Does preoperative opioid use predict outcomes to 6 months following primary unilateral knee or hip arthroplasty for osteoarthritis? A data-linked retrospective study.

BACKGROUND: Few Australian studies have examined the incidence of prescribed opioid use prior to primary total knee or total hip arthroplasty (TKA, THA) and whether it predicts post-surgery outcomes. A recent Australian study demonstrated that the prevalence of pre-arthroplasty opioid use was approximately 16%. In the United States, approximately 24% of people undergoing TKA or THA are chronic opioid users preoperatively. PURPOSE: This study aimed to determine (i) the proportion of TKA and THA patients who use prescribed opioids regularly (daily) before surgery (i.e., opioid use reported between the time of waitlisting and any time up to 3 months before surgery), (ii) if opioid use before surgery predicts (a) complication/readmission rates to 6-months post-surgery, and (b) patient-reported outcomes to 6-months post-surgery. METHODS: A retrospective cohort study of patients who underwent TKA or THA between January 2013 and June 2018 from two Australian public hospitals was undertaken utilizing linked individual patient-level data from two prospectively collected independent databases comprising approximately 3,500 and 9,500 people (database contained known opioid usage data within the 5-year time frame). Inclusion criteria included (i) primary diagnosis of osteoarthritis of the index joint, (ii) primary elective THA or TKA, and (iii) age ≥ 18 years. Exclusion criteria included (i) revision arthroplasty, (ii) non-elective arthroplasty, (iii) hip hemiarthroplasty, (iv) uni-compartmental knee arthroplasty, and (v) previous unilateral high tibial osteotomy. RESULTS: Analysis was completed on 1,187 study participants (64% female, 69% TKA, mean (SD) age 67 [9.9]). 30% were using regular opioids preoperatively. Adjusted regression analyses controlling for multiple co-variates indicated no significant association between preoperative opioid use and complications/readmission rates or patient-reported outcomes to 6 months post-surgery. Model diagnostics produced poor discrimination for area under the curves and non-significant goodness of fit tests. Pre-arthroplasty opioid use was associated with lower health-related quality of life (EuroQol-Visual Analogue Scale) compared to non-opioid users undergoing primary THA (mean difference -5.04 [-9.87, -0.22], P = 0.04, Adjusted R2 = 0.06) CONCLUSION: In this study, 30% of patients were using prescribed opioids daily prior to primary TKA or THA. Pre-arthroplasty opioid use was not associated with postoperative adverse events or patient-reported pain, function, or global perceived improvement up to six months post-surgery.

High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life.

BACKGROUND AND AIMS: Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively. METHODS: A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain. RESULTS: There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01). CONCLUSIONS: Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Cardiac dysfunction in solid tumours: scoping review.

Cardio-oncology is a dynamic field. Research has suggested that cancer itself can damage the heart, independent of cancer treatment-related cardiac dysfunction (CTRCD). The aim of this study was to establish the nature of cardiovascular abnormalities reported in cancer, excluding CTRCD. Scoping review search included cardiovascular abnormalities in adults with solid tumour malignancies, and excluded CTRCD and thrombotic events. Three databases (CINAHL, Embase, Medline) were searched, supplemented by a handsearch. All screening and data extraction was done by two researchers with consensus reached for any conflicts. Given the heterogeneous nature of the studies identified, data synthesis was narrative. The search identified 42 366 studies. Following deduplication and title/abstract screening, 195 studies were assessed for full-text eligibility. Forty-four studies are included in the final analysis. There are 19 prospective observational studies, 13 retrospective studies, 9 case reports and 3 cross-sectional studies. Types of abnormality identified include cardiomyopathy (16, including Takotsubo (9)), autonomic nervous system (ANS) dysfunction (10), biomarker disturbances (9), reduced myocardial strain (6) and others (3). Due to variable study design, the prevalence was not determined. Cardiovascular abnormalities were associated with morbidity (chest pain, dyspnoea, fatigue) and shortened prognosis. In conclusion: (1) There is evidence for cardiovascular dysfunction in patients with solid tumour malignancies, distinct from CTRCD. People with solid tumours have higher rates of cardiac disease, even when newly diagnosed and treatment naïve. (2) Abnormalities manifest mainly as cardiomyopathies, ANS dysfunction and raised biomarker levels and are associated with significant symptoms. (3) Treatment plans need to take account of these risks, and widen criteria for screening.

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort.

BACKGROUND: Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis. METHODS: A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis. RESULTS: From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar. CONCLUSIONS: Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study.

BACKGROUND: Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty. METHODS: Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5% of their baseline weight preoperatively. The presence of postoperative complications, Oxford Hip Score, Oxford Knee Score, EuroQol Visual Analogue Scale and patient-rated improvement 6 months post-surgery were compared using unadjusted and adjusted techniques. RESULTS: From 3,552 and 9,562 patients identified from the datasets, 1,337 were included in the analysis after merging. After adjustment for covariates, there was no difference in postoperative complication rate to 6 months post-surgery according to BMI category (OR 1.0, 95%CI 0.8-1.4, P = 0.8) or preoperative weight loss (OR 1.1, 95%CI 0.7-1.8, P = 0.7). There was no between-group difference according to BMI or preoperative weight change for any patient-reported outcomes 6 months post-surgery. CONCLUSION: Preoperative BMI or a 5% reduction in preoperative BMI in people with obesity was not associated with postoperative outcomes to 6 months following total knee or hip arthroplasty.

A mixed methods approach to investigating physical activity in people with obesity participating in a chronic care programme awaiting total knee or hip arthroplasty.

AIMS: To describe patient-reported physical activity and step count trajectory and explore perceived barriers and enablers to physical activity amongst people with obesity participating in a chronic care programme whilst awaiting arthroplasty. DESIGN: Convergent parallel mixed-method study. METHOD: A patient cohort derived from a longitudinal sample of adults with end-stage osteoarthritis and obesity from a chronic care programme whilst awaiting primary total knee or hip arthroplasty (n = 97) was studied. Physical activity was measured at baseline (entry to the wait list) and before surgery (9-12 months waiting time) using the Lower Extremity Activity Scale (LEAS) and activity monitors (activPAL™). A subset of participants completed in-depth semi-structured interviews 6 months after being waitlisted to explore perceived barriers and enablers to physical activity. Themes were inductively derived and then interpreted through the COM-B model. RESULTS: Baseline LEAS and activPAL™ data were available from 97 and 63 participants, respectively. The proportion of community ambulant individuals reduced from 43% (95% CI 33%-53%) at baseline to 17% (95% CI 9%-28%) pre-surgery. Paired activPAL™ data (n = 31) for step count, upright time, and stepping time remained unchanged. Twenty-five participants were interviewed. Five themes underpinning physical activity were mapped to the COM-B model components of capability (physical capability), opportunity (accessibility and social norms), and motivation (self-efficacy and beliefs and physical activity). CONCLUSIONS: Participation in a chronic care programme did not improve physical activity levels for people with obesity awaiting arthroplasty. Programs cognisant of the COM-B model components may be required to address the natural trajectory of declining physical activity levels while awaiting arthroplasty.

Preliminary insights into patient preparedness for knee or hip arthroplasty: a descriptive survey study.

OBJECTIVE: Knowledge-based preparedness for surgery is achieved through education. It is unclear which of brief or extended education programs prior to knee or hip arthroplasty provides better patient preparedness. Using the Patient Preparedness for Surgery survey, we investigated whether people awaiting arthroplasty attending a hospital that provided education over multiple visits via a pre-surgery management program ('Extended') report superior preparedness compared to those attending a hospital in the same health district that only provides education at the pre-admission clinic assessment ('Brief'). RESULTS: A consecutive sample of 128 people (n = 101, 'Extended', n = 27 'Brief') completed the anonymized survey. COVID-19 related service disruptions undermined the sample size, reducing statistical power. The pre-specified superiority of the Extended program (a relative 20% more reporting 'agree'/'strongly agree') was not observed for 'Overall preparedness' [95% (Extended) vs. 89% (Brief), p = 0.36]. Between-group differences exceeding 20% relative superiority were observed for three preparedness sub-domains ['Alternatives explained' (52 vs. 33%, p = 0.09); 'Prepared for home' (85 vs. 57%, p < 0.01); 'Recall of complications' (42 vs 26%, p = 0.14)]. The preliminary findings suggest an extended education program potentially yields better patient-reported preparedness in some preparedness sub-domains, but not all.

Myocardial strain: a clinical review.

BACKGROUND: Myocardial strain-change in myocardial fibre length over the cardiac cycle-is a measure of cardiac muscle function. It is obtained using conventional techniques such as echocardiography and magnetic resonance imaging, adding additional clinical information to augment the current techniques. METHODS: A narrative review of the current relevant literature with respect to myocardial strain, with a focus on strain measured by echocardiography. RESULTS: Myocardial strain identifies global and regional abnormalities in myocardial function and differentiates types of cardiomyopathy. It is an earlier marker of myocardial disease than ejection fraction and is predictive of cardiovascular adverse events. Accurate measurement requires high-quality images and experienced practitioners. CONCLUSION: This review explains advantages and disadvantages of myocardial strain imaging and explains why, through adding increased precision without additional burden, it should be a standard part of cardiac assessment.

Is inpatient rehabilitation a predictor of a lower incidence of persistent knee pain 3-months following total knee replacement? A retrospective, observational study.

BACKGROUND: Moderate to severe levels of persistent knee pain have been estimated to affect up to 25% of people 3-months or more after a total knee replacement. It is unknown whether the type of rehabilitation pathway is associated with persistent high pain after surgery. Using a prospectively followed Australian cohort who underwent total knee replacement for knee osteoarthritis, this study aimed to i) report the incidence of high-intensity knee pain (defined as a score ≤ 15 on the Oxford Knee Score pain subscale) across time and ii) identify whether referral to inpatient rehabilitation was one of the predictors of persistent pain at 3-months post-surgery. METHODS: A retrospective analysis of a large prospective study was conducted using the Oxford Knee Score pain subscale to determine if participants had high pain at 3-months, 12-months and 36-months post-surgery. Relative risks for high pain at 3-, 12- and 36-months between the type of rehabilitation pathway were determined using Poisson multivariable regression with robust standard errors. The same technique was also employed to determine potential predictors, including rehabilitation pathway, of high pain at 3 months. RESULTS: The incidence of high pain in all participants was 73% pre-surgery and 10, 5 and 6% at 3-, 12- and 36-months respectively following knee replacement. There was a significant interaction between time and rehabilitation pathway, suggesting that the effect of the rehabilitation pathway varied across time. The incidence of high pain at 3-months did not significantly differ between those who attended inpatient rehabilitation (11.6%) and those discharged directly home (9.5%). Multivariable Poisson regression analysis identified the pre-surgical presence of high pain, co-morbid low back pain or other lower limb problem, younger age and having a major complication within 3-months following surgery as significant predictors of persistent pain whilst discharge to inpatient rehabilitation was not. CONCLUSION: A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis. Participation in an inpatient rehabilitation program does not appear to be an important predictor of ongoing knee pain. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Cancer treatment-related cardiac dysfunction.

OBJECTIVES: This paper describes cardiotoxicity and cancer treatment-related cardiac dysfunction (CTRCD). Long-term sequelae of treatment are important, and changing, and may manifest when a patient is under the care of a supportive care service. METHODS: Key messages for supportive and palliative care clinicians are outlined to facilitate identification and management of CTRCD. RESULTS: Not all cardiotoxicity is alike. Types of cardiotoxicity, cardiac complications of immunotherapy, the challenge of autonomic nervous system dysfunction in cancer and management of cardiotoxicity are highlighted. CONCLUSIONS: The key strategies are early detection of cardiotoxicity, monitoring for development of CTRCD during treatment and surveillance in survivorship.

Effect of weight-loss diets prior to elective surgery on postoperative outcomes in obesity: A systematic review and meta-analysis.

This systematic review investigated the effects of weight-loss diets before elective surgery on preoperative weight loss and postoperative outcomes in people with obesity. Electronic databases were searched from inception to May 2021. Inclusion criteria were prospective cohort or randomised controlled studies that compared effects of weight-loss diets to standard care on postoperative outcomes in adults with obesity awaiting surgery. Participants with cancer or undergoing bariatric surgery were excluded. Data on preoperative weight change, length of stay, postoperative complications and patient-reported outcome measures were extracted and synthesised in meta-analyses. One randomised controlled trial involving total knee arthroplasty and two that investigated general surgery were eligible that included 173 participants overall. Each study compared low-calorie diets using meal replacement formulas to usual care. There is very-low-quality evidence of a statistically significant difference favouring the intervention for preoperative weight loss (mean difference [MD] -6.67 kg, 95% confidence interval [CI] -12.09 to -1.26 kg; p = 0.02) and low-quality evidence that preoperative weight-loss diets do not reduce postoperative complications to 30 days (odds ratio [OR] 0.34, 95% CI 0.08-1.42; p = 0.14) or length of stay (MD -3.72 h, 95% CI -10.76 to 3.32; p = 0.30). From the limited data that is of low quality, weight loss diets before elective surgery do not reduce postoperative complications.

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component.

BACKGROUND: Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. METHOD: A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. RESULTS: Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. CONCLUSION: Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study.

BACKGROUND: Retrospective studies have found that daily opioid use pre-arthroplasty predicts worse longer-term service, clinical and patient-reported outcomes. Prospective studies are needed to confirm these observations. This prospective, exploratory study aimed to determine: the proportion of total knee or hip arthroplasty (TKA, THA) patients who use opioids regularly (daily) pre-surgery; if opioid use pre-surgery is associated with acute and sub-acute outcomes to 12-weeks post-surgery. METHODS: Consecutive patients undergoing primary TKA or THA were prospectively enrolled pre-surgery and followed-up by telephone to 12-weeks post-surgery. Acute-care (oral morphine equivalent dosage (OMED), length of stay, discharge to inpatient rehabilitation, complications) and 12-week outcomes (Oxford Knee or Hip Score, Euroqol 'today' health score, current use of opioids, and complications including readmissions) were monitored. Unadjusted and adjusted Odds Ratios (ORs) (95% Confidence Interval, CI), Rate Ratios and ß coefficients (standard error) were calculated. RESULTS: Five Hundred Twenty-One patients were included (TKA n = 381). 15.7% (95%CI 12.6 to 18.9) used opioids regularly pre-surgery. 86.8% (452/521) were available for follow-up at 12-weeks. In unadjusted analyses, pre-surgical opioid use was significantly associated with higher average acute daily OMED [ß 0.40 (0.07), p <  0.001], presence of an acute complication [OR 1.75 (1.02 to 3.00)], and ongoing use of opioids at 12-weeks [OR 5.06 (2.86 to 8.93)]. After adjusting for covariates, opioid use pre-surgery remained significantly associated with average acute daily OMED [ß 0.40 (0.07), p <  0.001] and ongoing use at 12-weeks [OR 5.38 (2.89 to 9.99)]. CONCLUSION: People who take daily opioids pre-surgery have significantly greater odds for greater opioid consumption acutely and ongoing use post-surgery. Adequately powered prospective studies are required to confirm whether pre-surgical opioid use is or is not associated with poorer joint and quality of life scores or a complication in the short-term.

Patient factors associated with weight gain and weight loss after knee or hip arthroplasty.

OBJECTIVES: Following total knee or total hip arthroplasty (TKA, THA), up to 31% of recipients experience significant weight gain while up to 14% experience significant weight loss. Factors associated with significant weight change (≥5% of baseline weight) have not been comprehensively explored. This study aimed to identify pre- and post-surgical (including current) patient factors associated with significant weight change three years after surgery. METHODS: A pre-existing nationally-acquired cohort who underwent TKA or THA for osteoarthritis participated in 3-year telephone follow-up. Updated weight, comorbidity, and complication data were collected along with ongoing index joint problems and other patient-reported outcomes including global improvement. These data, along with body mass index (BMI) pre-surgery and post-surgery rehabilitation received, were incorporated into two multivariable logistic regression models to determine separately the factors associated with ≥5% weight gain and ≥5% loss at 3-years post-surgery. RESULTS: 73.4% (1289/1757) participated in the follow-up; 1191 (n = 663 TKA) provided updated weight data. Patterns of weight change were similar for both surgeries (TKA: 16.1% gained ≥5%, 19.6% lost ≥5%; THA: 15.8% gained ≥5%, 17.8% lost ≥5%). In multivariable modelling, younger age and lower pre-surgery BMI were significantly associated with weight gain; female gender and an absence of ongoing index joint issues were associated with weight loss. CONCLUSION: Different mechanisms are likely associated with significant weight gain or loss at 3-years post-surgery. Cogent weight management entails consideration of both outcomes. Many post-surgical factors appear not to be importantly associated with weight change.

The Intersections of Chronic Noncancer Pain: Culturally Diverse Perspectives on Disease Burden.

OBJECTIVE: This study highlights the burden of chronic non-cancer-related pain from the perspectives of three culturally and linguistically diverse communities, using an intersectionality analysis. Specifically, we identify how multiple social identities intersect to account for the unequal distribution of the burden of chronic pain. DESIGN AND METHODS: Six focus groups of 41 culturally and linguistically diverse participants (Mandaean, Assyrian, and Vietnamese) living with chronic noncancer pain were conducted in South-West Sydney, Australia, between February and July 2015. Data were analyzed using inductive and intersectional methodology. RESULTS: The interaction between a patient with chronic pain from a culturally and linguistically diverse background and the health system is influenced by four identified social identities that interact to create relative positions of disadvantage for the patient within the health system and with health care providers. The social identities identified were ethnoculture, social class, migration status, and gender. CONCLUSIONS: Health care providers must consider how the intersectionality of social identities related to ethnoculture, social class, migration status, and gender can factor into the creation and maintenance of chronic pain disparities. A greater, more thoughtful incorporation of intersectionality in chronic pain research and clinical practice will ensure that pain management approaches are designed and applied in a way that reflects the social context of affected communities and individuals from those communities.

Proteomic classification of breast cancer.

Being a significant health problem that affects patients in various age groups, breast cancer has been extensively studied to date. Recently, molecular breast cancer classification has advanced significantly with the availability of genomic profiling technologies. Proteomic technologies have also advanced from traditional protein assays including enzyme-linked immunosorbent assay, immunoblotting and immunohistochemistry to more comprehensive approaches including mass spectrometry and reverse phase protein lysate arrays (RPPA). The purpose of this manuscript is to review the current protein markers that influence breast cancer prediction and prognosis and to focus on novel advances in proteomic classification of breast cancer.

The addition of aquatic therapy to rehabilitation following surgical rotator cuff repair: a feasibility study.

BACKGROUND AND PURPOSE: Rotator cuff tears are frequently encountered in medical outpatient settings and often require surgical repair to achieve desirable functional outcomes. However, the optimal form of post-operative rehabilitation of rotator cuff repairs remains unidentified by the research literature. The aim of this study was to determine the feasibility of implementing and investigating the effect of a combined aquatic and land-based rehabilitation programme in the post-operative rehabilitation of rotator cuff tears. METHODS: A cohort of 18 subjects undergoing rotator cuff repair were examined over a treatment period of 12 weeks. Twelve subjects participated in a combined aquatic and land-based programme, while six subjects received a standard land-based protocol. Passive range of motion and the Western Ontario Rotator Cuff Index outcomes were measured pre-operatively and at three, six and 12 weeks, post-operatively. Subjective responses on patient's assurance and confidence in the value of the exercises (questionnaire using an 11-point Visual Analogue Scale (VAS)) were collected at 12 weeks for both groups. RESULTS: There was a significant improvement in both range of motion and Western Ontario Rotator Cuff scores in all subjects with treatment (p < 0.001). Furthermore, participation in aquatic therapy significantly improved passive flexion range of motion measures at three weeks (mean 46 degrees , 95% CI 17-75, p = 0.005) and six weeks (30 degrees , 95% CI 8-51, p = 0.01). There was no significant difference in the attendance rates (80% in both groups) or patients perceptions of the programmes (100% confidence and assurance in both groups). CONCLUSION: The implementation of a combined aquatic and land-based physiotherapy programme following surgical repair of the rotator cuff is feasible and presents a potential viable alternative to conventional land-based exercise with comparable outcomes.