Efficacy of two brief trauma-focussed writing interventions in comparison to positive experiences writing: A randomized controlled trial.

BACKGROUND: There is emerging literature regarding the efficacy of trauma-focussed writing therapies (TF-WTs) for posttraumatic stress. Such therapies have the potential to reduce posttraumatic stress symptoms (PTSS) in a brief time frame and can be delivered remotely. There remains a need for further research assessing the efficacy of different types of TF-WTs, as well comparing them to alternative control conditions not previously assessed. The present study assessed two TF-WTs that had differing writing instructions in comparison to an intervention that involved writing about positive experiences. METHODS: Adult community participants (n = 83) with subthreshold or clinical PTSD symptoms were randomized to one of three conditions (two of which involved trauma-focussed writing, and the other involved writing about positive experiences). All conditions involved three weekly telehealth-delivered writing appointments. Outcomes were measured using the PTSD Checklist (PCL-5) and the Depression, Anxiety and Stress Scales (DASS-21), and were evaluated at baseline, one-week post-intervention, and five-weeks post-intervention. This trial was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR Protocol 12620001065987). RESULTS: There was no evidence that the two TF-WTs were more efficacious in reducing PTSS or producing clinically meaningful change in comparison to positive experiences writing. Instead, a significant reduction from baseline to follow-up in PTSS, depression, anxiety and stress was observed in all three conditions. LIMITATIONS: The results should be interpreted with consideration of the modest sample size and absence of longer-term follow-up. CONCLUSIONS: Three-session trauma-focussed writing delivered via telehealth may not be superior to writing about positive experiences.

What is known from the existing literature about self-management of pessaries for pelvic organ prolapse? A scoping review.

OBJECTIVES: Pelvic organ prolapse can be managed with a pessary. However, regular follow-up may deter women due to the inconvenience of frequent appointments, as well as preventing autonomous decision making. Pessary self-management may be a solution to these issues. However, there remains a number of uncertainties regarding pessary self-management. This scoping review aims to map available evidence about pessary self-management to identify knowledge gaps providing the basis for future research. DESIGN: Scoping review as detailed in the review protocol. DATA SOURCES: A search of MEDLINE, CINAHL, EMBASE and PsycINFO databases and a handsearch were undertaken during May 2021 to identify relevant articles using the search terms 'pessary' and 'self-management' or 'self-care'. DATA EXTRACTION AND SYNTHESIS: Data relevant to pessary self-management was extracted and the Mixed Methods Appraisal Tool used to assess empirical rigour. Thematic analysis was performed to evaluate the results. RESULTS: The database search identified 82 publications. After duplicates and articles not meeting the inclusion and exclusion criteria were removed, there were 23 eligible articles. A hand search revealed a further 19 articles, resulting in a total of 42 publications.Findings relevant to pessary self-management were extracted and analysed for the emergence of themes. Recurrent themes in the literature were; the characteristics of self-managing women; pessary care; factors associated with decision making about self-management; teaching self-management and cost benefit. CONCLUSIONS: Pessary self-management may offer benefits to some women without increased risk. Some women do not feel willing or able to self-manage their pessary. However, increased support may help women overcome this. Further in-depth exploration of factors which affect women's willingness to self-manage their pessary is indicated to ensure better understanding and support as available for other conditions.

What is known from the existing literature about self-management of pessaries for pelvic organ prolapse? A scoping review protocol.

INTRODUCTION: Pelvic organ prolapse (POP) can be managed with a pessary; however, regular follow-up may deter women from pessary management due to the inconvenience of frequent appointments, as well as preventing pessary users from autonomous decision-making. Pessary self-management, whereby the woman removes and inserts her own pessary may be a solution to these issues. However, there remains a number of uncertainties regarding the potential benefits and risks of pessary self-management. This scoping review aims to map available evidence about the subject of pessary self-management for POP to identify knowledge gaps providing the basis for future research. METHODS AND ANALYSIS: The scoping review will be conducted using the Joanna Briggs Institute scoping review methodology and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A search of Medline, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles which meet the eligibility criteria using the search terms 'pessary' and 'self-management' or 'self-care'. A hand search of the reference list of non-original research identified during the search but excluded, will be conducted for additional publications which meet the inclusion and exclusion criteria. Data relevant to the topic of pessary self-management will be extracted and critical appraisal of all included publications undertaken. ETHICS AND DISSEMINATION: No ethical or Health Research Authority approval is required to undertake the scoping review. However, it has been registered with The Open Science Framework (DOI 10.17605/OSF.IO/DNGCP). The findings will inform future research exploring pessary self-management and be disseminated via both a presentation at a national conference and publications in peer reviewed journals.

Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture.

BACKGROUND: Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture. METHODS: Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery ('early weight-bearing' group) or to not weight-bear for a further four weeks ('delayed weight -bearing' group). All other treatment will be as per the guidance of the treating clinician. Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation. A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options. DISCUSSION: The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures. TRIAL REGISTRATION: ISRCTN12883981 , Registered 02 December 2019.

What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews.

BACKGROUND: Hip fracture is a common serious injury in older people and reducing readmission after hip fracture is a priority in many healthcare systems. Interventions which significantly reduce readmission after hip fracture have been identified and the aim of this review is to collate and summarise the efficacy of these interventions in one place. METHODS: In a rapid review of systematic reviews one reviewer (ELS) searched the Ovid SP version of Medline and the Cochrane Database of Systematic Reviews. Titles and abstracts of 915 articles were reviewed. Nineteen systematic reviews were included. (ELS) used a data extraction sheet to capture data on interventions and their effect on readmission. A second reviewer (RK) verified data extraction in a random sample of four systematic reviews. Results were not meta-analysed. Odds and risk ratios are presented where available. RESULTS: Three interventions significantly reduce readmission in elderly populations after hip fracture: personalised discharge planning, self-care and regional anaesthesia. Three interventions are not conclusively supported by evidence: Oral Nutritional Supplementation, integration of care, and case management. Two interventions do not affect readmission after hip fracture: Enhanced Recovery pathways and comprehensive geriatric assessment. CONCLUSIONS: Three interventions are most effective at reducing readmissions in older people: discharge planning, self-care, and regional anaesthesia. Further work is needed to optimise interventions and ensure the most at-risk populations benefit from them, and complete development work on interventions (e.g. interventions to reduce loneliness) and intervention components (e.g. adapting self-care interventions for dementia patients) which have not been fully tested yet.

Primary surgical management of anterior pelvic organ prolapse: a systematic review, network meta-analysis and cost-effectiveness analysis.

BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP. METHODS: We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. MAIN RESULTS: We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values. CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. TWEETABLE ABSTRACT: New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.

Management of mesh complications following surgery for stress urinary incontinence or pelvic organ prolapse: a systematic review.

BACKGROUND: Mesh surgery for stress urinary incontinence or pelvic organ prolapse can result in complications such as mesh exposure, mesh extrusion, voiding dysfunction, dyspareunia, and pain. There is limited knowledge or guidance on the effective management for mesh-related complications. OBJECTIVE: To determine the best management of mesh complications; a systematic review was conducted as part of the national clinical guideline 'Urinary incontinence (update) and pelvic organ prolapse in women: management'. SEARCH STRATEGY: Search strategies were developed for each indication for referral. SELECTION CRITERIA: Relevant interventions included complete or partial mesh removal, mesh division, and non-surgical treatments such as vaginal estrogen. DATA COLLECTION AND ANALYSIS: Characteristics and outcome data were extracted, and as a result of the heterogeneous nature of the data a narrative synthesis was conducted. MAIN RESULTS: Twenty-four studies were included; five provided comparative data and four studies stated the indication for referral. Reported outcomes (including pain, dyspareunia, satisfaction, quality of life, incontinence, mesh exposure, and recurrence) and the reported incidences of these varied widely. CONCLUSIONS: The current evidence base is limited in quantity and quality and does not permit firm recommendations to be made on the most effective management for mesh-related complications. Robust data are needed so that mesh complications can be managed effectively in the future. TWEETABLE ABSTRACT: Systematic review demonstrates that the outcomes following mesh revision surgery are highly variable.

Moderators and predictors of outcomes in telephone delivered compared to face-to-face cognitive behaviour therapy for paediatric obsessive-compulsive disorder: preliminary evidence from a non-inferiority RCT.

This study provides a preliminary exploration of factors which differentially predict treatment response to telephone-delivered cognitive behavioural therapy (TCBT) compared to face-to-face CBT (CBT) in a randomised non-inferiority controlled trial of 72 children (aged 11-18 years) with obsessive-compulsive disorder (OCD). Potential moderator variables, their interaction with treatment group (CBT, TCBT) and baseline levels of OCD severity were entered into separate regression models where the primary outcome measure was the post-intervention Children's Yale-Brown Obsessive-Compulsive Scale total score (CYBOCS). Separate regressions were also used to test associations between predictors and outcome controlling for pretreatment CYBOCS. Only pretreatment level of parent-rated child peer problems moderated the effects of the two interventions on CYBOCS severity at post-treatment. After controlling for baseline CYBOCS, only family accommodation rated by mothers predicted poorer outcomes in both groups. While CBT and TCBT may be equally effective for adolescents with OCD, the current results tentatively suggest that higher baseline level of peer problems strengthened the response to therapy for youth receiving TCBT and the predictor analyses reinforce the importance of directly addressing family accommodation during CBT for paediatric OCD regardless of delivery mode. Limitations of the current findings and directions for future work are discussed.

Factors associated with profitability in pasture-based systems of milk production.

The global dairy industry needs to reappraise the systems of milk production that are operated at farm level with specific focus on enhancing technical efficiency and competitiveness of the sector. The objective of this study was to quantify the factors associated with costs of production, profitability, and pasture use, and the effects of pasture use on financial performance of dairy farms using an internationally recognized representative database over an 8-yr period (2008 to 2015) on pasture-based systems. To examine the associated effects of several farm system and management variables on specific performance measures, a series of multiple regression models were developed. Factors evaluated included pasture use [kg of dry matter/ha and stocking rate (livestock units/ha)], grazing season length, breeding season length, milk recording, herd size, dairy farm size (ha), farmer age, discussion group membership, proportion of purchased feed, protein %, fat %, kg of milk fat and protein per cow, kg of milk fat and protein per hectare, and capital investment in machinery, livestock, and buildings. Multiple regression analysis demonstrated costs of production per hectare differed by year, geographical location, soil type, level of pasture use, proportion of purchased feed, protein %, kg of fat and protein per cow, dairy farm size, breeding season length, and capital investment in machinery, livestock, and buildings per cow. The results of the analysis revealed that farm net profit per hectare was associated with pasture use per hectare, year, location, soil type, grazing season length, proportion of purchased feed, protein %, kg of fat and protein per cow, dairy farm size, and capital investment in machinery and buildings per cow. Pasture use per hectare was associated with year, location, soil type, stocking rate, dairy farm size, fat %, protein %, kg of fat and protein per cow, farmer age, capital investment in machinery and buildings per cow, breeding season length, and discussion group membership. On average, over the 8-yr period, each additional tonne of pasture dry matter used increased gross profit by €278 and net profit by €173 on dairy farms. Conversely, a 10% increase in the proportion of purchased feed in the diet resulted in a reduction in net profit per hectare by €97 and net profit by €207 per tonne of fat and protein. Results from this study, albeit in a quota limited environment, have demonstrated that the profitability of pasture-based dairy systems is significantly associated with the proportion of pasture used at the farm level, being cognizant of the levels of purchased feed.

Large-scale expansion of no-take closures within the Great Barrier Reef has not enhanced fishery production.

A rare opportunity to test hypotheses about potential fishery benefits of large-scale closures was initiated in July 2004 when an additional 28.4% of the 348 000 km2 Great Barrier Reef (GBR) region of Queensland, Australia was closed to all fishing. Advice to the Australian and Queensland governments that supported this initiative predicted these additional closures would generate minimal (10%) initial reductions in both catch and landed value within the GBR area, with recovery of catches becoming apparent after three years. To test these predictions, commercial fisheries data from the GBR area and from the two adjacent (non-GBR) areas of Queensland were compared for the periods immediately before and after the closures were implemented. The observed means for total annual catch and value within the GBR declined from preclosure (2000-2003) levels of 12780 Mg and Australian $160 million, to initial post-closure (2005-2008) levels of 8143 Mg and $102 million; decreases of 35% and 36% respectively. Because the reference areas in the non-GBR had minimal changes in catch and value, the beyond-BACI (before, after, control, impact) analyses estimated initial net reductions within the GBR of 35% for both total catch and value. There was no evidence of recovery in total catch levels or any comparative improvement in catch rates within the GBR nine years after implementation. These results are not consistent with the advice to governments that the closures would have minimal initial impacts and rapidly generate benefits to fisheries in the GBR through increased juvenile recruitment and adult spillovers. Instead, the absence of evidence of recovery in catches to date currently supports an alternative hypothesis that where there is already effective fisheries management, the closing of areas to all fishing will generate reductions in overall catches similar to the percentage of the fished area that is closed.

Achilles tendon rupture rehabilitation: a mixed methods investigation of current practice among orthopaedic surgeons in the United Kingdom.

OBJECTIVES: The evidence base to inform the management of Achilles tendon rupture is sparse. The objectives of this research were to establish what current practice is in the United Kingdom and explore clinicians' views on proposed further research in this area. This study was registered with the ISRCTN (ISRCTN68273773) as part of a larger programme of research. METHODS: We report an online survey of current practice in the United Kingdom, approved by the British Orthopaedic Foot and Ankle Society and completed by 181 of its members. A total of ten of these respondents were invited for a subsequent one-to-one interview to explore clinician views on proposed further research in this area. RESULTS: The survey showed wide variations in practice, with patients being managed in plaster cast alone (13%), plaster cast followed by orthoses management (68%), and orthoses alone (19%). Within these categories, further variation existed regarding the individual rehabilitation facets, such as the length of time worn, the foot position within them and weight-bearing status. The subsequent interviews reflected this clinical uncertainty and the pressing need for definitive research. CONCLUSIONS: The gap in evidence in this area has resulted in practice in the United Kingdom becoming varied and based on individual opinion. Future high-quality randomised trials on this subject are supported by the clinical community. Cite this article: Bone Joint Res 2015;4:65-9.

Experimental evidence for the co-evolution of hominin tool-making teaching and language.

Hominin reliance on Oldowan stone tools-which appear from 2.5 mya and are believed to have been socially transmitted-has been hypothesized to have led to the evolution of teaching and language. Here we present an experiment investigating the efficacy of transmission of Oldowan tool-making skills along chains of adult human participants (N=184) using five different transmission mechanisms. Across six measures, transmission improves with teaching, and particularly with language, but not with imitation or emulation. Our results support the hypothesis that hominin reliance on stone tool-making generated selection for teaching and language, and imply that (i) low-fidelity social transmission, such as imitation/emulation, may have contributed to the ~700,000 year stasis of the Oldowan technocomplex, and (ii) teaching or proto-language may have been pre-requisites for the appearance of Acheulean technology. This work supports a gradual evolution of language, with simple symbolic communication preceding behavioural modernity by hundreds of thousands of years.

Automated analysis of respiratory behavior in extremely preterm infants and extubation readiness.

BACKGROUND: Rates of extubation failure of extremely preterm infants remain high. Analysis of breathing patterns variability during spontaneous breathing under endotracheal tube continuous positive airway pressure (ETT-CPAP) is a potential tool to predict extubation readiness. OBJECTIVE: To investigate if automated analysis of respiratory signals would reveal differences in respiratory behavior between infants that were successfully extubated or not. METHODS: Respiratory Inductive Plethysmography (RIP) signals were recorded during ETT-CPAP just prior to extubation. Signals were digitized, and analyzed using an Automated Unsupervised Respiratory Event Analysis (AUREA). Extubation failure was defined as reintubation within 72 hr. Statistical differences between infants who were successfully extubated or failed were calculated. RESULTS: A total of 56 infants were enrolled and one was excluded due to instability during the ETT-CPAP; 11 out of 55 infants studied failed extubation (20%). No differences in demographics were observed between the success and failure groups. Significant differences on the variability of some respiratory parameters or 'metrics' estimated by AUREA were observed between the 2 groups. Indeed, a simple classification using the variability of two metrics of respiratory behavior predicted extubation failure with high accuracy. CONCLUSION: Automated analysis of respiratory behavior during a short ETT-CPAP period may help in the prediction of extubation readiness in extremely preterm infants.

Achilles tendinopathy management: A pilot randomised controlled trial comparing platelet-richplasma injection with an eccentric loading programme.

OBJECTIVES: To conduct a pilot randomised controlled trial to evaluate the feasibility of conducting a larger trial to evaluate the difference in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores at six months between patients with Achilles tendinopathy treated with a platelet-rich plasma (PRP) injection compared with an eccentric loading programme. METHODS: Two groups of patients with mid-substance Achilles tendinopathy were randomised to receive a PRP injection or an eccentric loading programme. A total of 20 patients were randomised, with a mean age of 49 years (35 to 66). All outcome measures were recorded at baseline, six weeks, three months and six months. RESULTS: The mean VISA-A score for the injection group at the primary endpoint of six months was 76.0 (95% confidence interval (CI) 58.3 to 93.7) and for the exercise group was 57.4 (95% CI 38.1 to 76.7). There was no statistically significant difference between these scores (p = 0.171), which was expected from such a pilot study. CONCLUSIONS: This pilot study has been key to providing data to inform a larger study and shows that the methodology is feasible. Cite this article: Bone Joint Res 2013;2:227-32.

A new movement artifact detector for photoplethysmographic signals.

Oximeters are commonly used in abbreviated cardiorespiratory studies (ACS) to monitor blood oxygen saturation and heart rate using the photoplethysmography (PPG) signal. These data are prone to movement artifacts, especially in infants who move or need to be handled often. Therefore segments of PPG data contaminated by movement artifact must be detected as a first stage of analysis. In ACS this identification is generally done manually, by having an expert visually assess the quality of the signal. This is subjective and very time consuming, especially for long data records. For this reason we present a novel detector of PPG movement artifacts that uses moving average filters to remove trends, reduce the effect of white noise, and notch filter pulse-related information. The normalized root mean square of the filtered signal is then used as a detection statistic. We demonstrate its detection properties using a data set from infants recovering from anesthesia, and show that it performs better than other automated methods based on entropy or higher-order statistics. Furthermore, the new method is more robust than the other methods in the presence of large noise.

'Discovery learning': an account of rapid curriculum change in response to accreditation.

BACKGROUND/AIMS: The purpose of this study was to explore the attitudes and experiences of leaders responsible for making rapid changes to a medical school curriculum in response to an adverse accreditation report. The new curriculum was based on the principles of problem-based learning ('Discovery Learning'), with changes to the way that students were assessed. METHODS: We conducted semi-structured interviews with leaders responsible for education at the school two and a half years after the adoption of the new curriculum. We coded the resulting transcripts to identify major and minor themes expressed by participants. RESULTS: Thirty-five senior leaders, administrators and course directors were invited for the interview; 14 (40%) were interviewed. Five main themes were noted in the data: (1) organization and control of the curriculum; (2) changes in the practices of teaching and learning; (3) effects on faculty members; (4) sources of resistance and (5) attitudes to curriculum change in general. CONCLUSION: This study demonstrates that major curriculum change can be achieved successfully in a short period of time. This study also illustrates some of the problems associated with making rapid changes to the medical school curriculum, and highlights the importance of attitudes to change amongst the leadership of a medical school.

The accuracy and inter-observer reliability of acetate templating in total hip arthroplasty.

AIM: The accuracy and inter-observer reliability (IOR) of acetate templating on hard copy X-rays in 33 primary total hip arthroplasties as measured by consultant and trainee surgeons was analyzed to find out how accurate are junior surgeons undertaking specialty training. METHODS: The study was questionnaire-based using a prospective cohort over a 4 weeks period. The Surgeon measurements of acetabular cup, femoral stem and femoral offset sizes were noted following acetate measurements and then compared with the final implant chosen during surgery. RESULTS: Prediction of sizing to within one size of the final match size was 75% accurate for cup and 91% accurate for femoral stem. Prediction of exact femoral offset sizes was 91% accurate. Templating showed strong IOR between senior consultant surgeon and junior trainee registrar within one size for cup (83%) and stem (100%) and for exact hip offset prediction (92%). CONCLUSION: We conclude that acetate templating on hard copy X-rays is beneficial to surgeons to gauge acetabular cup and femoral stem size to within one size range. This further helps in predicting nearly exact femoral offset size.

Evaluation of urogynaecology care of an elderly population in a specialist urogynaecology centre.

The ageing population of the UK means that demand for urogynaecology services is expected to increase substantially, particularly in patients aged over 65 years. To assess service provision and predict future needs, we reviewed the demographic profile and service requirements of elderly patients referred to our urogynaecology service. We performed a retrospective review of case notes of 125 patients over 65 years of age who attended our urogynaecology clinic within a 6 month period, including comorbidity scoring using a validated instrument. A substantial proportion (56%) of patients did not require hospital-based management, and none of the patients had an adult comorbidity evaluation (ACE-27) score >2. Hence, we recommend assessing patients using the ACE-27 score and not on chronological age alone. A restructuring of urogynaecology services towards better access to community-based clinics is required to reflect the treatment needs of the patient population. This would be in line with national continence care guidance.