Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study.

AIM: To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. BACKGROUND: There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. DESIGN: A mixed-methods study. METHODS: Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. RESULTS: Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. CONCLUSIONS: Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. RELEVANCE TO CLINICAL PRACTICE: Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. NO PATIENT OR PUBLIC CONTRIBUTION: No patients, service users, care-givers or members of the public were involved in the study.

The segond fracture: A narrative review of the anatomy, biomechanics and clinical implications.

The Segond fracture is commonly regarded as pathognomonic for significant intra-articular pathology such as an anterior cruciate ligament (ACL) tear. There is worsened rotatory instability in patients with concomitant ACL tear and Segond fracture. Current evidence does not suggest that a concomitant and unrepaired Segond fracture leads to worst clinical outcomes after ACL reconstruction. However, there remains a lack of consensus on several aspects of the Segond fracture such as its exact anatomical attachments, ideal imaging modality for detection and indication for surgical treatment. There is currently no comparative study evaluating the outcomes of combined ACL reconstruction and Segond fracture fixation. More research is necessary to deepen our understanding and establish consensus on the role of surgical intervention.

Surgical Management of Patella Alta in Patellofemoral Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists regarding the accepted surgical management for this condition. PURPOSE: To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The random-effects model was used to analyze pooled estimates of preoperative and postoperative differences for outcomes that were reported in ≥3 studies. If heterogeneity existed among the studies, further analysis was performed using random-effects meta-regression analysis, which allowed for the identification of moderators. RESULTS: A total of 11 studies with 546 knees were included. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. The pooled weighted mean improvement (WMI) for the Kujala and Lysholm scores postoperatively was 31.98 (95% CI, 28.66-35.30) and 35.93 (95% CI, 30.12-41.74), respectively. The pooled WMI for patellar tilt angles postoperatively was 10.94 (95% CI, 7.87-14.01). These outcomes were homogeneous across all studies. The pooled WMI for Insall-Salvati ratio, Caton-Deschamps index, and tibial tubercle-trochlear groove distance postoperatively was 0.31 (95% CI, 0.17-0.45), 0.24 (95% CI, 0.12-0.36), and 6.77 (95% CI, 1.96-11.58), respectively. These outcomes were heterogeneous across the studies, with the presence of distal procedures being a significant moderator. The presence of distal procedures had a significantly higher unweighted RR of 38.07 (95% CI, 2.37-613.09) for major complications compared with proximal procedures alone, although the incidence of minor complications was comparable (unweighted RR, 1.25; 95% CI, 0.35-4.48). CONCLUSION: Surgical management for patellofemoral instability in the presence of patella alta consistently led to improvement in clinical and functional outcomes, regardless of the type of procedure performed. Distal procedures were better able to correct the patellar height and tibial tubercle-trochlear groove distance, although these procedures also posed a higher RR of subsequent surgery compared with proximal procedures alone.

Equivalent 10-Year Outcomes After Implantation of Autologous Bone Marrow-Derived Mesenchymal Stem Cells Versus Autologous Chondrocyte Implantation for Chondral Defects of the Knee.

BACKGROUND: The use of bone marrow-derived mesenchymal stem cells (BMSCs) in cartilage repair procedures circumvents some of the limitations of autologous chondrocyte implantation (ACI), but long-term outcomes for this newer procedure are lacking. The authors previously reported comparable outcomes for the 2 procedures at 2-year follow-up. PURPOSE/HYPOTHESIS: The purpose was to compare the long-term clinical outcomes of ACI versus BMSCs. It was hypothesized that there would be no significant difference between the groups in terms of patient-reported outcome scores and safety outcomes at 10-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Seventy-two patients who underwent either ACI or BMSC implantation-matched in terms of age and lesion site- were followed up to a median of at least 10 years. Patients were assessed with the 36-item Short Form Health Survey (SF-36), the International Knee Documentation Committee knee evaluation form, the Lysholm Knee Score, and the Tegner Activity Scale. In addition, information was obtained regarding any additional surgical procedures as well as safety data, with particular attention to infection and tumor formation. RESULTS: There was an improvement in all patient-reported outcomes scores apart from the Mental Component Summary of the SF-36 after cartilage repair surgery. There was no significant difference in any of the patient-reported outcomes between cohorts at any time point. Six and 5 patients in the ACI and BMSC groups, respectively, underwent subsequent surgical procedures, including 1 total knee replacement in the BMSC group. None of the patients in either group developed any deep infection or tumor within the follow-up period. CONCLUSION: BMSC implantation used for the treatment of chondral defects of the knee appears to result in equivalent clinical outcomes to first-generation ACI at up to 10 years, with no apparent increased tumor formation risk.

Human activities and landscape features interact to closely define the distribution and dispersal of an urban commensal.

The rock pigeon, Columba livia, is a cosmopolitan human commensal, domesticated thousands of years ago. However, the human-mediated factors governing its distribution and dispersal are not well understood. In this study, we performed (a) hierarchical distance sampling on ~400 island-wide point transects, (b) a population genomic inquiry based on ~7,000 SNPs from almost 150 individuals, and (c) landscape genomic analyses on the basis of extensive ecological and socio-economic databases to characterize the distribution and dispersal patterns of rock pigeons across Singapore. Our distance sampling results indicated that the volume of intentional "mercy feeding" and availability of high-rise buildings are the most reliable predictors of high pigeon densities in Singapore. Genomic analyses demonstrated that rock pigeons in Singapore form a single population possibly derived from rapid expansion from a genetically homogenous group of founder individuals. In specific, rock pigeons in Singapore lack sex-biased dispersal and are clustered with a genetic patch size of ~3 km. Landscape genomic analyses of great precision pointed to the presence of dense trees as agents of resistance to dispersal, whereas a high road density reduces this resistance. By pinpointing a range of ecological and socio-economic variables determining the distribution and dispersal of pigeons, our study provides urban planners with the tools for optimal management of this human commensal, such as a curtailment of the practice of mercy feeding and modifications to the urban landscape to reduce pigeon density and to lower the likelihood of repopulation by dispersal.