Clinical Reasoning in Physical Therapy: A Concept Analysis

Background Physical Therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research. Objective The objective was to conceptualize a broad description of physical therapists’ clinical reasoning grounded in the published literature and to unify our understanding for future work related to teaching, assessment, and research. Design/Methods The design included a systematic concept analysis using Rodgers’ Evolutionary methodology. A concept analysis is a research methodology in which a concept\u27s characteristics and the relationship between features of the concept is clarified. Results Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management. Limitations Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature was incomplete or key sources were mistakenly excluded. Conclusions A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to be done to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice

Perceptions of risk for stress fractures: A qualitative study of female runners with and without stress fracture histories.

OBJECTIVES: To gain insight into perceived factors related to bone health and stress fracture (SF) prevention for female runners and to understand their experiences within the medical community. DESIGN: Cohort qualitative study. SETTING: University health system. PARTICIPANTS: Forty female runners, 20 who had SF histories and 20 age-and-running-distance matched women without SF. MAIN OUTCOME MEASURES: Women participated in audiotaped qualitative semi-structured interviews. For women with a SF history, questions sought their perspectives on factors that they felt contributed to SF, experiences with the medical community, and changes made post SF. For women without a SF history, questions sought perspectives on factors felt important to perceived running-related bone health. RESULTS: Six themes emerged; 1) Previous/Recurrent Musculoskeletal Injuries, 2) Activity Patterns and Training Regimens, 3) Nutrition, 4) Prevention and Intervention, 5) Pain, and 6) Mindset. Within these themes, between group differences are characterized by differences in knowledge and/or application of knowledge for health and wellness. Compared to women without SF, women with SF histories increased training load more quickly, had poorer nutrition, performed less cross-training, and kept running despite pain. CONCLUSIONS: More education is needed for female runners to decrease risks for SF

The influence of HLA genotype on the development of metal hypersensitivity following joint replacement

We thank Innovate UK Edge for providing funding to allow this research to be carried out.Background  Over five million joint replacements are performed across the world each year. Cobalt chrome (CoCr) components are used in most of these procedures. Some patients develop delayed type hypersensitivity (DTH) responses to CoCr implants, resulting in tissue damage and revision surgery. DTH is unpredictable and genetic links have yet to be definitively established. Methods At a single site, we carried out an initial investigation to identify HLA alleles associated with development of DTH following metal-on-metal hip arthroplasty. We then recruited patients from other centres to train and validate an algorithm incorporating patient age, gender, HLA genotype44 and blood metal concentrations to predict the development of DTH. Accuracy of the modelling was assessed using performance metrics including time dependent receiver operator curves. Results Using next generation sequencing, here we determine the HLA genotypes of 606 patients. 176 of these patients had experienced failure of their prostheses; the remaining 430 remain asymptomatic at a mean follow up of twelve years. We demonstrate that the development of DTH is associated with patient age, gender, the magnitude of metal exposure and the presence of certain HLA class II alleles. We show that the predictive algorithm developed from this investigation performs to an accuracy suitable for clinical use, with weighted mean survival probability errors of 1.8% and 3.1%53 for pre-operative and post-operative models respectively. Conclusions The development of DTH following joint replacement appears to be determined by the interaction between implant wear and a patient’s genotype. The algorithm described in this paper may improve implant selection and help direct patient surveillance following surgery. Further consideration should be given towards understanding patient specific responses to different biomaterials.Publisher PDFPeer reviewe

Sleeping sickness and its relationship with development and biodiversity conservation in the Luangwa valley, Zambia

The Luangwa Valley has a long historical association with Human African trypanosomiasis (HAT) and is a recognised geographical focus of this disease. It is also internationally acclaimed for its high biodiversity and contains many valuable habitats. Local inhabitants of the valley have developed sustainable land use systems in co-existence with wildlife over centuries, based on non-livestock keeping practices largely due to the threat from African Animal Trypanosomiasis. Historical epidemics of human sleeping sickness have influenced how and where communities have settled and have had a profound impact on development in the Valley. Historical attempts to control trypanosomiasis have also had a negative impact on conservation of biodiversity. Centralised control over wildlife utilisation has marginalised local communities from managing the wildlife resource. To some extent this has been reversed by the implementation of community based natural resource management programmes in the latter half of the 20th century and the Luangwa Valley provides some of the earliest examples of such programmes. More recently, there has been significant uncontrolled migration of people into the mid-Luangwa Valley driven by pressure on resources in the eastern plateau region, encouragement from local chiefs and economic development in the tourist centre of Mfuwe. This has brought changing land-use patterns, most notably agricultural development through livestock keeping and cotton production. These changes threaten to alter the endemically stable patterns of HAT transmission and could have significant impacts on ecosystem health and ecosystem services. In this paper we review the history of HAT in the context of conservation and development and consider the impacts current changes may have on this complex social-ecological system. We conclude that improved understanding is required to identify specific circumstances where win-win trade-offs can be achieved between the conservation of biodiversity and the reduction of disease in the human population.Ecosystem Services for Poverty Alleviation (ESPA

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p&lt;0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p&lt;0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p&lt;0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP &gt;5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Near‐Surface Hydrology and Soil Properties Drive Heterogeneity in Permafrost Distribution, Vegetation Dynamics, and Carbon Cycling in a Sub‐Arctic Watershed

Discontinuous permafrost environments exhibit strong spatial heterogeneity at scales too small to be driven by weather forcing or captured by Earth System Models. Here we analyze effects of observed spatial heterogeneity in soil and vegetation properties, hydrology, and thermal dynamics on ecosystem carbon dynamics in a watershed on the Seward Peninsula in Alaska. We apply a Morris global sensitivity analysis to a process-rich, successfully tested terrestrial ecosystem model (TEM), ecosys, varying soil properties, boundary conditions, and weather forcing. We show that landscape heterogeneity strongly impacts soil temperatures and vegetation composition. Snow depth, O-horizon thickness, and near-surface water content, which vary at scales of O(m), control the soil thermal regime more than an air temperature gradient corresponding to a 140&nbsp;km north–south distance. High shrub productivity is simulated only in talik (perennially unfrozen) soils with high nitrogen availability. Through these effects on plant and permafrost dynamics, landscape heterogeneity impacts ecosystem productivity. Simulations with near-surface taliks have higher microbial respiration (by 78.0&nbsp;gC&nbsp;m−2&nbsp;yr−1) and higher net primary productivity (by 104.9&nbsp;gC&nbsp;m−2&nbsp;yr−1) compared to runs with near-surface permafrost, and simulations with high shrub productivity have outlying values of net carbon uptake. We explored the prediction uncertainty associated with ignoring observed landscape heterogeneity, and found that watershed net carbon uptake is 60% larger when heterogeneity is accounted for. Our results highlight the complexity inherent in discontinuous permafrost environments and demonstrate that missing representation of subgrid heterogeneity in TEMs could bias predictions of high-latitude carbon budget

Receiver operating characteristic curves for biomarker discrimination between septic versus control febrile and healthy subjects.

<p>ROC curves for MMP-9/TIMP-1 ratio, mr-ProANP and A-FABP levels for (A) septic versus febrile subjects; (B) septic versus healthy subjects and (C) febrile versus healthy subjects. Triangle, A-FABP levels; Circle, mr-ProANP levels; Square, MMP-9/TIMP-1 ratio.</p

Box and whiskers plots for MMP-9 and TIMP-1 levels, and MMP-9/TIMP-1 ratio in septic patients compared to controls.

<p><b>(A)</b> MMP-9, (B) TIMP-1 levels (ng/ml), and (C) MMP-9/TIMP-1 ratios in healthy and febrile controls (gray boxes) compared to septic patients (white boxes) on days-1, 2, 3, 5, and 7 after ICU admission. Data are presented as median, interquartile range, and whiskers indicating 10^th to 95^th%ile (Outliers represented as +). (A) * P <0.05, ** P <0.01 versus healthy and febrile controls. (B) ** P <0.01 versus healthy and febrile controls; *P <0.05 versus febrile controls. (C) ** P <0.01 versus healthy and febrile controls; *P <0.05 versus healthy controls.</p

Box and whiskers plots for A-FaBP and mrProANP levels in septic patients compared to controls.

<p>(A) A-FaBP levels (ng/ml) in healthy and febrile controls (gray boxes) compared to septic patients on days 1–2 (combined samples) and day 3 of ICU admission (white boxes). (B) mrProANP levels (ng/ml) in healthy and febrile controls (gray boxes) compared to septic patients (pooled samples for days 1–2) (white boxes). Data are presented as median, interquartile range, and whiskers indicating 10^th to 95^th%ile (Outliers represented as +). (A) * P <0.05 versus healthy controls.</p