To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA).Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale.The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA.The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings.Level II, randomized controlled trial.
Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies.A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement.Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue).A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.
Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative manag...
Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic–based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery.
What's New
As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.
1Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and the University of Toronto, Toronto, ON M5C 1R6, Canada. E-mail address for P.D.G. Henry: [email protected]. E-mail address for M.D. McKee: [email protected]
BACKGROUND: Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site. RESULTS: The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance. CONCLUSIONS: In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.
This paper presents a four-staged training model (the STEP Model) which underpins a rights and child-centred approach to working with street-connected children and acts as a basis for change and improvement in the quality of their lives. The model moves through a sequence from planning to reconnaissance, to contact and development of practice. It has been informed primarily by training developed by StreetInvest (a London based charity), the subsequent evaluation of their training in the Democratic Republic of the Congo and literature on street work practice. Much has been written about street-connected children but much less about those who work with them on the streets. This model is intended to add to the broader discourse and practice surrounding street work and street-connected children globally.
Review question/objective The overall objectives of this review are i) to determine the effects of nurse-led Chronic Obstructive Pulmonary Disease (COPD) management programs on patients' health outcomes and health service utilization; and ii) identify the framework (i.e. structure/ process) of the nurse-led COPD management programs (DMP) which is most effective in improving patient outcomes and health service utilization. Background COPD as a major public health problem COPD is a disabling respiratory disease characterized by irreversible narrowing of small airways, increasing airflow obstruction, loss of pulmonary elastic recoil, trapped air, and impaired gas exchange, with classic symptoms presented as dyspnoea, activity intolerance and fatigue. According to the World Health Organization (WHO)1, it has been estimated that as many as 64 million people around the world have COPD. As COPD mainly affects people in old age, the associated disease burden is expected to increase in the coming decades due to the ageing global population. By 2030, the disease is expected to become the 5th leading cause of global disease burden (WHO).2 Hong Kong has a similar epidemiological pattern for COPD. An earlier study, which used a validated COPD prevalence model to estimate the prevalence of COPD in 12 Asia-Pacific countries and regions, projected that 3.5% of people aged 30 and above in Hong Kong had moderate to severe COPD.3Another study which recruited a random sample of older people aged 60 or above from 20 elderly community centers found that 14% of the sample had COPD. 4 Impact of COPD on the patients' well-being and health service utilization COPD is a chronic debilitating, progressive deteriorating and incurable disease. Patients with this pathological condition experience different levels of breathlessness, air hunger and activity intolerance. Such symptoms not only cause functional dependence but also bring about feelings of impending death. Indeed, the loss in activity tolerance greatly limits the patient's functional ability, and results in loss of social and role functioning. Depression and isolation are highly prevalent among this vulnerable group. In addition, managing the disease requires patients to follow a regimen of complex life-style modifications. Patients report life restriction and have to give up their previous way of living. Yet, disease exacerbation is inevitable and this results in elevated feelings of frustration and as a result, the literature consistently identifies a compromised quality of life (QOL) among this vulnerable group.5 Apart from the patient's outcome, COPD also brings about an overwhelming impact on health service utilization. This disease causes considerable morbidity and hospital readmission worldwide.6&7According to the WHO, COPD represented 5% of all deaths globally in 2011 and is predicted to be the 3 rd leading cause of death worldwide by 2030.2 Such a high mortality rate is not only related to the impact of this serious pathology on the vital respiratory organ, but the deteriorating lung function also contributes to multi-organ failure. In Hong Kong, there were over 29,600 episodes of in-patient discharges and deaths attributed to COPD in public and private hospitals in 2009. Despite the fact that age-standardized death rates due to COPD have decreased markedly in the past 19 years, the disease accounted for 1,628 registered deaths in 2009, representing 4.0% of all registered deaths in that year.8 This disease also ranked second as a respiratory cause for hospitalization and in-patient bed days in Hong Kong (HK). In those aged greater than 75, the hospitalization rate for COPD was as high as 2,225/100,000 and it also comprised the highest portion (51.7%) of unplanned, readmitted patients.9,10One of the reasons for such a high readmission rate is related to the disease pattern of COPD which is characterized by frequent episodic and repetitive clinical exacerbation, with a progressive deteriorating course. Moreover, the disease maintenance and management relies heavily on the patients' compliance to the complex treatment regimen and restrictive lifestyle modification.11 However, the disease-related debilitation, ineffective tissue perfusion and the associated psychological impact greatly compromises a patients' functional ability and motivation in managing self-care. Loss of independence, confidence and self-esteem may also lead to relationship difficulties and social isolation, which may further affect their social support mechanisms in managing their disease.12 Application of the 'chronic disease management' model in managing COPD In view of the devastating impact of COPD on the patient's well-being and the health care system, identifying an effective care model to optimize the health outcome has become a highly prioritized agenda in managing this debilitating chronic disease. This is especially true as the traditional model relies heavily on an already over-stretched hospital service, which provides very limited opportunity for empowering self-care. The underdevelopment of transitional and primary care has further contracted the health care support required to manage this disease at the community level to improve patients' QOL.13 The Chronic Disease Management Model is a concept model developed by Wagner to capture the complexity of managing a chronic condition to improve the patient and health care system outcomes by implementing systematic and coordinated care.14 According to the Care Continuum Alliance15, chronic disease management is defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant”. Its purpose was to enhance the quality and cost-effectiveness of care for chronic diseases. The key features of chronic disease management include a patient-centered approach, systematic care planning, patient empowerment, evidence-based care, ongoing and systematic evaluation on humanistic (e.g. psychological status), clinical and economic outcomes.15 The emphases are on successful disease maintenance, early detection of disease deterioration, minimization of symptom exacerbation and disease-related complications, and optimized continuity of care across different care settings.17This concept model has been the mainstay in reducing healthcare costs and/or improving QOL for individuals with chronic conditions.18 In applying the Chronic Disease Management Model for COPD care, several care components are regarded as crucial. These components are i) effective collaborations and shared decision-making between physician, health care disciplines and patients in care planning and delivery, with or without a designated case manager, ii) intensive disease surveillance and monitoring, iii) evidence-based and guideline-driven care standards, iv) patients self-management education and empowerment, v) prompt follow-up care and optimal care accessibility to patients and family, vi) process and outcome evaluation and vii) the corresponding service and care redesign. These care components can be delivered as home-based, tele-based and/ or clinic-based care, depending on the characteristics of the chronic disease, level of disease severity, and the infrastructure of the health care system.19,20 Nurses play a pivotal role in acting as case managers to lead this type of care.21,22,23 Description of a COPD disease management program using Donabedian's model Donabedian's model has been a widely recognized framework used to evaluate health services and patient's outcomes.24 By using the model as a guiding framework, the operation of a nurse-led disease management program for COPD can be clearly described as a structure-process-outcome schema. According to Donabedian, the structure is defined as the physical and organizational properties of the settings, including the human factor, in which care is provided; the process is the treatment, services or interventions provided to the patient in managing a chronic condition; and outcomes are the changes in the patients' condition or health services as a result of the process elements.24 Structure of a nurse-led DMP for COPD The model is led by a qualified nurse with specialty training in respiratory care. The nurse training can be offered by a multi-disciplinary team so that the nurse can integrate the expertise of different disciplines in care planning and provision. The clinical decision making process may be guided by an evidence-based protocol which has been agreed on by a multi-disciplinary team and this team is available to support the nurse through a referral system or consultation mechanism. Care could be delivered in a home setting, clinical setting or through tele-care. A combined approach might be used based on the patients' needs. Process of a nurse-led DMP for COPD The core elements of nurse-led DMPs are patient empowerment and continuity of care. The nurses' roles include coordinating the care between different settings (e.g. hospital/ community) and across different disciplines as well as proactive assessment and monitoring of patients' health status. Prompt care/ therapeutic treatment should be provided according to research evidence/ clinical protocol and international guidelines. Prompt referral should be made to physician / other health care disciplines for early disease deterioration / clinical problems. Most importantly, nurses empower patients and caregivers in disease management and develop partnership relationships with patients. Moreover, in the nurse-led DMPs, it is crucial to provide ongoing psychological support and counseling, optimize informal care support and community support resources. Lastly, regular meetings with the multi-disciplinary team should be held to improve care planning for the COPD patients. Outcome of nurse-led DMP for COPD For evaluating the outcomes of nurse-led COPD DMP, indicators include symptom control such as dyspnea, prevalence of COPD-related complications, disease progression (Forced expiratory volume in 1 second, FEV1), health-related QOL issues such as psychological distress, depression, anxiety, patient satisfaction, health services utilization (general practitioner (GP) visit / emergency room attendance / hospital admission) and mortality rate. Empirical effects of nurse-led COPD DMP The empirical effect of a nurse-led COPD DMP has been repeatedly evaluated in the last decade.26,27,28 The nurse-led model was found to be commonly used in delivering this innovation. Intensive disease surveillance, guideline-based or multi-disciplinary care, optimized continuity of care and increased nurses' accessibility were the frequently included care components which delivered in home-based, clinic-based and/ or tele-care approach. 25,26,27,28 In general, the nurse-led COPD DMP has shown positive effects on patient outcome and/ or health service utilization. Yet, incoherence of the findings in terms of the effect size and outcome types was noted. A meta-analysis conducted to examine DMPs' outcomes following nurse-led interventions in COPD,29 the heterogeneity of the programs effect on different outcomes were noted. The authors concluded that current evidence might not be adequate to support the widespread implementation of nurse-led management interventions for COPD. However, this report gave very limited consideration to the structure and process factors in interpreting the program effects. Another systematic-review indicated that a more comprehensive program with two or more care components showed more promising effects on curtailing hospital service utilization.30 Yet, this study did not take into account the type of care component and structural factors in concluding the program effect. A preliminary search was undertaken of the Joanna Briggs Institute Library of Systematic Reviews, Cochrane Library, MEDLINE, CINAHL, DARE and PROSPERO databases. No systematic review report on the topic was identified. The aim of this systematic review is to adopt a comprehensive approach to examine the effects of nurse-led DMP on health outcomes of patients and health service utilization. Emphasis will also be placed on examining the impact of the structural and process factors on such outcomes. Inclusion criteria Types of participants The review will consider studies that include adults with a diagnosis of COPD, who are over 18 years old. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD)31 and the American Thoracic/European Respiratory Society Guidelines (ATS/ERS)32, the description of the severity of disease is as follows: Airflow obstruction is measured as a reduced FEV1/FVC (FVC: Forced vital capacity) ratio (< 0.7) with stage I or mild disease as an FEV1 of ≥ 80% predicted; stage II or moderate disease as an FEV1 of 50-79% predicted; stage III or severe as an FEV1 of 30-49% predicted and stage IV or very severe as an FEV1 <30% predicted. COPD includes patients with chronic bronchitis and emphysema but not asthma. Types of intervention(s) The review will consider nurse-led COPD disease management programs, as defined according to the Care Continuum Alliance.15 which implies that disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.15 The nurse-led DMPs may be delivered by home visit, clinic visit, or tele care and can be delivered either in community-based settings or hospital/medical settings or combined settings. Nurse-led DMPs will be compared with usual care, with “usual care” referring to a wide range of general / routine care options offered in the study settings such as hospitals and out-patient clinics. The structure, process and outcome of the nurse-led COPD management programs will be presented in a narrative report to give an overview of the effectiveness the programs. Types of outcomes The outcomes to be considered in this review are: Self-reported measures of exercise-related dyspnoea Standardized lung function tests Exercise capacity as assessed by standardized walking tests Self-reported measures of health status and health-related QOL (e.g. SF-36, St. George's Respiratory Questionnaire)33,34 Self-reported measures of patient satisfaction and experience with the process of care Respiratory medication use All-cause mortality Number of telephone contacts Health service outcomes including readmission rates, hospitalization (length of stay) and emergency visit Types of studies This review will consider any randomized controlled trials (RCTs) that evaluated nurse-led COPD management programs. In the absence of RCTs, other research designs such as quasi-experimental designs, cohort and case-control studies, as well as time series studies will be considered. The results of included studies will be combined in a meta analysis where possible and appropriate. Otherwise results will be presented in a narrative summary to give an overview of current approaches and outcomes concerning nurse-led COPD disease management programs. Search strategy The search strategy will be designed to access both published and unpublished material and will be restricted to studies published from database inception to November 2012. The search strategy is aimed at obtaining all published and unpublished studies in English and Chinese using a three-step approach. Firstly, the electronic databases will be searched to identify key words used in the titles, abstracts, index terms and matched subject headings. Search strategies specific to each database will be developed. Secondly a more extensive search of the databases using the developed search strategies will be performed. The search strategies will include the keywords, index terms and matched subject headings that are specific to each database. Thirdly a hand search of other sources of studies will be performed to identify studies or additional relevant source materials that are not located through the previous search strategies. This will include a manual search of relevant conference proceedings, journals, postgraduate and doctoral dissertations. An online search of databases and websites such as Google Scholar will also be performed to identify research studies relevant to the field of interest. Furthermore the reference lists and bibliographies of all retrieved articles from all searches will be screened to identify any additional relevant studies. The databases to be searched will include: MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, All EBM Reviews, ProQuest (Dissertation), ISI Web of Science, Academic OneFile, Bandolier - Evidence Based Health Care, PubMed, SCOPUS, Scirus.com, BioMed Central, Centre for Reviews and Dissemination (CRD), AMED (Allied and Complementary Medicine), British Nursing Index, Health & Medical Complete, Health Sciences, Intermid.co.uk, Internurse.com, JAMAevidence, OLDMEDLINE, PreMEDLINE, ProQuest Social Science Journals, PsycArticles, PsycINFO, Science Citation Index at Web of Science, Social Work Abstracts, Sociological Abstracts and Sociology. Electronic databases to be searched for primary publications written in Chinese include: WanFang Data, China Journal Net, Chinese Biomedical Literature Database, Chinese Medical Current Contents, Hong Kong Index to Chinese Periodical Literature, Chinese Electronic Periodical Services, Chinese Electronic Theses & Dissertations Service, and Taiwan Electronic Periodical Services. The Chinese search terms will be based on the terminology used in Taiwan and China. In order to minimize publication bias, unpublished studies or grey literature will also be identified using the following databases: Dissertation Abstracts International, Netting the Evidence, Digital Dissertations, Index to Theses, Lancashire Care Library and Information Service, Grey Literature Report (via New York Academy of Medicine), NLM Gateway, The Networked Digital Library of Theses and Dissertations (NDLTD), DIY A Academic Archive Online, Althealth Watch, Agency of Health care Research and Quality (AHRQ).FigureA proposed detailed search strategy on MEDLINE is shown in Appendix I. Assessment of eligibility Two reviewers will independently assess the identified studies from the search for relevance to the review based on the title and abstract. The assessment will be performed using the inclusion and exclusion criteria regarding the types of studies, participants, interventions and outcome measures of the studies. If a research study is considered relevant and eligible for inclusion into the review, its full text will be retrieved. If the title or abstract of a study is inconclusive, the full text will also be retrieved for further assessment. Disagreement between reviewers will be resolved via discussion or by consultation with a third reviewer. The details of eligible studies will be stored in a bibliographic software package (RefWorks). Duplicated studies will be deleted. A study verification form will be used for assessment of eligibility of the study (Appendix II). Assessment of methodological quality The methodological quality of eligible studies will be assessed independently by two reviewers using the Joanna Briggs Institute (JBI) Meta Analysis of Statistics Assessment and Review Instrument (MAStARI) - Critical appraisal checklists (Appendix III). Any disagreements that arise between the reviewers will be resolved by discussion or a third reviewer. Data collection Details of the included studies will be extracted and summarized independently by one reviewer using the standardized data extraction instrument from JBI-MAStARI (Appendix IV). A second reviewer will independently check for accuracy. Discrepancies between the reviewers will be resolved by discussion. The data extracted will include specific details about the settings; the populations and participant demographics; patient inclusion and exclusion criteria; study methods and outcomes of significance to the review question, results; and the number and reasons for withdrawals and dropouts and specific objectives. Data synthesis Quantitative papers will, where possible, be pooled in a statistical meta-analysis using JBI-MAStARI. In order to minimize the risk of errors during data entry, all results will be subject to double data entry. For continuous data that are collected using the same scale, the mean difference and 95% confidence interval will be calculated for each included study and used as the summary measure of effect; while for continuous data collected using different scales, the standardized mean differences and their 95% confidence interval will be calculated. For dichotomous data, relative risks, odd ratios and their 95% confidence interval will be calculated and used as a summary measure of effect. The studies will be assessed for clinical heterogeneity by considering the settings, populations, interventions and outcomes. The statistical heterogeneity of the combined studies will be tested using the I2, which describes the percentage of total variation across a study that is due to heterogeneity rather than chance. A fixed effects model will be applied for pooling if there is no clinical or statistical heterogeneity; while a random effects model will be used in the absence of clinical heterogeneity but with the presence of statistical heterogeneity. If statistical pooling of the results of the included studies is not appropriate or possible, the findings will be summarized in narrative form. Evaluation of the following comparisons by subgroup analysis will be performed: 1. Post-discharge patients versus community dwelling patients 2. Mode of service delivery e.g. Single format: Home / Clinic / Tele-care versus combined format 3. Intervention implemented across health care settings or in a single setting Conflicts of interest None Acknowledgements No external source of funding
Abstract Rotator cuff pathology is a commonly encountered clinical and radiologic entity that can manifest as tendinopathy or tearing. Magnetic resonance imaging (MRI) and ultrasonography offer similar sensitivity and specificity for the evaluation of the native rotator cuff, and the chosen modality may vary, depending on local practice and accessibility. MR arthrography is frequently used in the postoperative setting as a problem-solving tool. Key findings to include in the preoperative MRI report include the size and location of the tear, thickness of the tendon involved (partial versus full thickness), and overall tendon quality. The report should also address features associated with poor surgical outcomes, such as fatty atrophy, a decreased acromiohumeral interval, and evidence of rotator cuff arthropathy. Musculoskeletal radiologists should be familiar with the various surgical techniques and expected postoperative imaging appearance of rotator cuff repairs. Imaging also plays a role in identifying recurrent tearing, graft failure, hardware loosening, infection, and other complications.
