Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review.

OBJECTIVE: Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18 months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation. METHODS: A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50 years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis. RESULTS: A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1 year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist-led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3 months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation. CONCLUSION: Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data. IMPACT: Many patients report persistent pain and functional limitations up to 18 months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.

Psychological burden of anaphylaxis and the fight for an EpiPen.

A university student with a background of atopy presented to her general practitioner (GP) 2 weeks following an episode of throat tightening and dizziness occurring after touching cashew nut to her lip. She took antihistamine medication immediately and went to sleep, fearing for her life. On waking, she felt astounded to be alive. Her symptoms resolved gradually over the following week. She waited 2 weeks for an appointment with her GP, who referred her to allergy clinic. Eight months later, she was still waiting for her clinic appointment, and was left fearing a future fatal reaction, having been provided with no interim treatment. Not all patients who have severe allergic reactions present to the emergency department. Living with the constant fear of anaphylaxis can be overwhelming for patients and their families, and it can negatively impact mental health. Therefore, we advise early allergy counselling and early EpiPen prescription.

Derivation of a prediction model for emergency department acute kidney injury.

BACKGROUND AND OBJECTIVE: Quality management of Acute Kidney Injury (AKI) is dependent on early detection, which is currently deemed to be suboptimal. The aim of this study was to identify combinations of variables associated with AKI and to derive a prediction tool for detecting patients attending the emergency department (ED) or hospital with AKI (ED-AKI). DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: This retrospective observational study was conducted in the ED of a tertiary university hospital in Wales. Between April and August 2016 20,421 adult patients attended the ED of a University Hospital in Wales and had a serum creatinine measurement. Using an electronic AKI reporting system, 548 incident adult ED-AKI patients were identified and compared to a randomly selected cohort of adult non-AKI ED patients (n = 571). A prediction model for AKI was derived and subsequently internally validated using bootstrapping. The primary outcome measure was the number of patients with ED-AKI. RESULTS: In 1119 subjects, 27 variables were evaluated. Four ED-AKI models were generated with C-statistics ranging from 0.800 to 0.765. The simplest and most practical multivariate model (model 3) included eight variables that could all be assessed at ED arrival. A 31-point score was derived where 0 is minimal risk of ED-AKI. The model discrimination was adequate (C-statistic 0.793) and calibration was good (Hosmer & Lomeshow test 27.4). ED-AKI could be ruled out with a score of <2.5 (sensitivity 95%). Internal validation using bootstrapping yielded an optimal Youden index of 0.49 with sensitivity of 80% and specificity of 68%. CONCLUSION: A risk-stratification model for ED-AKI has been derived and internally validated. The discrimination of this model is objective and adequate. It requires refinement and external validation in more generalisable settings.

Epidemiology of emergency department acute kidney injury.

AIM: The epidemiology of acute kidney injury (AKI) diagnosed in the emergency department (ED) is poorly described. This study describes the incidence, demographics and outcomes of patients diagnosed with AKI in the ED (ED-AKI). METHODS: A prospective cohort study was completed in a University Teaching Hospital, (UK) between April and August 2016. In total, 20 421 adult patients attended the ED and had a serum creatinine measurement. The incident ED-AKI patient episodes were compared with a randomly selected cohort of non-AKI ED patients. RESULTS: A total of 572 patients had confirmed eAlert ED-AKI (548 incident cases), incidence 2.8% (of all ED attendances). ED-AKI was associated with a 24.4% in-patient mortality (non-AKI 3.2%, P < .001) of which 22.3% of deaths occurred within 24 hours and 58% within 7 days. Progression of the admission AKI stage to a higher AKI stage was associated with a 38.8% mortality compared with a 21.4% mortality in those who did not progress (P < .001). In multivariate analysis, ED-AKI was an independent risk for mortality (hazard ratio, 6.293; 95% confidence interval, 1.887-20.790, P = .003). For those discharged from hospital, 20.4% of ED-AKI patients re-attend for acute assessment within 30-days post-discharge (non-AKI 7.6%, P < .001). At 90-days post-discharge, 10.0% of ED-AKI patients died (non-AKI 1.4%, P < .001). Twelve months post-discharge 17.8% of ED-AKI patients developed CKD progression or de-novo CKD (non-AKI 6.0%). CONCLUSION: The ED-AKI is an independent predictor of death. Mortality is predominantly in the early stages of hospital admission, but for those who survive to discharge have significant long-term morbidity and mortality.

Society for Acute Medicine Benchmarking Audit 2015: The Patient Perspective.

INTRODUCTION: The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual national audit in the UK. METHODS: In SAMBA 2015 patient feedback questionnaires were introduced to help measure the quality of patient experience on Acute Medical Units (AMUs) over a 24-hour period on 25th June 2015. RESULTS: 55 AMUs submitted data on 945 patients, of these 824 (87.2%) would be extremely likely or likely to recommend the AMU. Patients below the age of 50 were less likely to recommend the admitting unit (p<0.013). Positive comments were three times more common than critical comments (976 vs 323). Categories of staff attitude, quality of communication, timeliness of care and catering were dominant themes. CONCLUSION: This survey has identified key themes for patients being managed on an AMU that can be used to guide future innovations.