What is the Most Effective Treatment for Frozen Shoulder?

What you need to know Consider the diagnosis in patients with pain and limitation of passive external rotation of the shoulder There is insufficient evidence to reliably recommend a treatment approach. Moderate evidence supports corticosteroid injection or hydrodilatation; and physiotherapy in reduction of pain and stiffness Consider specialist referral if the patient does not respond to conservative treatment or if the diagnosis is in doub

Implementing mental health training programmes for non-mental health trained professionals : a qualitative synthesis

Introduction Given the prevalence of mental health problems globally, there is an increasing need for the police and other non-mental health trained professionals to identify and manage situations involving individuals with mental health problems. The review aimed to identify and explore qualitative evidence on views and experiences of non-mental health professionals receiving mental health training and the barriers and facilitators to training delivery and implementation. Methods A meta-synthesis of qualitative evidence on the barriers, facilitators and perceived impact of mental health training programmes for non-mental health trained professionals. Systematic literature searches were undertaken of the following databases: Criminal Justice Abstracts (CJA); MEDLINE; Embase; PsycINFO; ASSIA; CENTRAL; SSCI; ERIC; Campbell Library;Social Care Online and EPOC from 1995 to 2016. Records were independently screened for eligibility by two researchers, data extraction and quality appraisal of studies was also undertaken independently by two researchers. The CASP tool was used to quality appraise included studies. Included studies were synthesised using a meta-ethnographic approach as outlined by Noblit and Hare. Results 10,282 records were identified and eight qualitative studies were included. A range of barriers and facilitators to training were identified and related to the delivery and content of training; the use of additional resources; and staff willingness to engage with training and organisational factors. The perceived impact of training was also discussed in terms of how it affects trainees; perceptions of mental health; self-perception; responses to situations involving mental health and the potential of training to reduce injury or physical harm in situations involving mental health. The value of training and how to measure its impact were also discussed. Conclusion Findings from this review have implications for those designing, implementing and evaluating mental health training programmes. It is recommended that research evaluating mental health training includes a qualitative component to ensure that the barriers and facilitators to training and its impact on trainees’ perceptions of mental health are understood. Protocol registration number: PROSPERO: CRD4201501598

Development of an occupational advice intervention for patients undergoing elective hip and knee replacement: a Delphi study

Objective: To obtain consensus on the content and delivery of an occupational advice intervention for patients undergoing primary hip and knee replacement surgery. The primary targets for the intervention were (1) patients, carers and employers through the provision of individualised support and information about returning to work and (2) hospital orthopaedic teams through the development of a framework and materials to enable this support and information to be delivered. Design: Modified Delphi study as part of a wider intervention development study (The Occupational advice for Patients undergoing Arthroplasty of the Lower limb (OPAL) study: Health Technology Assessment Reference 15/28/02) (ISRCTN27426982). Setting: Five stakeholder groups (patients, employers, orthopaedic surgeons, general practitioners, allied health professionals and nurses) recruited from across the UK. Participants: Sixty-six participants. Methods: Statements for the Delphi process were developed relating to the content, format, delivery, timing and measurement of an occupational advice intervention. The statements were based on evidence gathered through the OPAL study that was processed using an intervention mapping framework. Intervention content was examined in round 1 and intervention format, delivery, timing and measurement were examined in round 2. In round 3, the developed intervention was presented to the stakeholder groups for comment. Consensus: For rounds 1 and 2, consensus was defined as 70% agreement or disagreement on a 4-point scale. Statements reaching consensus were ranked according to the distribution of responses to create a hierarchy of agreement. Round 3 comments were used to revise the final version of the developed occupational advice intervention. Results: Consensus was reached for 36 of 64 round 1 content statements (all agreement). In round 2, 13 questions were carried forward and an additional 81 statements were presented. Of these, 49 reached consensus (44 agreement/5 disagreement). Eleven respondents provided an appraisal of the intervention in round 3. Conclusions: The Delphi process informed the development of an occupational advice intervention as part of a wider intervention development study. Stakeholder agreement was achieved for a large number of intervention elements encompassing the content, format, delivery and timing of the intervention. The effectiveness and cost-effectiveness of the developed intervention will require evaluation in a randomised controlled trial

Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty : a systematic review and meta-analysis

Objectives: Preoperative anaemia is associated with increased risks of postoperative complications, blood transfusion and mortality. This meta-analysis aims to review the best available evidence on the clinical effectiveness of preoperative iron in anaemic patients undergoing elective total hip (THR) or total knee replacement (TKR). Design: Electronic databases and handsearching were used to identify randomised and non-randomised studies of interventions (NRSI) reporting perioperative blood transfusion rates for anaemic participants receiving iron before elective THR or TKR. Searches of CENTRAL, MEDLINE, Embase, PubMed and other databases were conducted on 17 April 2019 and updated on 15 July 2020. Two investigators independently reviewed studies for eligibility and evaluated risk of bias using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and a modified Newcastle-Ottawa scale for NRSIs. Data extraction was performed by ABS and checked by AB. Meta-analysis used the Mantel-Haenszel method and random-effects models. Results: 807 records were identified: 12 studies met the inclusion criteria, of which 10 were eligible for meta- analyses (one RCT and nine NRSIs). Five of the NRSIs were of high-quality while there were some concerns of bias in the RCT. Meta-analysis of 10 studies (n=2178 participants) showed a 39% reduction in risk of receiving a perioperative blood transfusion with iron compared with no iron (risk ratio 0.61, 95% CI 0.50 to 0.73, p<0.001, I2=0%). There was a significant reduction in the number of red blood cell units transfused with iron compared with no iron (mean difference −0.37units, 95% CI −0.47 to 2-0.27, p<0.001, I =40%); six studies (n=1496). Length of stay was significantly reduced with iron, by an average of 2.08 days (95% CI −2.64 to −1.51, p<0.001, I2=40%); five studies (n=1140). Conclusions: Preoperative iron in anaemic, elective THR or TKR patients, significantly reduces the number of patients and number of units transfused and length of stay. However, high-quality, randomised trials are lacking. PROSPERO registration number CRD42019129035

Effectiveness of pre-operative anaemia screening and increased Tranexamic acid dose policies on outcomes following unilateral primary, elective total hip or knee replacement : a statistical analysis plan for an interrupted time series and regression discontinuity study

Perioperative blood transfusion is associated with poorer postoperative outcomes following hip and knee replacement surgery. Evidence for the effectiveness of some measures aimed at reducing blood transfusions in this setting are limited and often rely on weak pre-post study designs. Quasi-experimental study designs such as interrupted time series (ITS) and regression discontinuity design (RDD) address many of the weaknesses of the pre-post study design. In addition, a priori publication of statistical analysis plans for such studies increases their transparency and likely validity, as readers are able to distinguish between pre-planned and exploratory analyses. As such, this article, written prospective of any analysis, provides the statistical analysis plan for an ITS and RDD study based on a data set of 20,772 primary elective hip and knee replacement patients in a single English NHS Trust. The primary aim is to evaluate the impact of a preoperative anaemia optimisation service on perioperative blood transfusion (within 7 days of surgery) using both ITS and RDD methods. A secondary aim is to evaluate the impact of a policy of increased tranexamic acid dose given at the time of surgery, using ITS methods

Interagency collaboration models for people with mental ill health in contact with the police: a systematic scoping review

Objective: To identify existing evidence on inter-agency collaboration between law enforcement, emergency services, statutory services and third sector agencies regarding people with mental ill-health. Design: Systematic scoping review. Scoping reviews map particular research areas to identify research gaps. Data sources and eligibility: ASSIA, CENTRAL, the Cochrane Library databases, Criminal Justice Abstracts, ERIC, Embase, MEDLINE, PsycINFO, PROSPERO and Social Care Online and Social Sciences Citation Index, were searched up to 2017, as were grey literature and hand searches. Eligible articles were empirical evaluations or descriptions of models of inter-agency collaboration between the police and other agencies. Study appraisal and synthesis: Screening and data extraction were undertaken independently by two researchers. Arksey’s framework was used to collate and map included studies. Results: One hundred and twenty-five studies were included. The majority of articles were of descriptions of models (28%), mixed methods evaluations of models (18%) and single service evaluations (14%). The most frequently reported outcomes (52%) were ‘organisational or service level outcomes’ (e.g. arrest rates). Most articles (53%) focused on adults with mental ill-health, whilst others focused on adult offenders with mental ill-health (17.4%). Thirteen models of inter-agency collaboration were described, each involving between 2-13 agencies. Frequently reported models were ‘pre-arrest diversion’ of people with mental ill-health (34%), ‘co-response’ involving joint response by police officers paired with mental health professionals (28.6%) and ‘jail diversion’ following arrest (23.8%). Conclusions: We identified 13 different inter-agency collaboration models catering for a range of mental health related interactions. All but one of these models involved the police and mental health services or professionals. Several models have sufficient literature to warrant full systematic reviews of their effectiveness, while others need robust evaluation, by RCT where appropriate. Future evaluations should focus on health related outcomes and the impact on key stakeholders

An assessment of the extent to which the contents of PROSPERO records meet the systematic review protocol reporting items in PRISMA-P [version 1; peer review: 2 approved]

Introduction PROSPERO is an international prospective register for systematic review protocols. Many of the registrations are the only available source of information about planned methods. This study investigated the extent to which records in PROSPERO contained the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Methods A random sample of 439 single entry PROSPERO records of reviews of health interventions registered in 2018 was identified. Using a piloted list of 19 PRISMA-P items, divided into 63 elements, two researchers independently assessed the registration records. Where the information was present or not applicable to the review a score of 1 was assigned. Overall scores were calculated and comparisons made by stage of review at registration, whether or not a meta-analysis was planned and whether or not funding/sponsorship was reported. Results Some key methodological details such as eligibility criteria, were relatively frequently reported, but much of the information recommended in PRISMA-P was not stated in PROSPERO registrations. Considering the 19 items, the mean score was 4.8 (SD 1.8; median 4; range 2-11) and across all the assessed records only 25% (2081/8227) of the items were scored as reported. Considering the 63 elements, the mean score was 33.4 (SD 5.8; median 33; range 18-47) and overall, 53% (14,469/27,279) of the elements were assessed as reported. Reporting was more frequent for items required in PROSPERO than optional items. The planned comparisons showed no meaningful differences between groups. Conclusions PROSPERO provides reviewers with the opportunity to be transparent in their planned methods and demonstrate efforts to reduce bias. However, where the PROSPERO record is the only available source of a priori reporting, there is a significant shortfall in the items reported, compared to those recommended. This presents challenges in interpretation for those wishing to assess the validity of the final review

Evidence based spinal surgery or the “journal of anecdotal medicine?” Using qualitative interviews with spinal surgeons to understand how the drivers of orthopaedic decision making can influence the creation and adoption of surgical trial evidence

Background: There is uncertainty regarding the best available treatment for stable thoracolumbar fractures without spinal cord injury. We explore what influences surgical decision making for the treatment of stable thoracolumbar fractures in the UK and discuss the implications of variation in spinal surgical work on the creation and adoption of future evidence. Methods: Qualitative semi-structured interviews with 19 spinal surgeons from 13 UK hospitals. Data were collected as part of a mixed methods randomised pilot study (PRESTO). A conceptual framework of drivers of variation in orthopaedic surgical work informed how we analysed and reported our findings. Results: We identified various patient, surgeon, organisational and cultural factors to influence surgical decision making and variation in the treatment of stable thoracolumbar fractures. We then use our findings to present the ‘cycle of uncertainty,’ to illustrate how a lack of evidence is a justification for a Randomised Controlled Trial (RCT) and the reason why a trial is not deemed feasible. Conclusion: Surgical decision-making is complex, particularly in the absence of robust evidence. The reliance on informal sources to inform decision making and the limited role of evidence, have implications for the likelihood that RCT evidence will be created and/or adopted. To break this cycle of uncertainty we suggest focussing earlier in the research cycle to develop context-specific strategies, designed to avoid equipoise from deeming future surgical trials unfeasible and encourage evidence based surgical decision-making. This could include targeted qualitative research conducted prior to RCTs to explore drivers of surgical decision making

What is important to adults after lower limb reconstruction surgery: a conceptual framework

Purpose Patient-reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction on patient’s Health-Related Quality of Life (HRQL). Existing measures have not involved this group of patients and their experiences during development. This study aimed to develop a conceptual framework to reflect what is important to patients requiring, undergoing or after undergoing reconstructive surgery. Methods Our population of interest was people requiring, undergoing or after undergoing reconstructive surgery due to trauma, malunion, nonunion, infection or congenital issues treated by internal or external fixation. We undertook semi-structured interviews with patients and orthopaedic healthcare professionals (surgeons, methodologists and patient contributors) in England. Results Thirty-two patients and 22 orthopaedic healthcare professionals (surgeons, methodologists and patient contributors) were interviewed between November 2020 and June 2021. Eight domains from a previously developed preliminary conceptual framework were used as a framework around which to code the interviews using thematic analysis. Six domains important to patients (from the perspective of patients and orthopaedic healthcare professionals) were included in the final conceptual framework: pain, perception-of-self, work and finances, daily lifestyle and functioning, emotional well-being, and support. These findings, plus meetings with our advisory panel led to the refinement of the conceptual framework. Conclusion The first five domains relate to important outcomes for patients; they are all inter-related and their importance to patients changed throughout recovery. The final domain—support (from work, the hospital, physiotherapists and family/friends)—was vital to patients and lessened the negative impact of the other domains on their HRQL. These new data strengthen our original findings and our understanding of the domains we identified in the QES. The next step in this research is to ascertain whether current PROMs used with this group of patients adequately capture these areas of importance

Systematic Review of Systematic Reviews for Effectiveness of Internal Fixation for Flail Chest and Rib Fractures in Adults

Objectives Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical fixation of rib fractures as evidenced by systematic reviews. Design A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or multiple rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR) and Science Citation Index were last searched 17th March 2017. Risk of bias was assessed using the ROBIS tool. The primary outcome was duration of mechanical ventilation. Results Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials, 19 non-randomised studies). Length of mechanical ventilation was shorter in the fixation group compared to the non–operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI [-5.54, -3.5] to -7.5 days, 95% CI [-9.9, -5.5]. Pneumonia, length of hospital and ICU stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of multiple rib fracture population; due to limited evidence the benefits with surgery are uncertain. Conclusions Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence isrequired before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, multiple rib fractures