis and therapy of OA was performed, giving a critical perspective of the possibilities for diagnostic and therapeutic use of miRNA in the management of Oa.
Abstract: Background Osteoarthritis (OA) is the most orthopedic condition. The pattern of gene expression and the transcription factors that exert control of chondrogenesis have been extensively studied. Sources of data A systematic search (up to July 2018) of articles assessing the role of microRNA (miRNA) in physiopathology, diagnosis and therapy of OA was performed, with the purpose of giving a critical perspective of the possibilities for diagnostic and therapeutic use of miRNA in the management of OA. Areas of agreement miRNAs are small noncoding RNAs that can regulate gene expression in human cells. miRNAs can be expressed in a different fashion in osteoarthritic compared to nonosteoarthritic cartilage. Areas of controversy The mechanisms that produce alteration of gene expression in OA are still not completely understood. miRNAs may be involved in the diagnosis of OA as well as in its treatment. Growing points There are complex interactions between miRNAs and their multiple target genes. These interactions may be important in gene regulation and the control of homeostatic pathways in OA. Areas timely for developing research miRNA could be useful for diagnostic or management purposes, but the issue of delivery of miRNA targeting agents needs to be overcome before miRNA can be applied in clinical practice.
98 citations
TL;DR: Measuring presenteeism as well as absenteeism will provide more accurate information about employee health and help raise awareness of the risks of working while sick and the economic, moral, cultural and social pressures on employees to do so.
Abstract: Introduction Presenteeism is defined as continuing to attend work during illness. As a growing health concern, awareness of the factors that encourage presenteeism and the risks of this behaviour is needed. Sources of data A narrative review of research obtained via several databases, including Medline and Psycinfo, was conducted. Areas of agreement A range of contextual and individual factors is associated with presenteeism. Workers in some sectors, such as healthcare, appear to be at greater risk. Presenteeism may facilitate rehabilitation and recovery but it can exacerbate existing health problems and increase the risk of subsequent illness and absence as well as impair workability. Areas of controversy The incidence of sickness presenteeism is rising, alongside reductions in absenteeism. The growing awareness of the costs of presenteeism, especially in safety-critical environments, suggests that it should be considered a risk-taking behaviour and carefully measured and managed. Growing points and areas for developing research Measuring presenteeism as well as absenteeism will provide more accurate information about employee health. Raising awareness of the risks of working while sick and the economic, moral, cultural and social pressures on employees to do so appears crucial. Systemic interventions to manage presenteeism based on research evidence are required.
73 citations
TL;DR: Interventions designed to help managers facilitate psychological resilience in their workforce could substantially increase resilience and reduce the risk of long-term mental health problems in trauma-exposed employees.
Abstract: Background Many people who experience a disaster will do so as part of an occupational group, either by chance or due to the nature of their role. Sources of data This review is based on literature published in scientific journals. Areas of agreement There are many social and occupational factors, which affect post-disaster mental health. In particular, effective social support-both during and post-disaster-appears to enhance psychological resilience. Areas of controversy There is conflicting evidence regarding the best way to support trauma-exposed employees. Many organisations carry out post-incident debriefing despite evidence that this is unhelpful. Growing points Employees who are well supported tend to have better psychological outcomes and as a result may be more likely to perform well at work. Areas timely for developing research The development and evaluation of workplace interventions designed to help managers facilitate psychological resilience in their workforce is a priority. Successful interventions could substantially increase resilience and reduce the risk of long-term mental health problems in trauma-exposed employees.
68 citations
TL;DR: Sustained virus surveillance and collection of ecological and physiological parameters from birds in different environments is required to better understand influenza virus ecology and identify risk factors for human infection.
Abstract: Background Human infections with avian influenza viruses (AIV) represent a persistent public health threat. The principal risk factor governing human infection with AIV is from direct contact with infected poultry and is primarily observed in Asia and Egypt where live-bird markets are common. Areas of agreement Changing patterns of virus transmission and a lack of obvious disease manifestations in avian species hampers early detection and efficient control of potentially zoonotic AIV. Areas of controversy Despite extensive studies on biological and environmental risk factors, the exact conditions required for cross-species transmission from avian species to humans remain largely unknown. Growing points The development of a universal ('across-subtype') influenza vaccine and effective antiviral therapeutics are a priority. Areas timely for developing research Sustained virus surveillance and collection of ecological and physiological parameters from birds in different environments is required to better understand influenza virus ecology and identify risk factors for human infection.
61 citations
TL;DR: Pathophysiology and epidemiology, the current diagnostic approach and its limitations and management of liver abscess in low resource settings, and growing points as antimicrobial resistance awareness and antibiotic stewardship programs are put into place.
Abstract: Introduction Liver abscesses are mainly caused by parasitic or bacterial infection and are an important cause of hospitalization in low-middle income countries (LMIC). The pathophysiology of abscesses is different depending on the etiology and requires different strategies for diagnosis and management. This paper discusses pathophysiology and epidemiology, the current diagnostic approach and its limitations and management of liver abscess in low resource settings. Sources of data We searched PubMed for relevant reviews by typing the following keywords: 'amoebic liver abscess' and 'pyogenic liver abscess'. Areas of agreement Amoebic liver abscess can be treated medically while pyogenic liver abscess usually needs to be percutaneously drained and treated with effective antibiotics. Areas of controversy In an LMIC setting, where misuse of antibiotics is a recognized issue, liver abscesses are a therapeutic conundrum, leaving little choices for treatment for physicians in low capacity settings. Growing points As antimicrobial resistance awareness and antibiotic stewardship programs are put into place, liver abscess management will likely improve in LMICs provided that systematic adapted guidelines are established and practiced. Areas timely for developing research The lack of a quick and reliable diagnostic strategy in the majority of LMIC makes selection of appropriate treatment challenging.
54 citations
TL;DR: What immune responses are required to control HCMV, and how best to raise these immune responses with a vaccine is understood, and a chemokine-based fusion toxin protein, F49A-FTP, has shown promise in killing both lytically and latently infected cells.
Abstract: Background Human cytomegalovirus (HCMV) is a threat to immunologically weak patients. HCMV cannot yet be eliminated with a vaccine, despite recent advances. Sources of data Sources of data are recently published research papers and reviews about HCMV treatments. Areas of agreement Current antivirals target the UL54 DNA polymerase and are limited by nephrotoxicity and viral resistance. Promisingly, letermovir targets the HCMV terminase complex and has been recently approved by the FDA and EMA. Areas of controversy Should we screen newborns for HCMV, and use antivirals to treat sensorineural hearing loss after congenital HCMV infection? Growing points Growing points are developing drugs against latently infected cells. In addition to small molecule inhibitors, a chemokine-based fusion toxin protein, F49A-FTP, has shown promise in killing both lytically and latently infected cells. Areas timely for developing research We need to understand what immune responses are required to control HCMV, and how best to raise these immune responses with a vaccine.
47 citations
TL;DR: The role of inflammation in tendon healing is still unclear, though it seems to affect the overall outcome, and a thorough understanding of the biochemical mediators of healing and their pathway of pain could be used to target tendinopathy and possibly guide its management.
Abstract: Background Tendinopathy is a common musculoskeletal condition affecting subjects regardless of their activity level. Multiple inflammatory molecules found in ex vivo samples of human tendons are related to the initiation or progression of tendinopathy. Their role in tendon healing is the subject of this review. Sources of data An extensive review of current literature was conducted using PubMed, Embase and Cochrane Library using the term 'tendon', as well as some common terms of tendon conditions such as 'tendon injury OR (tendon damage) OR tendonitis OR tendinopathy OR (chronic tendonitis) OR tendinosis OR (chronic tendinopathy) OR enthesitis' AND 'healing' AND '(inflammation OR immune response)' as either key words or MeSH terms. Areas of agreement An environment characterized by a low level of chronic inflammation, together with increased expression of inflammatory cytokines and growth factors, may influence the physiological tendon healing response after treatment. Areas of controversy Most studies on this topic exhibited limited scientific translational value because of their heterogeneity. The evidence associated with preclinical studies is limited. Growing points The role of inflammation in tendon healing is still unclear, though it seems to affect the overall outcome. A thorough understanding of the biochemical mediators of healing and their pathway of pain could be used to target tendinopathy and possibly guide its management. Areas timely for developing research We require further studies with improved designs to effectively evaluate the pathogenesis and progression of tendinopathy to identify cellular and molecular targets to improve outcomes.
31 citations
TL;DR: Chest ultrasound should be considered as a first-line imaging modality for children with suspected pneumonia, and comparing against a valid gold standard is recommended.
Abstract: Background Chest ultrasound is an emerging imaging modality, for several paediatric pulmonary diseases. Sources of data MEDLINE and EMBASE (1946-47 to 10 March 2017) were searched to collect evidence on the diagnostic accuracy of chest ultrasound, compared to other imaging modalities, for the diagnosis of paediatric pulmonary diseases. Areas of agreement Eighteen pneumonia studies, comprising 2031 children, were included for meta-analysis; the summary estimate sensitivity was 95.0% (95%CI: 90.7-97.3%) and specificity was 96.1% (95%CI: 89.1-98.7%). Areas of controversy Other pulmonary diseases also yielded high sensitivity and specificity, but a meta-analysis could not be conducted due to a limited number of studies includable, and their heterogeneity. Growing points Chest ultrasound should be considered as a first-line imaging modality for children with suspected pneumonia. Areas timely for developing research Further research should focus on the diagnostic accuracy of chest ultrasound for the diagnosis of paediatric pulmonary diseases, other than pneumonia, comparing against a valid gold standard.
30 citations
TL;DR: There is renewed and intense interest in understanding the complex 'new biology' of the neutrophils, specifically whether this cell might be a valid therapeutic target in ARDS and other neutrophil-driven diseases and developing understanding of ways to enhance the beneficial role of the Neutrophil in the resolution phase of ARDS.
Abstract: Introduction Neutrophils are the primary effectors of the innate immune system but are profoundly histotoxic cells. The acute respiratory distress syndrome (ARDS) is considered to be a prime example of neutrophil-mediated tissue injury. Sources of data The information presented in this review is acquired from the published neutrophil cell biology literature and the longstanding interest of the senior authors in ARDS pathogenesis and clinical management. Areas of agreement Investigators in the field would agree that neutrophils accumulate in high abundance in the pulmonary microcirculation, lung interstitium and alveolar airspace of patients with ARDS. ARDS is also associated with systemic neutrophil priming and delayed neutrophil apoptosis and clearance of neutrophils from the lungs. In animal models, reducing circulating neutrophil numbers ameliorates lung injury. Areas of controversy Areas of uncertainty include how neutrophils get stuck in the narrow pulmonary capillary network-whether this reflects changes in the mechanical properties of primed neutrophils alone or additional cell adhesion molecules, the role of neutrophil sub-sets or polarization states including pro-angiogenic and low-density neutrophils, whether neutrophil extracellular trap (NET) formation is beneficial (through bacterial capture) or harmful and the potential for neutrophils to participate in inflammatory resolution. The latter may involve the generation of specialized pro-resolving molecules (SPMs) and MMP-9, which is required for adequate matrix processing. Growing points Different and possibly stable endotypes of ARDS are increasingly being recognized, yet the relative contribution of the neutrophil to these endotypes is uncertain. There is renewed and intense interest in understanding the complex 'new biology' of the neutrophil, specifically whether this cell might be a valid therapeutic target in ARDS and other neutrophil-driven diseases and developing understanding of ways to enhance the beneficial role of the neutrophil in the resolution phase of ARDS. Areas timely for developing research Aside from treatment of the precipitating causes of ARDS, and scrupulous fluid, infection and ventilation management, there are no pharmacological interventions for ARDS; this represents an urgent and unmet need. Therapies aimed at reducing overall neutrophil numbers risk secondary infection; hence better ways are needed to reverse the processes of neutrophil priming activation, hyper-secretion and delayed apoptosis while enhancing the pro-resolution functions of the neutrophil.
29 citations
TL;DR: An overview of health impacts and the current evidence for designing programmes and policies related to rural health emergency and disaster risk management (health-EDRM) in Asia is provided.
Abstract: Introduction Disaster epidemiological studies indicate that Asia has the highest frequency of natural disasters. Rural communities are heavily impacted by natural disasters and have different healthcare needs to urban ones. Referencing Asian countries, this paper's objective is to provide an overview of health impacts and the current evidence for designing programmes and policies related to rural health emergency and disaster risk management (health-EDRM). Sources of data This paper uses published English-only reports and papers retrieved from PubMed, Google Scholar, Embase, Medline and PsycINFO on rural disaster and emergency responses and relief, health impact and disease patterns in Asia (January 2000-January 2018). Areas of agreement Earthquakes are the most studied natural disasters in rural communities. The medical burden and health needs of rural communities were most commonly reported among populations of extreme age. Most of the existing research evidence for rural interventions was reported in China. There lacks published peer-reviewed reports of programme impacts on personal and community preparedness. Areas of controversy There is a lack of evidence-based health-EDRM interventions to evaluate implementation effectiveness in rural areas despite vast volumes of health-related disaster literature. Growing points Climate change-related disasters are increasing in frequency and severity. Evidence is needed for disaster risk reduction interventions to address the health risks specific to rural populations. Areas timely for developing research To support global policy development, urgent evidence is needed on the intervention effectiveness, long-term health outcomes, local and cultural relevance as well as sustainability of health relief produced by Health-EDRM programmes in rural areas.
TL;DR: Evidence is needed to understand health impacts on vulnerable populations living in growing urbanized cities and urban enclaves, in particular migrant workers, and location-specific climate-health outcome thresholds will be needed to support evidence-based clinical management plans and health impact mitigation strategies to protect vulnerable communities.
Abstract: Background This review examines the human health impact of climate change in China. Through reviewing available research findings under four major climate change phenomena, namely extreme temperature, altered rainfall pattern, rise of sea level and extreme weather events, relevant implications for other middle-income population with similar contexts will be synthesized. Sources of data Sources of data included bilingual peer-reviewed articles published between 2000 and 2018 in PubMed, Google Scholar and China Academic Journals Full-text Database. Areas of agreement The impact of temperature on mortality outcomes was the most extensively studied, with the strongest cause-specific mortality risks between temperature and cardiovascular and respiratory mortality. The geographical focuses of the studies indicated variations in health risks and impacts of different climate change phenomena across the country. Areas of controversy While rainfall-related studies predominantly focus on its impact on infectious and vector-borne diseases, consistent associations were not often found. Growing points Mental health outcomes of climate change had been gaining increasing attention, particularly in the context of extreme weather events. The number of projection studies on the long-term impact had been growing. Areas timely for developing research The lack of studies on the health implications of rising sea levels and on comorbidity and injury outcomes warrants immediate attention. Evidence is needed to understand health impacts on vulnerable populations living in growing urbanized cities and urban enclaves, in particular migrant workers. Location-specific climate-health outcome thresholds (such as temperature-mortality threshold) will be needed to support evidence-based clinical management plans and health impact mitigation strategies to protect vulnerable communities.
TL;DR: This review considers how to prepare for and manage the vulnerable elderly surgical patient through the entire spectrum, from preoperative assessment to postoperative period, fromPreclinical and clinical reports were considered.
Abstract: Author(s): Saxena, S; Lai, IK; Li, R; Maze, M | Abstract: IntroductionThe demographics of aging of the surgical population has increased the risk for perioperative neurocognitive disorders in which trauma-induced neuroinflammation plays a pivotal role.Sources of dataAfter determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered.Areas of agreementNeuroinflammation is a sine qua non for development of perioperative neurocognitive disorders.Areas of controversyWhat is the best method for ameliorating trauma-induced neuroinflammation while preserving inflammation-based wound healing.Growing pointsThis review considers how to prepare for and manage the vulnerable elderly surgical patient through the entire spectrum, from preoperative assessment to postoperative period.Areas timely for developing researchWhat are the most effective and safest interventions for preventing and/or reversing Perioperative Neurocognitive Disorders.
TL;DR: This review summarizes and critiques the academic literature on ethical and policy issues raised by UTx, focusing on three key issues: the choice between deceased and living donors, ensuring valid consent to the procedure and access to treatment.
Abstract: Introduction In 2014, Brannstrom and colleagues reported the first human live birth following uterine transplantation (UTx). Research into this treatment for absolute uterine factor infertility has since grown with clinical trials currently taking place across centers in at least thirteen countries worldwide. Sources of data This review summarizes and critiques the academic literature on ethical and policy issues raised by UTx. Areas of agreement There is general agreement on the importance of risk reduction and, in principle, to the sharing and maintenance of patient data on an international registry. Areas of controversy There are numerous areas of controversy ranging from whether it is ethically justified to carry out uterus transplants at all (considering the associated health risks) to how deceased donor organs for transplant should be allocated. This review focuses on three key issues: the choice between deceased and living donors, ensuring valid consent to the procedure and access to treatment. Growing points UTx is presently a novel and rare procedure but is likely to become more commonplace in the foreseeable future, given the large number of surgical teams working on it worldwide. Areas timely for developing research Uterus transplantation requires us to re-examine fundamental questions about the ethical and social value of gestation. If eventually extended to transgender women or even to men, it may also require us to reconceptualize what it is to be a 'father' or to be a 'mother', and the definition of these terms in law.
TL;DR: This systematic review investigates the biological and chemical mechanisms that affect the health and structure of tendons following the use of fluoroquinolones (FQs) and identifies five mechanisms.
Abstract: Introduction The present systematic review investigates the biological and chemical mechanisms that affect the health and structure of tendons following the use of fluoroquinolones (FQs). Sources of data A total of 12 articles were included, organized, and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Areas of agreement Five mechanisms were identified: arrest of proliferation through a decreased activity of cyclin B, CDK-1, CHK-1, and increased PK-1; decrease tenocytes migration through decreased phosphorylation of FAK; decrease type I collagen metabolism through increased MMP-2; chelate effect on ions that influence epigenetics and several enzymes; fluoroquinolones-induced ROS (radical oxygen species) production in mitochondria. Areas of controversy There is no definite structure-damage relationship. The dose-effect relationship is unclear. Growing points Knowing and defining the damage exerted by FQs plays a role in clinical practice, replacing FQs with other antibacterial drugs or using antioxidants to attenuate their pathological effects. Areas timely for developing research Clinical and basic sciences studies for each FQs are necessary.
TL;DR: Novel tissue engineering strategies focus on the development of cartilaginous biomimetic materials able to repair cartilage lesions in association to cell, trophic factors and gene therapies.
Abstract: Background Given the limited regenerative capacity of injured articular cartilage, the absence of suitable therapeutic options has encouraged tissue-engineering approaches for its regeneration or replacement. Sources of data Published articles in any language identified in PubMed and Scopus electronic databases up to August 2019 about the in vitro and in vivo properties of cartilage engineered constructs. A total of 64 articles were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Areas of agreement Regenerated cartilage lacks the biomechanical and biological properties of native articular cartilage. Areas of controversy There are many different approaches about the development of the architecture and the composition of the scaffolds. Growing points Novel tissue engineering strategies focus on the development of cartilaginous biomimetic materials able to repair cartilage lesions in association to cell, trophic factors and gene therapies. Areas timely for developing research A multi-layer design and a zonal organization of the constructs may lead to achieve cartilage regeneration.
TL;DR: Although many scoring systems have been used to evaluate hip function, there is still far from a single outcome evaluation system which is reliable, valid and sensitive.
Abstract: Introduction During the past decades, several rating scales have been developed to assess the functional status of patients with hip pain. Source of data A search in Medline, PubMed, Cochrane and CINAHL was performedusing combinations of the following'hip', 'scoring system', 'scale', 'scores', 'outcome assessment', 'arthroplasty', 'arthroscopy' and 'clinical evaluation'. Areas of agreement A total 16 scoring systems are currently available for the evaluation of the hip. Areas of controversy Two types of questionnaires are available: physician-rated and patient-rated questionnaires. Growing points Each hip score consists of different domains. Interpreting these domains becomes sometimes difficult, because, even though they can be common to more than one scoring system, each stresses them in a different way. Areas timely for developing research Although many scoring systems have been used to evaluate hip function, we are still far from a single outcome evaluation system which is reliable, valid and sensitive.
TL;DR: The direct intraligamentary stabilization technique was the most widely and accurately reported technique, with acceptable success and improvement of functional outcomes, in comparison with ACL reconstruction and no sufficient evidence was available to support these techniques.
Abstract: Background The most common procedure to manage a torn anterior cruciate ligament (ACL) is surgical reconstruction. Primary repair of the ACL is returning on the forefront in the management of acute ACL, aiming to be less invasive and preserve the original ligament. Several techniques have been reported; the present systematic review investigates the clinical outcomes of ACL primary repair in adults. Sources of data Following an electronic search through Medline, Cochrane and Google Scholar databases, articles of interest were retrieved and evaluated, including case series, retrospective studies, case-control studies and randomized controlled trials. The main outcome data were extracted and summarized in tables and text. The methodology of the studies was assessed using the Coleman methodology score (CMS). Areas of agreement Of the articles included, one was of level I, two of level III and the remaining of level IV. The direct intraligamentary stabilization technique was the most widely and accurately reported technique, with acceptable success and improvement of functional outcomes. The CMS averaged 58.75 (range 48 to 69), with no significant association with year of publication (Pearson's regression r = -0.397, P = 0.207). Areas of controversy Concerning stump sutures and suture anchors repair, although leading to good results, also in comparison with ACL reconstruction, no sufficient evidence was available to support these techniques. Growing points The overall good results were reported also for other techniques are not supported by adequate evidence. More and better trials are required to improve our knowledge and understanding in this controversial area.
TL;DR: There is a need for a validated reproducible method of rotator cuff tendon biopsy evaluation and further studies with improved designs are required to effectively evaluate the histological and immunohistochemical features of rotators cuff tendinopathy.
Abstract: Background Rotator cuff tendinopathy is a common musculoskeletal ailment in sedentary and athletic individuals. Various mediators of inflammation have been detected in human tendons: they are thought to initiate or progress the course of tendinopathy. Sources of data An online search was conducted using AMED, CINAHL, Embase, The Cochrane Library, PEDro and Pubmed, using the terms tendinopathy, tendon, tendinitis, tendinosis, histology, histopathology, immunohistochemistry, immunohistochemical, rotator cuff and pain. Areas of agreement Histological examination of tendinopathic tendons shows degeneration of the collagen structure and infiltration of fat and vessels, together with increased expression of inflammatory cytokines, MMP-1, 2, 3, 9, 13, vascular endothelial growth factor and Hypoxia inducible factor (HIF). Areas of controversy Most of the studies about this topic exhibited limited validity because of lack of appropriately matched controls and no inclusion or exclusion criteria. The evidence associated with the histopathological analysis of the rotator cuff is limited. Growing points The histochemical and immunohistochemical features of rotator cuff tendinopathy are still unclear. A thorough understanding of the vascularity, innervation and biochemical mediators of pain could be used to target rotator cuff pathology, and possibly guide the therapy of painful rotator cuff disorders. Areas timely for developing research There is a need for a validated reproducible method of rotator cuff tendon biopsy evaluation. We require further studies with improved designs to effectively evaluate the histological and immunohistochemical features of rotator cuff tendinopathy.
TL;DR: The action of ozone is unclear, but it is a promising therapeutic modality capable of impacting, favourably, function and quality of life and the lack of a clear protocol of use is a major limitation.
Abstract: Background Osteoarthritis (OA) is a most common orthopaedic condition, often complicated by inflammatory features. Sources of data A systematic search in PubMed, Embase, Google Scholar and Scopus databases (to January 2019) was performed to define the effect obtained in patients with OA of the knee by injections of ozone, on pain and physical function. Six RCTs and 353 patients were included. Areas of agreement Recently, an increasing number of physicians have used ozone therapy to alleviate the symptoms of acute and chronic OA of the knee. Ozone can allow greater mobility of the knee joint, pain relief and decrease in effusion. Areas of controversy The volume and concentration of ozone injected are different in the various treatment protocols published. Growing points The action of ozone is unclear, but it is a promising therapeutic modality capable of impacting, favourably, function and quality of life. Areas timely for developing research The lack of a clear protocol of use is a major limitation, and to date there is no clear evidence of long-term efficacy.
TL;DR: The clinical and economic benefits of treating women with milder levels of glucose intolerance during pregnancy and the development of alternative diagnostic markers and application of novel technologies for GDM management are highlighted.
Abstract: Background Gestational diabetes mellitus (GDM) is highly prevalent and has both short- and long-term implications for mother and infant. Sources of data Literature search using PubMed with keywords 'Gestational diabetes' and 'diabetes in pregnancy' together with published papers known to the authors. Areas of agreement The cornerstone of management is medical nutrition therapy with regular self-monitoring of capillary blood glucose levels and intensification of therapy if glycaemic goals are not achieved. Post-partum, annual assessment for type 2 diabetes is recommended. Areas of controversy Diagnostic criteria and new biomarkers for GDM and the clinical and economic benefits of treating women with milder levels of glucose intolerance during pregnancy. Growing points Women with GDM are a heterogeneous group with varying degrees of insulin resistance and beta cell dysfunction. Areas timely for developing research Development of alternative diagnostic markers and application of novel technologies for GDM management.
TL;DR: It is clear that even for air quality, where electric cars are suggested to offer benefits these are unlikely to be as great as has been suggested, and overall, the negative health consequences of electric cars seem likely to be at least those of internal combustion engine cars.
Abstract: Introduction Roads facilitate trade, development and communication, as well as spread illness and disease, but since mass car use began, the disbenefits, including injuries, pollution and physical inactivity have been significantly magnified. Electric cars are now being seen by many as the solution to the problems associated with internal combustion engine cars. Sources of data This article reviews existing literature to determine the extent to which a switch to electrification can solve many of the problems that cars have wrought. Areas of agreement It concludes that there may be some benefits in rural areas, where public transport is poor. Areas of controversy However, it also argues that even in rural areas it may be better to invest in public transport for many, rather than electric car infrastructure for some. It is clear that even for air quality, where electric cars are suggested to offer benefits these are unlikely to be as great as has been suggested. Overall, the negative health consequences of electric cars seem likely to be at least those of internal combustion engine cars.
TL;DR: There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients.
Abstract: BACKGROUND Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes. SOURCES OF DATA A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents. AREAS OF AGREEMENT There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients. AREAS OF CONTROVERSY Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities. GROWING POINT The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery. AREAS OF RESEARCH To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.
TL;DR: The methodological quality of the included studies is average-low, and the published evidence is not of sufficient quality to allow to draw final conclusion on the topic, but good results were reported for both ORIF and CRIF techniques.
Abstract: BACKGROUND Femoral neck fractures account for <1% of the fractures in children, and are produced by high energy trauma. The most commonly accepted treatment for such fractures is gentle manual anatomical reduction and internal fixation, yielding a healing rate between 80% and 90%. SOURCES OF DATA Electronic search through major web databases (Medline, Cochrane and Google Scholar). All types of article were eligible for inclusion, except for reviews, systematic reviews, meta-analyses and case reports. The methodological quality of the studies was assessed using the Methodological Index for NOn-Randomized Studies (MINORS). AREAS OF AGREEMENT Both open reduction and internal fixation (ORIF) and closed reduction and internal fixation (CRIF) can be used to manage hip fractures in paediatric patients. ORIF is more accurate in reducing and fixing the fracture, with better clinical and functional outcomes, and lower complication rate. Delayed fixation decreases the rate of acceptable outcome and increases the rate of complications. AREAS OF CONTROVERSY The methodological quality of the included studies is average-low, and the published evidence is not of sufficient quality to allow to draw final conclusion on the topic. GROWING POINTS Good results were reported for both ORIF and CRIF techniques, but are not supported by scientific evidence of adequate quality. More and better studies, including randomized trials, should be carried out to provide more scientifically evidence based conclusions.
TL;DR: Investigations into the accuracy of NEWS2 to predict sepsis-associated mortality are required and calls to move away from using simple comorbidity scores to predict the risk of sepsi- associated mortality should be considered.
Abstract: Introduction and background Incidence of gram-negative bloodstream infections (GNBSIs) and sepsis are rising in the UK. Healthcare-associated risk factors have been identified that increase the risk of infection and associated mortality. Current research is focused on identifying high-risk patients and improving the methods used for surveillance. Sources of data Comprehensive literature search of the topic area using PubMed (Medline). Government, professional and societal publications were also reviewed. Areas of agreement A range of healthcare-associated risk factors independently associate with the risk of GNBSIs and sepsis. Areas of controversy There are calls to move away from using simple comorbidity scores to predict the risk of sepsis-associated mortality, instead more advanced multimorbidity models should be considered. Growing points and areas for developing research Advanced risk models should be created and evaluated for their ability to predict sepsis-associated mortality. Investigations into the accuracy of NEWS2 to predict sepsis-associated mortality are required.
TL;DR: Further data on the natural history and effects of treatment of mild and asymptomatic PHPT are required to determine thresholds for surgery, and further investigations of non-skeletal and non-renal parameters, such as neurocognitive quality of life and cardiovascular disease are required.
Abstract: Introduction The presentation of primary hyperparathyroidism (PHPT) has shifted from a disease characterized by renal and skeletal complications to a mild or asymptomatic condition. Modern imaging allows localization of a surgical target in the majority of cases. Sources of data Data were collected from literature searches of online databases including PUBMED, MEDLINE and Cochrane. A narrative review was performed. Areas of agreement Parathyroidectomy is the only therapy with curative potential with good outcomes and low risk of complications in experienced hands. Current guidelines advocate that surgery is offered in all symptomatic cases and in those who meet criteria depending on age, serum calcium concentration, skeletal and renal parameters. A structured monitoring approach should be offered to those who do not undergo surgery. Areas of controversy Thresholds for intervention to improve skeletal and renal outcomes are debatable. In addition, controversy persists over the benefit of surgery for non-skeletal/renal outcomes. Growing points The role of medical management of PHPT using agents such as bisphosphonates, denosumab and cinacalcet are discussed. Areas timely for developing research In summary, further data on the natural history and effects of treatment of mild and asymptomatic PHPT are required to determine thresholds for surgery. In particular, further investigations of non-skeletal and non-renal parameters, such as neurocognitive quality of life and cardiovascular disease are required. Data on normocalcaemic PHPT are lacking. Large-scale randomized controlled trials would be welcome in these areas, however in view of the cost implications a more pragmatic approach may be to develop collaborative multi-centre registries.
TL;DR: This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears.
Abstract: INTRODUCTION This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears. SOURCES OF DATA A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'. AREAS OF AGREEMENT In all of the 10 studies included, conservative management for 6 weeks to 6 months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears. AREAS OF CONTROVERSY The optimal treatment modalities for TFC tears remain to be defined. GROWING POINTS Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears. AREAS TIMELY FOR DEVELOPING RESEARCH Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.
TL;DR: An overview of literature related to hydration interventions for older people living with multi-morbidity and dementia in care homes is provided and gaps in knowledge are highlighted.
Abstract: Introduction Care home populations experiencing high levels of multi-morbidity and dementia require support from caregivers to meet their hydration requirements. This article provides an overview of literature related to hydration interventions and highlights gaps in knowledge. Sources of data This paper draws on UK-focused literature from Applied Social Sciences Index and Abstracts (ASSIA), CINAHL, Medline, Proquest Hospital Premium Collection, Cochrane Library and RCN databases on hydration interventions for older people living with multi-morbidity and dementia in care homes. Areas of agreement Fluid intake is too low in care home residents, and no single hydration intervention is effective in addressing the complex problems that older residents present. Areas of controversy There is a lack of consensus about how much fluid an older person should consume daily for optimum health. There is also lack of agreement about what interventions are effective in supporting individuals with complex physical and cognitive problems to achieve daily fluid intake targets. Growing points To improve hydration care for residents, care home teams should be competent in the delivery of hydration care, and work closely with integrated multi-professional healthcare specialists to provide proactive case management. Areas timely for developing research There is a need for understanding of what hydration practices and processes are effective for care home residents and including these in multi-component interventions.
TL;DR: The role PHE played as a national public health agency supporting reconstruction and long-term development through the UK Government (Department for International Development) programme called 'Resilient Zero' is described.
Abstract: BACKGROUND West African governments, the WHO and wider international community were caught unprepared for the world's largest Ebola outbreak of 2014-16. This was an unprecedented challenge to local services and international agencies, since the emergency required high-tech molecular diagnostic services operated by specialist staff and a coordinated emergency response in addition to humanitarian support, which was not available at the beginning of the outbreak. Public Health England (PHE), as a new national public health agency was well placed to provide support for these needs. After the outbreak, PHE supported reconstruction to ensure diagnostic and emergency planning capability remained in place in the immediate aftermath of the outbreak and build necessary public health infrastructure for the future. The article describes the role PHE played as a national public health agency supporting reconstruction and long-term development through the UK Government (Department for International Development) programme called 'Resilient Zero'. SOURCES OF DATA Public Health England (PHE), UK Government's Department for International Development, WHO, US Centers for Communicable Diseases (CDC), China Centre for Communicable Diseases (China CDC). AREAS OF AGREEMENT The need for reliable, sustainable, in country molecular diagnostics, together with a programme to strengthen in country Emergency Planning, Preparedness and Response (EPRR). AREAS OF CONTROVERSY Providing high tech molecular capability in a resource-poor West African country with variable provision of basic diagnostic equipment, intermittent power supply, ineffective supply chains and maintaining training capacity for emergency planning in the long term. Emergency planning models from the West needed to be adapted for the countries' context. Short term aid projects as a model did not suite this development requirement. GROWING POINTS PHE had strong local and international political support to reconstruct three Government regional laboratories and deploy molecular technology. Significant learning by PHE as a national public health agency and sharing this will be of benefit to other national public health agencies. UK staff reported increased levels of satisfaction and experience relevant to public health practice. The Sierra Leonean Government and officials requested long-term levels of commitment. It is important for agencies such as PHE to constantly learn, develop long-term institutional partnerships and play a bigger role with other similar agencies internationally. AREAS TIMELY FOR DEVELOPING RESEARCH How best to support sustainable high-tech molecular technology in West Africa and modules for emergency planning relevant to the context; evidence for long term versus short-term support for highly complex diagnostic capabilities; relevance to maintaining individual country public health infrastructure to ensuring global health security; benefits of overseas work for employee of a national agency.
TL;DR: If hospices are to continue to be important providers of palliative care in children they must develop robust and fair relationships with local healthcare providers, and local providers should work with hospices to help redress the inequity that children face in accessing specialist palliatives care.
Abstract: Introduction Children's hospices offer support to children and their families according to a model that is quite different from adult hospices and has evolved in parallel with specialist paediatric palliative medicine services. Sources of data Published research, Together for Short Lives. Areas of agreement The services hospices offer are highly valued by families. Areas of controversy It is not always clear that hospices can be described as 'specialist', which can make it difficult for hospices to negotiate appropriate commissioning arrangements with the statutory sector. Growing points Children's palliative care generally is poorly developed compared with the adult specialty, and local providers should work with hospices to help redress the inequity that children face in accessing specialist palliative care. Areas timely for developing research If hospices are to continue to be important providers of palliative care in children they must develop robust and fair relationships with local healthcare providers. That would be facilitated by development of a funding formula for children that properly acknowledges the part hospices already play in palliative care.