Common elective orthopaedic procedures and their clinical effectiveness:umbrella review of level 1 evidence

OBJECTIVE: To determine the clinical effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines. DESIGN: Umbrella review of meta-analyses of randomised controlled trials or other study designs in the absence of meta-analyses of randomised controlled trials. DATA SOURCES: Ten of the most common elective orthopaedic procedures—arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement—were studied. Medline, Embase, Cochrane Library, and bibliographies were searched until September 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that compared the clinical effectiveness of any of the 10 orthopaedic procedures with no treatment, placebo, or non-operative care. DATA EXTRACTION AND SYNTHESIS: Summary data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check whether recommendations for each procedure reflected the body of evidence. MAIN OUTCOME MEASURES: Quality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of recommendations in relevant national clinical guidelines. RESULTS: Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. No randomised controlled trials specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care. CONCLUSIONS: Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018115917

Ecosystem services and disservices associated with vultures : A systematic review and evidence assessment

Nature's contribution to people (i.e. ecosystem services) is becoming integral to conservation science and policy, yet our knowledge is restricted to only a few services and taxa. Vultures (family: Accipitridae and Cathartidae), most of which are threatened with extinction, have been touted for delivering regulation and maintenance services via their capacity to rapidly consume organic matter. As such, their appellation as "nature's clean-up crew" has become very popular. However, a comprehensive evaluation of the supporting evidence for such appellation was absent from the published literature. We performed a systematic review and evidence assessment to quantify the global contribution of vultures towards over 20 ecosystem services and disservices. Our analysis determined a critical imbalance in the scope and focus of published research. In contrast to the birds' popularised image as cleaners of the environment, we found only weak evidence to support any regulation and maintenance services for vultures. Moreover, studies on regulation and maintenance disservices were prominent. The only ecosystem services supported by strong evidence were cultural, although even these were evidenced by a limited number of studies. Finally, we unveil major knowledge gaps in the ecosystem service and disservice literature on a taxonomic and spatial scale related to vultures. Our analysis highlights the urgent need to quantify the net contribution of vultures to people.Peer reviewe

Research priorities for intra-articular corticosteroid injections for osteoarthritis:A Delphi study

OBJECTIVE: To identify research priorities for intra-articular corticosteroid injections for osteoarthritis using a Delphi study. DESIGN: In the Round 1 questionnaire, participants generated up to five potential research topics related to corticosteroid injections for osteoarthritis. These responses were collated and grouped to develop candidate research questions. Literature searches were conducted and questions with a lack of evidence were included in the next round. In Round 2, importance ratings (1–9; not important to very important) were assigned to each question. Those questions given an importance rating of 7–9 by ≥ 70% of participants were carried forward. In Round 3, participants were provided with the group ratings and the rating process was repeated to develop the final research priority list. RESULTS: All three Delphi rounds were completed by 75 participants (82%; 34 patients, 21 healthcare professionals and 20 academics). A total of 310 research topics were generated in Round 1, from which 26 research questions were developed. None had been robustly answered by research and therefore all were included in the Round 2 questionnaire. In Round 2, 14 research questions were retained; all 14 were prioritised in Round 3 and included in the final research priority list. The questions covered long-term effects, clinical and cost-effectiveness, measurement of outcomes, comparison to other treatments, provision, safety, identifying responders, maximising benefits, patient experience, delaying the need for joint replacement, and dosage. CONCLUSION: Using a robust consensus technique with key stakeholders, we have developed a research priority list to guide future research into corticosteroid injections for osteoarthritis

Influence of blade aerodynamic model on prediction of helicopter rotor aeroacoustic signatures

Brown’s vorticity transport model has been used to investigate how the local blade aerodynamic model influences the quality of the prediction of the high-frequency airloads associated with blade–vortex interactions, and thus the accuracy with which the acoustic signature of a helicopter rotor can be predicted. The vorticity transport model can accurately resolve the structure of the wake of the rotor and allows significant flexibility in the way that the blade loading can be represented. The Second Higher-Harmonic Control Aeroacoustics Rotor Test was initiated to provide experimental insight into the acoustic signature of a rotor in cases of strong blade–vortex interaction. Predictions of two models for the local blade aerodynamics are compared with the test data. A marked improvement in accuracy of the predicted high-frequency airloads and acoustic signature is obtained when a lifting-chord model for the blade aerodynamics is used instead of a lifting-line-type approach. Errors in the amplitude and phase of the acoustic peaks are reduced, and the quality of the prediction is affected to a lesser extent by the computational resolution of the wake, with the lifting-chord model producing the best representation of the distribution of sound pressure below the rotor

Influence of blade aerodynamic model on the prediction of helicopter high-frequency airloads

Brown’s vorticity transport model has been used to investigate the influence of the blade aerodynamic model on the accuracy with which the high-frequency airloads associated with helicopter blade–vortex interactions can be predicted. The model yields an accurate representation of the wake structure yet allows significant flexibility in the way that the blade loading can be represented. A simple lifting-line model and a somewhat more sophisticated liftingchord model, based on unsteady thin aerofoil theory, are compared. A marked improvement in the accuracy of the predicted high-frequency airloads of the higher harmonic control aeroacoustic rotor is obtained when the liftingchord model is used instead of the lifting-line approach, and the quality of the prediction is affected less by the computational resolution of the wake. The lifting-line model overpredicts the amplitude of the lift response to blade–vortex interactions as the computational grid is refined, exposing the fundamental deficiencies in this approach when modeling the aerodynamic response of the blade to interactions with vortices that are much smaller than its chord. The airloads that are predicted using the lifting-chord model are relatively insensitive to the resolution of the computation, and there are fundamental reasons to believe that properly converged numerical solutions may be attainable using this approach

Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting

AbstractObjective: Radial artery harvesting for coronary artery bypass may lead to digit ischemia if collateral hand circulation is inadequate. The modified Allen's test is the most common preoperative screening test used. Unfortunately, this test has high false-positive and false-negative rates. The purpose of this study was to compare the results of a modified Allen's test with digit pressure change during radial artery compression for assessing collateral circulation before radial artery harvest. Methods: One hundred twenty-nine consecutive patients were studied before coronary artery bypass operations. A modified Allen's test was performed with Doppler ultrasound to assess blood flow in the superficial palmar arch before and during radial artery compression. A decreased audible Doppler signal after radial artery compression was considered a positive modified Allen's test. First and second digit pressures were measured before and during radial artery compression. A decrease in digit pressure of 40 mm Hg or more (digit ΔP) with radial artery compression was considered positive. Results: Seven of 14 dominant extremities (50%) and 8 of the 16 nondominant extremities (50%) with a positive modified Allen's test had a digit ΔP of less than 40 mm Hg (false positive). Sixteen of 115 dominant extremities (14%) and 5 of 112 nondominant extremities (4%) with a negative Allen's test had a digit ΔP of 40 mm Hg or more with radial artery compression (false negative). Conclusion: Use of the modified Allen's test for screening before radial artery harvest may unnecessarily exclude some patients from use of this conduit and may also place a number of patients at risk for digit ischemia from such harvest. Direct digit pressure measurement is a simple, objective method that may more precisely select patients for radial artery harvest. Additional studies are needed to define objective digital pressure criteria that will accurately predict patients at risk for hand ischemia after radial harvest. (J Thorac Cardiovasc Surg 1999;117:261-6

Mortality and implant survival with simultaneous and staged bilateral total knee arthroplasty experience from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND: Total knee arthroplasty (TKA) is an effective procedure for relieving pain and restoring function in osteoarthritis, with a significant proportion of patients having severe disease bilaterally. However, although there are differences in patient selection criteria for bilateral procedures, there is no consensus regarding the optimal timing for bilateral TKA. The aim of this study was to compare rates and causes of revision and 30-day mortality between simultaneous and staged bilateral TKA using data from the Australian Orthopaedic Association National Joint Replacement Registry. METHODS: Data for over 36,000 bilateral TKAs were collected from September 1999 to December 2015. Rates and causes of revision and 30-day mortality rates were obtained for simultaneous bilateral and staged procedures with intervals of 1 day-6 weeks, 6 weeks-3 months, and 3-6 months. Yearly cumulative percent revision or cumulative percent survival with 95% confidence intervals calculated using the Kaplan-Meier method and adjusted hazard ratios were used for comparisons. RESULTS: There was no significant difference between revision rates or reasons for revision between staged bilateral and simultaneous TKA (hazard ratio 1.09 [95% confidence interval {CI} 0.85-1.40; P = .511] for 1 day-6 weeks, 0.93 [95% CI 0.77-1.14; P = .494] for 6 weeks-3 months, and 1.10 [95% CI 0.98-1.23; P = .115] for 3-6 months). The most common reasons for revision were loosening/lysis and infection. The 30-day mortality rates were lower in the 6 weeks-3 months group than simultaneous bilaterals (P = .007). CONCLUSION: This study demonstrates that simultaneous and staged bilateral TKA have similar rates of revision over the medium term but that 30-day mortality is reduced in the 6 weeks-3 months group

Genomic Informed Breeding Strategies for Strawberry Yield and Fruit Quality Traits

Over the last two centuries, breeders have drastically modified the fruit quality of strawberries through artificial selection. However, there remains significant variation in quality across germplasm with scope for further improvements to be made. We reported extensive phenotyping of fruit quality and yield traits in a multi-parental strawberry population to allow genomic prediction and quantitative trait nucleotide (QTN) identification, thereby enabling the description of genetic architecture to inform the efficacy of implementing advanced breeding strategies. A negative relationship (r = -0.21) between total soluble sugar content and class one yield was identified, indicating a trade-off between these two essential traits. This result highlighted an established dilemma for strawberry breeders and a need to uncouple the relationship, particularly under June-bearing, protected production systems comparable to this study. A large effect of quantitative trait nucleotide was associated with perceived acidity and pH whereas multiple loci were associated with firmness. Therefore, we recommended the implementation of both marker assisted selection (MAS) and genomic prediction to capture the observed variation respectively. Furthermore, we identified a large effect locus associated with a 10% increase in the number of class one fruit and a further 10 QTN which, when combined, are associated with a 27% increase in the number of marketable strawberries. Ultimately, our results suggested that the best method to improve strawberry yield is through selecting parental lines based upon the number of marketable fruits produced per plant. Not only were strawberry number metrics less influenced by environmental fluctuations, but they had a larger additive genetic component when compared with mass traits. As such, selecting using "number" traits should lead to faster genetic gain