A Prediction Model for Falls in Community-Dwelling Older Adults in Podiatry Practices.

INTRODUCTION: Falls are a worldwide health problem among community-dwelling older adults. Emerging evidence suggests that foot problems increase the risk of falling, so the podiatrist may be crucial in detecting foot-related fall risk. However, there is no screening tool available which can be used in podiatry practice. The predictive value of existing tools is limited, and the implementation is poor. The development of risk models for specific clinical populations might increase the prediction accuracy and implementation. Therefore, the aim of this study was to develop and internally validate an easily applicable clinical prediction model (CPM) that can be used in podiatry practice to predict falls in community-dwelling older adults with foot (-related) problems. METHODS: This was a prospective study including community-dwelling older adults (≥65 years) visiting podiatry practices. General fall-risk variables, and foot-related and function-related variables were considered as predictors for the occurrence of falls during the 12-month follow-up. Logistic regression analysis was used for model building, and internal validation was done by bootstrap resampling. RESULTS: 407 participants were analyzed; the event rate was 33.4%. The final model included fall history in the previous year, unsteady while standing and walking, plantarflexor strength of the lesser toes, and gait speed. The area under the receiver operating characteristic curve was 0.71 (95% CI: 0.66-0.76) in the sample and estimated as 0.65 after shrinkage. CONCLUSION: A CPM based on fall history in the previous year, feeling unsteady while standing and walking, decreased plantarflexor strength of the lesser toes, and reduced gait speed has acceptable accuracy to predict falls in our sample of podiatry community-dwelling older adults and is easily applicable in this setting. The accuracy of the model in clinical practice should be demonstrated through external validation of the model in a next study.

Development and Validation of a Dynamically Updated Prediction Model for Attrition From Marine Recruit Training.

ABSTRACT: Dijksma, I, Hof, MHP, Lucas, C, and Stuiver, MM. Development and validation of a dynamically updated prediction model for attrition from Marine recruit training. J Strength Cond Res 36(9): 2523-2529, 2022-Whether fresh Marine recruits thrive and complete military training programs, or fail to complete, is dependent on numerous interwoven variables. This study aimed to derive a prediction model for dynamically updated estimation of conditional dropout probabilities for Marine recruit training. We undertook a landmarking analysis in a Cox proportional hazard model using longitudinal data from 744 recruits from existing databases of the Marine Training Center in the Netherlands. The model provides personalized estimates of dropout from Marine recruit training given a recruit's baseline characteristics and time-varying mental and physical health status, using 21 predictors. We defined nonoverlapping landmarks at each week and developed a supermodel by stacking the landmark data sets. The final supermodel contained all but one a priori selected baseline variables and time-varying health status to predict the hazard of attrition from Marine recruit training for each landmark as comprehensive as possible. The discriminative ability (c-index) of the prediction model was 0.78, 0.75, and 0.73 in week one, week 4 and week 12, respectively. We used 10-fold cross-validation to train and evaluate the model. We conclude that this prediction model may help to identify recruits at an increased risk of attrition from training throughout the Marine recruit training and warrants further validation and updates for other military settings.

Grit was not associated to dropout in Dutch Marine recruits.

Approximately half of all recruits drop out of Marine recruit training. Identifying associated and predisposing factors for dropout would be helpful to understand dropout patterns and induce preventive strategies. Grit has been suggested to be a predictor of who is likely to succeed and who is not. We aimed to investigate the association between baseline grit scores and dropout of Marine recruit training in the Netherlands Armed Forces. We performed an exploratory study using data of three platoons Marine recruit training of the Royal Netherlands Marine Corps. Individual grit levels were measured using the NL-Grit scale, including two subscales. The primary outcome of this study was successful completion or dropout of Marine recruit training. Data were available from 270 recruits, of whom 119 (44%) dropped out of training. The odds ratio for dropout were 1.01 (95% CI 0.84-1.21, p = .917) and 1.07 (95% CI 0.89-1.29, p = .481) per standard deviation increase of consistency of interests and perseverance of effort, respectively. Our study did not confirm the proposed association between baseline grit levels and dropout of Marine recruit training in Dutch Marine recruits using the NL-Grit scale.

The prognostic value of heart rate recovery in patients with coronary artery disease: A systematic review and meta-analysis.

BACKGROUND: Routine outpatient care of patients with coronary artery disease (CAD) lacks a simple measure of physical fitness and risk of mortality. Heart rate recovery (HRR) is noninvasive and easily obtainable in outpatient settings. Prior studies have suggested that delayed postexercise HRR in the first minutes is associated with mortality in several types of populations. However, a comprehensive overview of the prognostic value of delayed HRR for time to mortality specifically in CAD patients is not available. The purpose of the current meta-analysis is to evaluate the prognostic value of delayed HRR in CAD patients. METHODS: We conducted a systematic search in OVID MEDLINE and OVID EMBASE to identify studies reporting on HRR and risk of incident cardiovascular events or mortality in CAD patients. Hazard ratios for delayed versus nondelayed HRR were pooled using random-effects meta-analysis. RESULTS: Four studies were included, comprising 2,428 CAD patients. The study quality of the included studies was rated moderate (n = 2) to high (n = 2). Delayed HRR was defined by ≤12 to ≤21 beat/min in the recovery period. During follow-up (range 2.0-9.8 years), 151 patients died (6.2% [range 2.5%-19.5%]). Only data on mortality could be pooled. Heterogeneity was limited (I2 = 32%; P = .23); pooled unadjusted hazard ratio for mortality, based on 3 studies, was 5.8 (95% CI 3.2-10.4). CONCLUSIONS: In CAD patients, delayed HRR is significantly associated with all-cause mortality. As exercise testing is performed routinely in CAD patients, HRR can be considered in monitoring exercise; still, further research must investigate the addition of HRR in current risk scores.

Brief multimodal psychosomatic therapy in patients with medically unexplained symptoms: feasibility and treatment effects.

BACKGROUND: Patients repeatedly presenting with medically unexplained symptoms (MUS) to their GPs, suffer from their symptoms. Experts in the field suggest a multicomponent approach for these patients. Brief multimodal psychosomatic therapy (BMPT) is such an intervention. OBJECTIVES: To test the systematic identification of eligible patients, acceptability of BMPT and potential treatment effects of BMPT. METHODS: The participants in this randomized pilot trial, patients consulting their GPs more than once with MUS, were randomized to intervention [usual care (UC) and additional BMPT] or control condition (UC alone).We monitored the number of patients identified and recruited, trial recruitment and retention. Potential treatment effects were measured with perceived symptom severity [Visual Analogue Scale (VAS)]; patients' self-rated symptoms of distress, depression, anxiety and somatization [Four-Dimensional Symptom Questionnaire (4DSQ)]; symptoms of hyperventilation [Nijmegen Hyperventilation List (NHL)]; physical and mental health status and quality of life [Short-Form Health Survey-36 items (SF-36)]; and level of functioning (measure of general functioning). Follow-up was 1 year. RESULTS: A total of 42 patients could be included in the trial. Four patients withdrew after randomization and two patients were lost to follow-up, resulting in 36 patients (86%). During the 12-month follow-up after BMPT, there was an improvement in perceived symptom severity [adjusted mean difference -2.0, 95% confidence interval (CI) -3.6 to -0.3], in somatization (adjusted mean difference -4.4, 95% CI -7.5 to -1.4) and in symptoms of hyperventilation (adjusted mean difference -5.7, 95% CI -10.5 to -0.8). CONCLUSIONS: This randomized pilot study shows that a larger trial studying the effectiveness of BMPT in patients with MUS in primary care is feasible and useful.

Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy.

BACKGROUND: Breast cancer-related lymphoedema can be a debilitating long-term sequela of breast cancer treatment. Several studies have investigated the effectiveness of different treatment strategies to reduce the risk of breast cancer-related lymphoedema. OBJECTIVES: To assess the effects of conservative (non-surgical and non-pharmacological) interventions for preventing clinically-detectable upper-limb lymphoedema after breast cancer treatment. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, PsycINFO, and the World Health Organization (WHO) International Clinical Trials Registry Platform in May 2013. Reference lists of included trials and other systematic reviews were searched. SELECTION CRITERIA: Randomised controlled trials that reported lymphoedema as the primary outcome and compared any conservative intervention to either no intervention or to another conservative intervention. DATA COLLECTION AND ANALYSIS: Three authors independently assessed the risk of bias and extracted data. Outcome measures included lymphoedema, infection, range of motion of the shoulder, pain, psychosocial morbidity, level of functioning in activities of daily life (ADL), and health-related quality of life (HRQoL). Where possible, meta-analyses were performed. Risk ratio (RRs) or hazard ratio (HRs) were reported for dichotomous outcomes or lymphoedema incidence, and mean differences (MDs) for range of motion and patient-reported outcomes. MAIN RESULTS: Ten trials involving 1205 participants were included. The duration of patient follow-up ranged from 2 days to 2 years after the intervention. Overall, the quality of the evidence generated by these trials was low, due to risk of bias in the included trials and inconsistency in the results. Manual lymph drainageIn total, four studies used manual lymph drainage (MLD) in combination with usual care or other interventions. In one study, lymphoedema incidence was lower in patients receiving MLD and usual care (consisting of standard education or exercise, or both) compared to usual care alone. A second study reported no difference in lymphoedema incidence when MLD was combined with physiotherapy and education compared to physiotherapy alone. Two other studies combining MLD with compression and scar massage or exercise observed a reduction in lymphoedema incidence compared to education only, although this was not significant in one of the studies. Two out of the four studies reported on shoulder mobility where MLD combined with exercise gave better shoulder mobility for lateral arm movement (shoulder abduction) and forward flexion in the first weeks after breast cancer surgery, compared to education only (mean difference for abduction 22°; 95% confidence interval (CI) 14 to 30; mean difference for forward flexion 14°; 95% CI 7 to 22). Two of the studies on MLD reported on pain, with inconsistent results. Results on HRQoL in two studies on MLD were also contradictory. Exercise: early versus delayed start of shoulder mobilising exercisesThree studies examined early versus late start of postoperative shoulder exercises. The pooled relative risk of lymphoedema after an early start of exercises was 1.69 (95% CI 0.94 to 3.01, 3 studies, 378 participants). Shoulder forward flexion was better at one and six months follow-up for participants who started early with mobilisation exercises compared to a delayed start (two studies), but no meta-analysis could be performed due to statistical heterogeneity. There was no difference in shoulder mobility or self-reported shoulder disability at 12 months follow-up (one study). One study evaluated HRQoL and reported difference at one year follow-up (mean difference 1.6 points, 95% CI -2.14 to 5.34, on the Trial Outcome Index of the FACT-B). Two studies collected data on wound drainage volumes and only one study reported higher wound drainage volumes in the early exercise group. Exercise: resistance trainingTwo studies compared progressive resistance training to restricted activity. Resistance training after breast cancer treatment did not increase the risk of developing lymphoedema (RR 0.58; 95% CI 0.30 to 1.13, two studies, 358 participants) provided that symptoms are monitored and treated immediately if they occur. One out of the two studies measured pain where participants in the resistance training group reported pain more often at three months and six months compared to the control group. One study reported HRQoL and found no significant difference between the groups. Patient education, monitoring and early interventionOne study investigated the effects of a comprehensive outpatient follow-up programme, consisting of patient education, exercise, monitoring of lymphoedema symptoms and early intervention for lymphoedema, compared to education alone. Lymphoedema incidence was lower in the comprehensive outpatient follow-up programme (at any time point) compared to education alone (65 people). Participants in the outpatient follow-up programme had a significantly faster recovery of shoulder abduction compared to the education alone group. AUTHORS' CONCLUSIONS: Based on the current available evidence, we cannot draw firm conclusions about the effectiveness of interventions containing MLD. The evidence does not indicate a higher risk of lymphoedema when starting shoulder-mobilising exercises early after surgery compared to a delayed start (i.e. seven days after surgery). Shoulder mobility (that is, lateral arm movements and forward flexion) is better in the short term when starting shoulder exercises earlier compared to later. The evidence suggests that progressive resistance exercise therapy does not increase the risk of developing lymphoedema, provided that symptoms are closely monitored and adequately treated if they occur.Given the degree of heterogeneity encountered, limited precision, and the risk of bias across the included studies, the results of this review should be interpreted with caution.

Nonsuturing or Skin Adhesives versus Suturing of the Perineal Skin After Childbirth: A Systematic Review.

BACKGROUND: Suturing of perineal trauma after childbirth can cause problems such as pain, discomfort because of tight sutures, the need for suture removal, and dyspareunia. It is unclear whether leaving the perineal skin unsutured or using skin adhesives might prevent these problems. METHODS: CENTRAL, MEDLINE, EMBASE, CINAHL, and prospective trial registers until January 2013 were searched for (quasi-)randomized controlled trials comparing nonsuturing of the perineal skin or skin adhesives versus suturing of the skin when repairing a second-degree perineal tear or episiotomy. Primary outcome measure was short-term and long-term pain and need for analgesic medication. RESULTS: Four randomized and two quasi-randomized controlled trials (involving 2,922 women) with heterogeneity in contexts, designs, and methodological quality were included. Nonsuturing of the skin leads to less short-term and long-term pain compared to suturing and an increased rate of skin separation. Skin adhesives lead to less short-term pain without an increased rate of skin separation. Nonsuturing or skin adhesives lead to less complaints and there are no other adverse effects. CONCLUSIONS: Nonsuturing of the skin or the use of skin adhesives appears preferable in terms of pain. Nonsuturing could lead to more short-term skin separation when no adhesives are used, but there is no evidence for the clinical importance of skin separation. There is a need for studies with a follow-up of at least 6 months, in which pain is measured homogeneously and for studies comparing the use of skin adhesives with nonsuturing of the skin with the focus on long-term cosmetic results.

Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients.

BACKGROUND: An accurate handover of clinical information is of great importance to continuity and safety of care. If clinically relevant information is not shared accurately and in a timely manner it may lead to adverse events, delays in treatment and diagnosis, inappropriate treatment and omission of care. During the last decade the call for interventions to improve handovers has increased. These interventions aim to reduce the risk of miscommunication, misunderstanding and the omission of critical information. OBJECTIVES: To determine the effectiveness of interventions designed to improve hospital nursing handover, specifically:to identify which nursing handover style(s) are associated with improved outcomes for patients in the hospital setting and which nursing handover style(s) are associated with improved nursing process outcomes. SEARCH METHODS: We searched the following electronic databases for primary studies: Cochrane EPOC Group specialised register (to 19 September 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (to 1 March 2013), MEDLINE (1950 to 1 March 2013) OvidSP, EMBASE (1947 to 1 March 2013) OvidSP, CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1980 to 1 March 2013) EbscoHost and ISI Web of Knowledge (Science Citation Index and Social Sciences Citation Index) (to 9 July 2012). The Database of Abstracts of Reviews (DARE) was searched for related reviews. We screened the reference lists of included studies and relevant reviews. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) http://www.who.int/ictrp/en/ and Current Controlled Trials www.controlled-trials.com/mrct and we conducted a search of grey literature web sites. SELECTION CRITERIA: Randomised controlled trials (RCTs or cluster-RCTs) evaluating any nursing handover style between nurses in a hospital setting with the aim of preventing adverse events or optimising the transfer of accurate essential information required for continuity of care, or both. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: The search identified 2178 citations, 28 of which were considered potentially relevant. After independent review of the full text of these studies, no eligible studies were identified for inclusion in this review due to the absence of studies with a randomised controlled study design. AUTHORS' CONCLUSIONS: There was no evidence available to support conclusions about the effectiveness of nursing handover styles for ensuring continuity of information in hospitalised patients because we found no studies that fulfilled the methodological criteria for this review. As a consequence, uncertainty about the most effective practice remains. Research efforts should focus on strengthening the evidence abut the effectiveness of nursing handover styles using well designed, rigorous studies. According to current knowledge, the following guiding principles can be applied when redesigning the nursing handover process: face-to-face communication, structured documentation, patient involvement and use of IT technology to support the process.

Intraexaminer reliability of hand-held dynamometry in the upper extremity: a systematic review.

OBJECTIVE: To summarize and appraise the literature on the intraexaminer reliability of hand-held dynamometry (HHD) in the upper extremity. DATA SOURCES: MEDLINE, CINAHL, and EMBASE were searched for relevant studies published up to December 2011. In addition, experts were contacted, and journals and reference lists were hand searched. STUDY SELECTION: To be included in the review, articles needed to (1) use a repeated-measures, within-examiner(s) design; (2) include symptomatic or asymptomatic individuals, or both; (3) use HHD to measure muscle strength in any of the joints of the shoulder, elbow, or wrist with the "make" or the "break" technique; (4) report measurements in kilogram, pound, or torque; (5) use a device that is placed between the examiner's hand and the subject's body; and (6) present estimates of intraexaminer reliability. DATA EXTRACTION: Quality assessment and data extraction were performed by 2 reviewers independently. DATA SYNTHESIS: Fifty-four studies were included, of which 26 (48%) demonstrated acceptable intraexaminer reliability. Seven high-quality studies showed acceptable reliability for flexion and extension of the elbow in healthy subjects. Conflicting results were found for shoulder external rotation and abduction. Reliability for all other movements was unacceptable. Higher estimates were reached for within-sessions reliability and if means of trials were used. CONCLUSIONS: Intraexaminer reliability of HHD in upper extremity muscle strength was acceptable only for elbow measurements in healthy subjects. We provide specific recommendations for future research. Physical therapists should not rely on HHD measurements for evaluation of treatment effects in patients with upper extremity disorders.

Clinical relevance of routinely measured vital signs in hospitalized patients: a systematic review.

BACKGROUND: Conflicting evidence exists on the effectiveness of routinely measured vital signs on the early detection of increased probability of adverse events. PURPOSE: To assess the clinical relevance of routinely measured vital signs in medically and surgically hospitalized patients through a systematic review. DATA SOURCES: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature, and Meta-analysen van diagnostisch onderzoek (in Dutch; MEDION) were searched to January 2013. STUDY SELECTION: Prospective studies evaluating routine vital sign measurements of hospitalized patients, in relation to mortality, septic or circulatory shock, intensive care unit admission, bleeding, reoperation, or infection. DATA EXTRACTION: Two reviewers independently assessed potential bias and extracted data to calculate likelihood ratios (LRs) and predictive values. DATA SYNTHESIS: Fifteen studies were performed in medical (n = 7), surgical (n = 4), or combined patient populations (n = 4; totaling 42,565 participants). Only three studies were relatively free from potential bias. For temperature, the positive LR (LR+) ranged from 0 to 9.88 (median 1.78; n = 9 studies); heart rate 0.82 to 6.79 (median 1.51; n = 5 studies); blood pressure 0.72 to 4.7 (median 2.97; n = 4 studies); oxygen saturation 0.65 to 6.35 (median 1.74; n = 2 studies); and respiratory rate 1.27 to 1.89 (n = 3 studies). Overall, three studies reported area under the Receiver Operator Characteristic (ROC) curve (AUC) data, ranging from 0.59 to 0.76. Two studies reported on combined vital signs, in which one study found an LR+ of 47.0, but in the other the AUC was not influenced. CONCLUSIONS: Some discriminative LR+ were found, suggesting the clinical relevance of routine vital sign measurements. However, the subject is poorly studied, and many studies have methodological flaws. Further rigorous research is needed specifically intended to investigate the clinical relevance of routinely measured vital signs. CLINICAL RELEVANCE: The results of this research are important for clinical nurses to underpin daily routine practices and clinical decision making.

Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds.

BACKGROUND: Hyperbaric oxygen therapy (HBOT) is used as a treatment for acute wounds (such as those arising from surgery and trauma). However, the effects of HBOT on wound healing are unclear.  OBJECTIVES: To determine the effects of HBOT on the healing of acute surgical and traumatic wounds. SEARCH METHODS: We searched the Cochrane Wounds Group Specialised Register (searched 9 August 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12); Ovid MEDLINE (2010 to July Week 5 2013); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, August 08, 2013); Ovid EMBASE (2010 to 2013 Week 31); EBSCO CINAHL (2010 to 8 August 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing HBOT with other interventions such as dressings, steroids, or sham HOBT or comparisons between alternative HBOT regimens. DATA COLLECTION AND ANALYSIS: Two review authors conducted selection of trials, risk of bias assessment, data extraction and data synthesis independently. Any disagreements were referred to a third review author.  MAIN RESULTS: Four trials involving 229 participants were included. The studies were clinically heterogeneous, which precluded a meta-analysis.One trial (48 participants with burn wounds undergoing split skin grafts) compared HBOT with usual care and reported a significantly higher complete graft survival associated with HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to 9.11). A second trial (10 participants in free flap surgery) reported no significant difference between graft survival (no data available). A third trial (36 participants with crush injuries) reported significantly more wounds healed (RR 1.70; 95% CI 1.11 to 2.61), and significantly less tissue necrosis (RR 0.13; 95% CI 0.02 to 0.90) with HBOT compared to sham HBOT. The fourth trial (135 people undergoing flap grafting) reported no significant differences in complete graft survival with HBOT compared with dexamethasone (RR 1.14; 95% CI 0.95 to 1.38) or heparin (RR 1.21; 95% CI 0.99 to 1.49).Many of the predefined secondary outcomes of the review were not reported. All four trials were at unclear or high risk of bias. AUTHORS' CONCLUSIONS: There is a lack of high quality, valid research evidence regarding the effects of HBOT on wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of skin grafting and trauma, these trials were at risk of bias. Further evaluation by means of high quality RCTs is needed.

Mydriatic visual acuity in diabetic patients: a randomized controlled trial.

PURPOSE: The aim of this randomized controlled equivalence trial was to demonstrate that, in diabetic patients, dilating the pupils before as compared with after refraction and visual acuity assessment would not lead to different advice given to patients. METHODS: Three hundred sixteen adult patients with diabetes mellitus were randomized. The experimental group was administered tropicamide 0.5% before refraction and visual acuity assessment and the control group after refraction and visual acuity assessment. Study outcomes were the advised time till next visit, the advice on adjustment of refractive correction, further diagnostics, treatment, duration of the eye examination, and patient satisfaction. RESULTS: No difference was seen in advised time till next visit between the experimental group (12.39 ± 5.01 months) and the control group (12.84 ± 4.96 months) (p = 0.425). In addition, the advice concerning adjustment of refractive correction (p = 0.069), further diagnostics (p = 1.000), and therapy (p = 0.178) did not significantly differ. Waiting time was significantly shorter for the experimental group (22.25 vs. 36.18 minutes; p < 0.001). People in the experimental group were relatively more often "very satisfied" than "satisfied" in comparison with participants in the control group for "attention being paid by the optometrist" (p = 0.025) and "advice on refractive correction" (p = 0.047). CONCLUSIONS: In diabetic patients, dilating pupils before refraction and visual acuity assessment does not lead to different advice given to patients compared with dilating pupils after refraction and visual acuity assessment, whereas waiting time significantly decreases and patient satisfaction is similar or even better. Increased efficiency is beneficial to both patients and clinicians.

Evaluation of a flexible acute admission unit: effects on transfers to other hospitals and patient throughput times.

INTRODUCTION: To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. METHODS: A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. RESULTS: Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). CONCLUSIONS: The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.

The use of video clips in teleconsultation for preschool children with movement disorders.

PURPOSE: To investigate the reliability and validity of video clips in assessing movement disorders in preschool children. METHODS: The study group included 27 children with neuromotor concerns. The explorative validity group included children with motor problems (n = 21) or with typical development (n = 9). Hempel screening was used for live observation of the child, full recording, and short video clips. The explorative study tested the validity of the clinical classifications "typical" or "suspect." RESULTS: Agreement between live observation and the full recording was almost perfect; Agreement for the clinical classification "typical" or "suspect" was substantial. Agreement between the full recording and short video clips was substantial to moderate. The explorative validity study, based on short video clips and the presence of a neuromotor developmental disorder, showed substantial agreement. CONCLUSION: Hempel screening enables reliable and valid observation of video clips, but further research is necessary to demonstrate the predictive value.

Significantly increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional study.

OBJECTIVE: To assess the impact of a laparoscopic approach on female fecundity in ileoanal pouch surgery. BACKGROUND: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is associated with tubal factor infertility in female patients. Different studies showed less adhesion formation after laparoscopic colectomy. The relation between laparoscopic pouch surgery and fertility, however, has not been studied so far. METHODS: This cross-sectional study was carried out in 3 university hospitals in the Netherlands and in Belgium. Female patients older than 18 years that had IPAA under the age of 41 were eligible for inclusion (n = 179). We sent them a questionnaire addressing medical and fertility history. The primary endpoint was time to first spontaneous pregnancy after IPAA. This study has been registered with ISRCTN.org (ISRCTN85421386). RESULTS: Of 179 eligible patients, 160 (89%) returned the questionnaire. After IPAA, 50 (31%) patients attempted to conceive. Of these, 23 (46%) had undergone open and 27 (54%) had undergone laparoscopic IPAA. Patient characteristics were similar in both groups. Indications for surgery were ulcerative colitis (UC) in 37 patients, familial adenomatous polyposis (FAP) in 12 patients, and colonic ischemia in 1 patient. A Kaplan-Meier survival function was plotted for time to first spontaneous pregnancy and showed a higher pregnancy rate after laparoscopic IPAA (log-rank, P = 0.023). Similarly, subsequent survival analysis for all patients with UC showed an increased pregnancy rate for the laparoscopic group (log-rank, P = 0.033). CONCLUSIONS: Pregnancy rates are significantly higher after laparoscopic IPAA. This makes the laparoscopic approach the method of choice in young women.

Does postoperative 'M' technique massage with or without mandarin oil reduce infants' distress after major craniofacial surgery?

AIM: This article is a report of a randomized controlled trial of the effects of 'M' technique massage with or without mandarin oil compared to standard postoperative care on infants' levels of pain and distress, heart rate and mean arterial pressure after major craniofacial surgery. BACKGROUND: There is a growing interest in non-pharmacological interventions such as aromatherapy massage in hospitalized children to relieve pain and distress but well performed studies are lacking. METHODS: This randomized controlled trial allocated 60 children aged 3-36 months after craniofacial surgery from January 2008 to August 2009 to one of three conditions; 'M' technique massage with carrier oil, 'M' technique massage with mandarin oil or standard postoperative care. Primary outcome measures were changes in COMFORT behaviour scores, Numeric Rating Scale pain and Numeric Rating Scale distress scores assessed from videotape by an observer blinded for the condition. RESULTS: In all three groups, the mean postintervention COMFORT behaviour scores were higher than the baseline scores, but differences were not statistically significant. Heart rate and mean arterial pressure showed a statistically significant change across the three assessment periods in all three groups. These changes were not related with the intervention. CONCLUSIONS: Results do not support a benefit of 'M' technique massage with or without mandarin oil in these young postoperative patients. Several reasons may account for this: massage given too soon after general anaesthesia, young patients' fear of strangers touching them, patients not used to massage.

Hyperbaric oxygen therapy: solution for difficult to heal acute wounds? Systematic review.

BACKGROUND: Hyperbaric oxygen therapy (HBOT) is used to treat various wound types. However, the possible beneficial and harmful effects of HBOT for acute wounds are unclear. METHODS: We undertook a systematic review to evaluate the effectiveness of HBOT compared to other interventions on wound healing and adverse effects in patients with acute wounds. To detect all available randomized controlled trials (RCTs) we searched five relevant databases up to March 2010. Trial selection, quality assessment, data extraction, and data synthesis were conducted by two of the authors independently. RESULTS: We included five trials, totaling 360 patients. These trials, with some methodologic flaws, included different kinds of wound and focused on different outcome parameters, which prohibited meta-analysis. A French trial (n = 36 patients) reported that significantly more crush wounds healed with HBOT than with sham HBOT [relative risk (RR) 1.70, 95% confidence interval (CI) 1.11-2.61]. Moreover, there were significantly fewer additional surgical procedures required with HBOT (RR 1.60, 95% CI 1.03-2.50), and there was significantly less tissue necrosis (RR 1.70, 95% CI 1.11-2.61). In one of two American trials (n = 141) burn wounds healed significantly quicker with HBOT (P < 0.005) than with routine burn care. A British trial (n = 48) compared HBOT with usual care. HBOT resulted in a significantly higher percentage of healthy graft area in split skin grafts (RR 3.50, 95% CI 1.35-9.11). In a Chinese trial (n = 145) HBOT did not significantly improve flap survival in patients with limb skin defects. CONCLUSIONS: HBOT, if readily available, appears effective for the management of acute, difficult to heal wounds.

Preoperative quadriceps strength as a predictor for short-term functional outcome after total hip replacement.

OBJECTIVE: To determine the preoperative strength of the muscle group of the lower extremity that is most important in predicting functional recovery after primary unilateral total hip replacement (THR). DESIGN: Prospective observational study with inception cohort. SETTINGS: Joint care program (hospital care/clinical division of a nursing home/outpatient physical therapy). PARTICIPANTS: Patients (N=55) undergoing primary unilateral THR. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Baseline measures within 2 weeks preoperative and follow-up at 6 and 12 weeks postoperative included isometric strength measurement of the hip (flexors, extensors, abductors, adductors) and knee (flexors, extensors) musculature using a handheld dynamometer. Functional outcome was tested using performance-based (Timed Up and Go Test, 6-Minute Walk Test) and self-report measures (Western Ontario and McMaster Universities Osteoarthritis Index, subscale Physical Function [WOMAC PF], 36-Item Short Form Health Survey subscale Mental Health, visual analog scale for pain). RESULTS: Of the patients (N=55; mean age, 72.7±6.8y; 41 women) included; 18 dropped out, leaving 37 patients for analyses. After correction for WOMAC PF score at baseline, body mass index, sex, and age, the preoperative knee extensors strength measure of the operated site was the only muscle group showing a significant effect on functional outcome measured by using the WOMAC PF at 12 weeks postoperatively (R(2)=.355; ß=-.105; P for ß=.004). CONCLUSION: Preoperative greater knee extensor strength of the operated site is associated with better physical function, measured by using the WOMAC PF at 12 weeks postoperative.

Refining a triage system for use in emergency departments.

This article reports on the implementation of an adapted version of the Manchester triage system (Mackway-Jones et al 1997) in a Dutch hospital to allow trained nurse practitioners to treat patients with minor injuries or illnesses, and to assess, treat and discharge patients autonomously. The project has helped to prevent long waits in emergency departments for patients with less urgent conditions.

Nonexercise Interventions for Prevention of Musculoskeletal Injuries in Armed Forces: A Systematic Review and Meta-Analysis.

CONTEXT: This study evaluates the effect of nonexercise interventions on the reduction of risk for musculoskeletal injuries in armed forces. EVIDENCE ACQUISITION: A database search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, SPORTdiscus, Greylit, Open Grey, the WHO trial registry, and the reference lists of included articles up to July 2019. RCTs and cluster RCTs evaluating nonexercise interventions for the prevention of musculoskeletal injuries in armed forces compared with any other intervention(s) or no intervention were eligible for inclusion. Data extraction and risk of bias assessment were done by 2 authors independently, followed by meta-analysis and Grading of Recommendations Assessment, Development, and Evaluation assessment, if appropriate. EVIDENCE SYNTHESIS: This study included 27 articles with a total number of 25,593 participants, examining nutritional supplementation, prophylactic medication, and equipment modifications with mostly high or unclear risk of bias. Meta-analysis and Grading of Recommendations Assessment, Development, and Evaluation assessment could be performed for 3 comparisons: custom-made insoles versus no insoles, tropical/hot-weather boots versus leather boots, and shock-absorbing insoles versus nonshock-absorbing insoles interventions, all showing the very low quality of evidence. Some evidence was found to support the preventive effect of shock-absorbing insoles, basketball shoes, padded polyester socks, calcium with vitamin D supplementation, only calcium supplementation, protein supplementation, and dynamic patellofemoral braces. CONCLUSIONS: Although an evidence base for the efficacy of preventive interventions for musculoskeletal injuries in armed forces is weak, there are some indications for the preventive effect of shock-absorbing insoles, basketball shoes, padded polyester socks, supplementation of calcium alone or combined with vitamin D, protein supplementation, and dynamic patellofemoral braces on the incidence of musculoskeletal injuries.