Initiation of an early mobilisation programme in intensive care units—A preliminary report

The Tropical Agriculturalist series Livestock product/on systems examines how individual species of domestic livestock can be integrated into the whole concept of sustainable agriculture in the tropics. The main part of the book is devoted to a series of case studies covering most, if not all, of the systems of livestock husbandry used in the tropics. The reasons why these systems have been developed are outlined, their limitations highlighted and the ways in which they could be improved are discussed. This part of the book is a useful short reference work presenting the main features of the extremely varied livestock production systems found across the tropics. Readers of the book will obtain a good insight into how livestock and crop husbandry can be linked in the wetter regions of the tropics to improve the use of resources. In the dry regions of the tropics, where crop husbandry is not an option, animal husbandry is the best way of utilizing these regions for the benefit of people. The book shows how livestock are essential for the development of ecologically sound systems of food production. All types of livestock are covered including buffalo, camels and poultry. Livestock production systems by Trevor Wilson 1995 141pp ISBN 0 333 60012 6 Animal health volume/explains the causes of animal diseases, how they are spread and the means available for their control. It covers not only diseases caused by micro-organisms, arthropods and helminths, but also deals with metabolic diseases and those caused by toxins. The signs of health and the symptoms to look for when an animal is suspected of being diseased are clearly presented using simple diagnostic keys. Tables are included to assist in diagnosis of diseases in the major farm animals found in the tropics. The book concludes by dealing with general veterinary procedures, including the administration of medicines. The book is a valuable guide for anyone involved with maintaining and establishing the health of animals in tropical and subtropical countries. It should be read in conjunction with volume 2 (which appeared earlier) and those volumes in the series which deal with individual animal species. Animal health volume l: general principles by Archie Hunter 1996 167pp ISBN 0 333 61202 7 Avocado is a succinct guide to the cultivation and marketing of a fruit of growing commercial importance throughout the world. It covers the plant's origins and distribution, botany, and selection and breeding. as well as providing more detailed guidance on the field operations needed to grow this sensitive crop successfully. Land preparation, the choice of cultivars and rootstocks, grafting techniques, irrigation requirements, and major pests and diseases are some of the topics covered. Lastly, the book turns to harvesting and processing considerations, with special emphasis on the requirements for export. A wealth of photographs, line drawings, tables and charts support the text, which is based on the authors' 20 years of experience as well as extensive reference to the global literature. Avocado by J P Gaillard and d Godefroy 1995 120pp ISBN 0 333 57468 0 The above titles are part of the Macmillan The Tropical Agriculturalist series which is published in association with, and are available from, CTA.The Tropical Agriculturalist seriesLivestock product/on systems examines how individual species of domestic livestock can be integrated into the whole concept of sustainable agriculture in the tropics. The main part of the book is devoted to a..

Using patient experience in optimizing the total knee arthroplasty patient journey

Information was used to improve the patient journey and to achieve patient-centered care. Patients (\u3e18 years, purposive sampling) were interviewed once at one point of their total knee arthrosis journey within the hospital setting. Patients were accompanied and observed during their hospital visit by one of the 19 healthcare professionals which were trained as interviewers. A qualitative research approach with in-depth and semi-structured interviews using a standardized interview guide were used to gather an in-depth understanding of the perceptions of patients. Interviews were written out with the emphasis on positive and negative feedback, quotes and observations that were made. The audio recordings were verbatim transcribed and coded using selective and open coding. Thirty-five semi-structured interviews were conducted. Five different themes were identified: overall experience, waiting, communication, information and facilities. Several easy fixes were dealt with immediately to improve service quality, productivity and the organization of the healthcare service. Other improvements were discussed with the stakeholders and were resolved directly or were planned for the long-term. Involving patients and let them collaborate with healthcare professionals is essential in optimizing patient-centered care. Most feedback was related to clarification and comprehensibility of the patient journey, to improve autonomy and to remove uncertainty of the patients. Continuity of care with medical personnel, personal attention and recognition of the problem are fundamental during the knee arthrosis patient journey. Experience Framework This article is associated with the Quality & Clinical Excellence lens of The Beryl Institute Experience Framework. (http://bit.ly/ExperienceFramework) Access other PXJ articles related to this lens. Access other resources related to this lens

Pain prediction by serum biomarkers of bone turnover in people with knee osteoarthritis: an observational study of TRAcP5b and cathepsin K in OA

Objectives: To investigate serum biomarkers, tartrate resistant acid phosphatase 5b (TRAcP5b) and cathepsin K, indicative of osteoclastic bone resorption, and their relationship to pain and pain change in knee osteoarthritis (OA). Methods: Sera and clinical data were collected from 129 people (97 with 3-year follow-up) with knee OA from the Prediction of Osteoarthritis Progression (POP) cohort. Knee OA-related outcomes in POP included: WOMAC pain, NHANES I (pain, aching and stiffness), subchondral sclerosis, and radiographically determined tibiofemoral and patellofemoral OA. Two putative osteoclast biomarkers were measured in sera: TRAcP5b and cathepsin K. Medial tibia plateaux were donated at knee arthroplasty for symptomatic OA (n=84) or from 16 post mortem controls from the Arthritis Research UK (ARUK) Pain Centre joint tissue repository. Osteoclasts were stained for TRAcP within the subchondral bone of the medial tibia plateaux. Results: Serum TRAcP5b activity, but not cathepsin K-immunoreactivity, was associated with density of TRAcP-positive osteoclasts in the subchondral bone of medial tibia plateaux. TRAcP-positive osteoclasts were more abundant in people with symptomatic OA compared to controls. Serum TRAcP5b activity was associated with baseline pain and pain change. Conclusions: Our observations support a role for subchondral osteoclast activity in the generation of OA pain. Serum TRAcP5b might be a clinically relevant biomarker of disease activity in OA

Boundary conditions for cartilage regeneration

Cartilage defects generally do not heal and may result in osteoarthritis (OA) development. Unfortunately, current treatment strategies result in repair tissue with insufficient structural and mechanical properties as compared to native cartilage, and, therefore, are thought to provide merely a temporary alleviation of symptoms and insufficient protection against osteoarthritis (OA) development. This composes a strong driving force for the rapid development of the field of regenerative medicine and the application of such strategies to the treatment of cartilage defects. The first clinical studies have reported promising results. As a result, cartilage regeneration techniques, such as ACI, are increasingly applied, although microfracturing is still considered the treatment of choice for articular cartilage defects by many surgeons as the full scope of information needed for final evaluation of the efficacy of cartilage regeneration techniques remains to be provided in prospective randomized clinical trials. Furthermore, a discrepancy in reliability and reproducibility of cartilage regeneration techniques has been observed when comparing the outcome of culture techniques and animal models with clinically applied ACI. This suggests that we need to explore the boundary conditions that determine these discrepancies. In this thesis, we have clearly demonstrated the superior structural repair resulting from ACI as compared to the traditionally used microfracturing technique. However, one should realize that these beneficial results were found under strict trial conditions with accurately defined in- and exclusion criteria based on previously reported trials. Still, we found that ACI resulted in morphologically variable regeneration tissue-quality, which led us to the subject of this thesis: “exploring the boundaries of successful cartilage regeneration”. In our effort to acquire adequate regenerative conditions, we established that in future clinically applied ACI, chondrocytes should be expanded under growth factor supplemented conditions. Furthermore, upon refining the surgical techniques, scaffold materials should not only be considered for practical reasons, but also because they may significantly enhance the process of chondrogenesis. Further optimization may be attained by in vitro and in vivo experiments comparing the influence of different scaffold materials on cartilage regeneration by expanded and implanted chondrocytes. Besides the culture conditions, we demonstrated the importance of selecting patients with sufficient donor tissue quality. Until the substantial differences in chondrogenic potency between healthy and OA chondrocytes can be overcome, ACI should not be implemented for the treatment of early OA. In addition, effort should be put into elucidating the transition from cartilage defects towards the development of OA and how this affects donor tissue characteristics, as this increases insight into adequate treatment timing and patient selection. Lastly, we have demonstrated that transferring clinically relevant variables, such as SF from injured knee joints, to the “controlled” environment of in vitro experiments significantly alters the process of cartilage regeneration. Therefore, exploring the variables of this environment will likely elucidate mediators unfavorable to in vivo cartilage regeneration. These mediators may provide feasible targets for optimization of joint homeostasis by pre-treating a damaged joint before implementing ACI. Among others, IL-1B might be such a target, as this pro-inflammatory cytokine has proven to be of key importance during wound repair throughout different tissue types in the human body. The biological efficacy of a newly developed autologous form of IL-1ra was demonstrated by clinical improvement found in patients with symptomatic knee OA. Whether this treatment modality actually results in improved cartilage regeneration remains to be proven. In conclusion, the aim of this thesis was to establish the position and to determine the boundary conditions of cartilage regeneration techniques for the treatment of articular cartilage defects. Based on our results, ACI should now be considered a first approach rather than a last resort for the treatment of articular cartilage defects. Still, we have demonstrated the significant impact of clinically relevant parameters on the outcome of these treatment strategies. Clarifying and targeting the mediators that account for the observed detrimental effects, have the potential to provide the key in our ongoing effort to enhance the clinical outcome of cartilage regeneration techniques

Interchangeability of Diverse Analog Scales Used Within the Constant-Murley Score

Purpose: To assess the interchangeability of various existing answering scales within the subjective part of the Constant-Murley Score (CMS) and to determine the effect of the different answering scales on the inter- and intraobserver reliability. Methods: In this prospective, single-center, cross-sectional trial, patients with shoulder problems were included from June to September 2018. Subjects recruited were 18 years or older, presented various shoulder complaints, e.g., diagnosis of osteoarthritis, subacromial pain syndrome, rotator cuff or biceps tendon problems, or frozen shoulder. An extended version of the CMS was prepared including the same questions multiple times but with varying answer scales. Six versions were made with random order of the questions. The answering scales were a verbal and paper based visual analog scale (VAS), smiley face scale, Numeric Rating Scale (NRS), and categories. Internal consistency of the various CMS, Spearman correlation coefficients, intraobserver, and interobserver agreement was assessed (ICC). Results: In total, 93 patients were included. The total CMS using the paper-based VAS, smiley face score, and NRS were 46.9 ± 19.4, 45.2 ± 18.5, and 45.0 ± 18.7. Correlations of the total scores of the different versions varied from 0.98 to 0.99. CMS-category versus CMS-smiley face score and CMS-category versus CMS-NRS pain were significantly different (P = .02 and P = .01). Good internal consistency (0.76-0.79) and acceptable inter- and intraobserver reliability were found (ICC: 0.89-0.97, 0.98-0.99; P < .001). Conclusions: The different answering scales for the subjective subscales within the CMS for pain, work, and recreational activity were not interchangeable on item level and significantly influenced the total CMS score. Differences were below the smallest detectable change and interpreted as not clinically relevant. Particularly on item level, data from different studies cannot be pooled and compared when different answering scales are being used. The inter- and intraobserver reliability were excellent. Level of Evidence: Level I, prospective cross-sectional study

Rater agreement reliability of the dial test in the ACL-deficient knee

Abstract Background Posterolateral rotatory instability (PLRI) of the knee can easily be missed, because attention is paid to injury of the cruciate ligaments. If left untreated this clinical instability may persist after reconstruction of the cruciate ligaments and may put the graft at risk of failure. Even though the dial test is widely used to diagnose PLRI, no validity and reliability studies of the manual dial test are yet performed in patients. This study focuses on the reliability of the manual dial test by determining the rater agreement. Methods Two independent examiners performed the dial test in knees of 52 patients after knee distorsion with a suspicion on ACL rupture. The dial test was performed in prone position in 30°, 60° and 90° of flexion of the knees. ≥10° side-to-side difference was considered a positive dial test. For quantification of the amount of rotation in degrees, a measuring device was used with a standardized 6 Nm force, using a digital torque adapter on a booth. The intra-rater, inter-rater and rater-device agreement were determined by calculating kappa (κ) for the dial test. Results A positive dial test was found in 21.2% and 18.0% of the patients as assessed by a blinded examiner and orthopaedic surgeon respectively. Fair inter-rater agreement was found in 30° of flexion, κF = 0.29 (95% CI: 0.01 to 0.56), p = 0.044 and 90° of flexion, κF = 0.38 (95% CI: 0.10 to 0.66), p = 0.007. Almost perfect rater-device agreement was found in 30° of flexion, κC = 0.84 (95% CI: 0.52 to 1.15), p < 0.001. Moderate rater-device agreement was found in 30° and 90° combined, κC = 0.50 (95% CI: 0.13 to 0.86), p = 0.008. No significant intra-rater agreement was found. Conclusions Rater agreement reliability of the manual dial test is questionable. It has a fair inter-rater agreement in 30° and 90° of flexion

A novel test for assessment of anterolateral rotatory instability of the knee: the tibial internal rotation test (TIR test)

Abstract Background Rotational instability of the knee may persist after anterior cruciate ligament (ACL) reconstruction, which may be due to insufficiency of anterolateral stabilizing structures. However, no reliable diagnostic tool or physical examination test is available for identifying patients with anterolateral rotatory instability (ALRI). As shown in cadaveric studies, static internal rotation of the knee is increased in higher flexion angles of the knee after severing the anterolateral structures. This might also be the case in patients with an ACL-deficient knee and concomitant damage to the anterolateral structures. The objective of this study is to assess anterolateral rotatory instability of the knee during physical examination with a tibial internal rotation test. Methods ACL-injured knees of 52 patients were examined by two examiners and side-to-side differences were compared. Both lower legs were internally rotated by applying manual internal rotation torque to both feet in prone position with the knees in 30°, 60° and 90° of flexion. For quantification of the amount of rotation in degrees, a torque adapter on a booth was used. Intra-rater, inter-rater and rater-device agreement were determined by calculating kappa (κ) for the tibial internal rotation test. Results Tibial internal rotation is increased in 19.2% of the patients with ACL injury according to the tibial internal rotation test. Good intra-rater agreement was found for the tibial internal rotation test, κC = 0.63 (95%CI -0.02-1.28), p = 0.015. Fair inter-rater agreement was found, κF = 0.29 (95%CI 0.02–0.57), p = 0.038. Good rater-device agreement was found, κC = 0.62 (95%CI 0.15–1.10), p = 0.001. Conclusion The tibial internal rotation test shows increased tibial internal rotation in a small amount of patients with ACL injury. Even though no gold standard for assessment of increased tibial internal rotation of the knee is available yet, the test can be of additional value. It can be used for assessment of internal rotatory laxity of the knee as part of ALRI in addition to the pivot shift test. No clinical implications should yet be based on this test alone