Patients' and clinicians' perspectives towards primary care consultations for shoulder pain: qualitative findings from the Prognostic and Diagnostic Assessment of the Shoulder (PANDA-S) programme.

BACKGROUND: Clinical management of musculoskeletal shoulder pain can be challenging due to diagnostic uncertainty, variable prognosis and limited evidence for long-term treatment benefits. The UK-based PANDA-S programme (Prognostic And Diagnostic Assessment of the Shoulder) is investigating short and long-term shoulder pain outcomes. This paper reports linked qualitative research exploring patients' and clinicians' views towards primary care consultations for shoulder pain. METHODS: Semi-structured interviews were conducted with 24 patients and 15 primary care clinicians. Twenty-two interviews (11 patients, 11 clinicians) were conducted as matched patient-clinician 'dyads'. Data were analysed thematically. RESULTS: Clinicians reported attempts to involve patients in management decisions; however, there was variation in whether patients preferred treatment choice, or for decisions to be clinician-led. Some patients felt uncertain about the decisions made, due to a lack of discussion about available management options. Many General Practitioners expressed a lack of confidence in diagnosing the underlying cause of shoulder pain. Patients reported either not being given a diagnosis, or receiving different diagnoses from different professionals, resulting in confusion. Whilst clinicians reported routinely discussing prognosis of shoulder pain, patients reported that prognosis was not raised. Patients also expressed concern that their shoulder pain could be caused by serious pathology; however, clinicians felt that this was not a common concern for patients. CONCLUSIONS: Findings showed disparities between patients' and clinicians' views towards shoulder pain consultations, indicating a need for improved patient-clinician communication. Findings will inform the design of an intervention to support treatment and referral decisions for shoulder pain that will be tested in a randomised controlled trial.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis.

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning. PURPOSE: To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over. METHODS: Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes. RESULTS: 78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes. CONCLUSION: Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further. PROSPERO: CRD42018116478.

Introduction to the Special Series, "Incorporating Nature-based Solutions into the Built Environment".

Incorporating nature-based solutions (NBSs) into the built environment supports the ongoing sustainability challenge as emphasized in the United Nations' Sustainable Development Goals (SDGs) and has particular relevance for SDG Goal #11 (Sustainable cities and communities), which seeks greater efficiencies in urban planning and management practices that address aging infrastructure and ongoing air, water, and soil pollution. The short communications and research articles in this special series exemplify many of these aspects, highlighting the application of NBSs and showcasing the latest environmental research and policy solutions to support this. Nature-based solutions in the built environment aim to promote the understanding of the transdisciplinary nature of NBSs and enhance the global awareness of the value of NBSs by providing a diversity of solutions to illustrate the positive economic, social, and environmental benefits of NBSs in the built environment. Integr Environ Assess Manag 2022;18:39-41. © 2021 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Nature-based solutions for improving navigation reliability on the Madeira River, Brazil.

The Madeira River Navigation and Improvement Project provides a unique opportunity to incorporate nature-based solutions (NbS) into the built environment to promote sustainable communities and water resources infrastructure. The Madeira River has no major physical interventions (river training structures, navigation locks and dams, etc.) to improve navigation, and so is one of the world's last remaining undeveloped megarivers that exhibits natural morphological processes. The objective of this study is to create a safe, reliable, and sustainable navigation channel in the Madeira River. This is being accomplished by designing navigation improvement measures that leverage natural geomorphic processes of the river while minimizing conventional engineering practices that alter the river's morphology. To meet this objective, fluvial geomorphology analysis and hydrodynamic modeling studies have been performed to improve understanding of the morphological behavior of the system. Measures that incorporate beneficial reuse of dredged sediment within the system are being prioritized and incorporated into the study's design. Natural processes are being leveraged through the implementation of an adaptive management process to shape the navigation channel by incorporating the use of dynamic structures using natural local materials (e.g., large woody debris already in the system), a direct application of NbS in practice. This process includes extensive stakeholder collaboration and utilizing nature's energy to balance navigation, ecological, and social benefits along the Madeira River. This project demonstrates that nature-based approaches not only provide navigation benefits but can also provide ecological and social benefits in ways that are sustainable in the long term, consistent with United Nations Sustainable Development Goals (SDGs) and the International Union for the Conservation of Nature's global standard for NbS. Integr Environ Assess Manag 2022;18:115-122. © 2021 SETAC. This article has been contributed to by US Government employees and their work is in the public domain in the USA.

A multicentre, randomised controlled trial to compare the clinical and cost-effectiveness of Lee Silverman Voice Treatment versus standard NHS Speech and Language Therapy versus control in Parkinson's disease: a study protocol for a randomised controlled trial.

BACKGROUND: Parkinson's disease (PD) affects approximately 145,519 people in the UK. Speech impairments are common with a reported prevalence of 68%, which increase physical and mental demands during conversation, reliance on family and/or carers, and the likelihood of social withdrawal reducing quality of life. In the UK, two approaches to Speech and Language Therapy (SLT) intervention are commonly available: National Health Service (NHS) SLT or Lee Silverman Voice Treatment (LSVT LOUD®). NHS SLT is tailored to the individuals' needs per local practice typically consisting of six to eight weekly sessions; LSVT LOUD® comprises 16 sessions of individual treatment with home-based practice over 4 weeks. The evidence-base for their effectiveness is inconclusive. METHODS/DESIGN: PD COMM is a phase III, multicentre, three-arm, unblinded, randomised controlled trial. Five hundred and forty-six people with idiopathic PD, reporting speech or voice problems will be enrolled. We will exclude those with a diagnosis of dementia, laryngeal pathology or those who have received SLT for speech problems in the previous 2 years. Following informed consent and completion of baseline assessments, participants will be randomised in a 1:1:1 ratio to no-intervention control, NHS SLT or LSVT LOUD® via a central computer-generated programme, using a minimisation procedure with a random element, to ensure allocation concealment. Participants randomised to the intervention groups will start treatment within 4 (NHS SLT) or 7 (LSVT LOUD®) weeks of randomisation. PRIMARY OUTCOME: Voice Handicap Index (VHI) total score at 3 months. Secondary outcomes include: VHI subscales, Parkinson's Disease Questionnaire-39; Questionnaire on Acquired Speech Disorders; EuroQol-5D-5 L; ICECAP-O; resource utilisation; adverse events and carer quality of life. Mixed-methods process and health economic evaluations will take place alongside the trial. Assessments will be completed before randomisation and at 3, 6 and 12 months after randomisation. The trial started in December 2015 and will run for 77 months. Recruitment will take place in approximately 42 sites around the UK. DISCUSSION: The trial will test the hypothesis that SLT is effective for the treatment of speech or voice problems in people with PD compared to no SLT. It will further test whether NHS SLT or LSVT LOUD® provide greater benefit and determine the cost-effectiveness of both interventions. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ID: 12421382. Registered on 18 April 2016.

Ecological Risk Assessment of Underwater Sounds from Dredging Operations.

There is an increasing international focus to understand and quantify the potential ecological risks of low-frequency underwater sounds produced from anthropogenic activities (e.g., commercial shipping, dredging, construction, and offshore energy production). For dredge operations, a risk-based approach has been proposed for identifying, assessing, and managing risks; however, specific details of the framework and demonstration of the approach are lacking. Thus, the goal of this study was to provide a practical, concise, and reliable framework for assessing the effects of dredging sounds on aquatic life. The specific objectives were to 1) further specify a risk assessment approach for assessing underwater sounds from dredging operations, 2) demonstrate the utility of the approach in practice using a case study, and 3) document the strengths and challenges of the approach. The risk framework was adapted for underwater sounds to include a project formulation step, an analysis step to analyze and assess exposure and biological responses, a risk characterization process in which the preceding steps are integrated and uncertainty is addressed, and a risk management step. A key beneficial component of this framework is the use of a phased approach, whereby a screening step offers a process that utilizes existing or readily available information to evaluate risk. In general, a limitation of evaluating risks due to dredge operations is the degree of uncertainty surrounding effect thresholds for many marine species; however, this approach emphasizes the importance of documenting and communicating uncertainty to regulators, stakeholders, and practitioners in the decision-making process. A case study example is included to illustrate how the framework can be applied in practice. The primary strength of this method is the intrinsic flexibility of the framework to adapt as the scientific understanding improves and new data become available in the rapidly evolving field of underwater acoustics. Integr Environ Assess Manag 2020;16:481-493. © 2020 SETAC.

Inter-comparison and assessment of gridded climate products over tropical forests during the 2015/2016 El Niño.

To understand the impacts of extreme climate events, it is first necessary to understand the spatio-temporal characteristics of the event. Gridded climate products are frequently used to describe climate patterns but have been shown to perform poorly over data-sparse regions such as tropical forests. Often, they are uncritically employed in a wide range of studies linking tropical forest processes to large-scale climate variability. Here, we conduct an inter-comparison and assessment of near-surface air temperature fields supplied by four state-of-the-art reanalysis products, along with precipitation estimates supplied by four merged satellite-gauge rainfall products. Firstly, spatio-temporal patterns of temperature and precipitation anomalies during the 2015-2016 El Niño are shown for each product to characterize the impact of the El Niño on the tropical forest biomes of Equatorial Africa, Southeast Asia and South America. Using meteorological station data, a two-stage assessment is then conducted to determine which products most reliably model tropical climates during the 2015-2016 El Niño, and which perform best over the longer-term satellite observation period (1980-2016). Results suggest that eastern Amazonia, parts of the Congo Basin and mainland Southeast Asia all experienced significant monthly mean temperature anomalies during the El Niño, while northeastern Amazonia, eastern Borneo and southern New Guinea experienced significant precipitation deficits. Our results suggest ERA-Interim and MERRA2 are the most reliable air temperature datasets, while TRMM 3B42 V7 and CHIRPS v2.0 are the best-performing rainfall datasets.This article is part of a discussion meeting issue 'The impact of the 2015/2016 El Niño on the terrestrial tropical carbon cycle: patterns, mechanisms and implications'.

Multicriteria decision analysis to assess options for managing contaminated sediments: Application to Southern Busan Harbor, South Korea.

Many years of untreated effluent discharge from residential areas, a shipyard, a marina, and a large fish market resulted in substantial contamination of bottom sediment in Southern Busan Harbor, South Korea. Contaminants in these sediments include heavy metals and organic compounds. Newly introduced regulations for ocean disposal of dredged material in South Korea pose significant challenges, because the previous practice of offshore disposal of contaminated dredged material was no longer possible after August 2008. The South Korean government has mandated that such sediments be assessed in a way that identifies the most appropriate dredged material management alternative, addressing environmental, social, and cost objectives. An approach using multicriteria decision analysis (MCDA) in combination with comparative risk assessment was used as a systematic and transparent framework for prioritizing several dredged sediment management alternatives. We illustrate how MCDA can recognize the multiple goals of contaminated sediment management. Values used in weighting decision criteria were derived from surveys of stakeholders who were sediment management professionals, business owners, or government decision makers. The results of the analysis showed that land reclamation was the preferred alternative among cement-lock, sediment washing, 3 contained aquatic disposal alternatives (one in combination with a hopper dredge), geotextile tubes, solidification, and land reclamation after solidification treatment. Land reclamation was the preferred alternative, which performed well across all MCDA objectives, because of the availability of a near-shore confined disposal facility within a reasonable distance from the dredging area.

A decision-analysis approach for contaminated dredged material management in South Korea.

To meet London Protocol requirements, South Korea is preparing to reduce the need for disposal of dredged material at sea. The new requirements controlling ocean disposal of dredged material pose significant challenges to the South Korean government, because the previous practice of offshore disposal of contaminated dredged material is no longer permitted. Hence, other alternatives for treating and disposing of contaminated dredged material are being evaluated and selected for implementation. A new management and decision approach is therefore needed for regulators and implementers to show what information and what decision-making processes were used to make the decision, to increase administrative transparency for such projects in the public domain. To address this need, an iterative approach was developed for dredged material management that includes the essential elements of process, people, and tools needed for successful environmental decision making. The approach has 6 steps: problem definition, developing objectives and criteria, identifying alternatives, performing the evaluation, comparing alternatives, and selecting the preferred alternative. The primary objective of the approach is to provide a systematic means of exploring contaminated dredged material management alternatives in South Korea using criteria that integrate risk with economic and stakeholder value information. The approach incorporates the desired decision-making attributes of transparency, comparative analysis, and inclusion of public input. Although it was developed for South Korea, the approach can be applied in any situation in which dredged material management alternatives are being considered to manage contaminated sediment risks.

Providing a community-based cancer risk assessment service for a socially and ethnically diverse population.

BACKGROUND: Patients from ethnic minorities are under-represented in referrals to cancer genetics services. In a regional genetics centre that serves two London boroughs, the existing service attracts 3% of its referrals from Black and Minority Ethnic (BME) and other ethnic groups, despite the fact that these groups make up 34% of the population. OBJECTIVES: To improve access to familial cancer risk assessment in a socially and ethnically diverse population. SETTING: The London boroughs of Lambeth and Southwark. DESIGN: Community-based, nurse-led clinics were established for people who were concerned about their familial cancer risk. Patients were asked to triage themselves by answering three questions. Self-referral was encouraged. MAIN OUTCOME MEASURES: Data were gathered on ethnicity of clients, cancer risk, source of referral and patient and health professional satisfaction with the service. RESULTS: Of the 415 people who have accessed the service, 46% were from not White British groups and 67% referred themselves to the service, demonstrating the success of this model in reaching 'hard to reach' groups. Thirty-seven percent of patients were assessed as being at population risk and 63% were assessed as being at moderate risk or higher, showing that the clinics were meeting an unmet need in the community.

Application of risk assessment and decision analysis to aquatic nuisance species.

The spread of nonindigenous (nonnative) species introduced into the United States is a significant and growing national problem and results in lost agricultural productivity, increased health problems, native species extinctions, and expensive prevention and eradication efforts. Thousands of nonindigenous species have either become established or spread, and introduction of aquatic nuisance species (ANS) into freshwater lakes threaten aquatic biodiversity. Expanding global trade is likely to increase the number of species that are spread across the globe, so the need to develop an approach to predict potential ANS invasions is great. Risk assessments currently being used to assess ANS risk rely on qualitative or semiquantitative information and expert opinion; thus, such approaches lack transparency and repeatability. A more quantitative approach is needed to augment the qualitative approaches currently in use. A quantitative approach with the use of the traditional ecological risk assessment (traditional ERA) framework combined with decision analysis tools was developed for assessing ANS risks in which the causative ecological risk agent is an organism rather than a chemical. This paper presents a systematic risk assessment framework that includes structured decision analysis to help organize and analyze pertinent data, state assumptions, address uncertainties in estimating the probability of an undesired ANS introduction, or spread and integrate these outputs with stakeholder values. This paper also describes when and how decision analysis tools can be used in such assessments for ANS. This framework and methodology will enable risk managers to systematically evaluate and compare alternatives and actions supporting ANS risk management and thus credibly prioritize resources.

Assessing the effect of interventions on the risk of cattle and sheep carrying Escherichia coli O157:H7 to the abattoir using a stochastic model.

Escherichia coli O157:H7 persists in being a threat to food safety. The mechanisms behind the spread of E. coli O157:H7 on the farm are complex and poorly understood. The objective of this study was to apply a Monte Carlo model, constructed to simulate the propagation of E. coli O157:H7 in cattle and sheep on the farm, to both test the effect of different interventions on the risk of animals carrying E. coli O157:H7 to the abattoir and to develop understanding of the underlying processes, including the identification of areas that could benefit from further research. An overview of the model including key assumptions is given. The output statistics from batches of 100 runs of the model were collected. From the model output, a cumulative frequency distribution of the prevalence and specific shedding level for the groups of cattle or sheep being sent to the abattoir were generated. Stochastic dominance was used to compare the results of the model outputs. Using the shorthand that "risk" means the likelihood of carrying E. coli O157:H7 to the abattoir, key conclusions from the study included: mixing sheep and cattle increases the risk in both groups; merging groups of animals of the same species into larger groups increases the risk substantially; increasing stocking density increases the risk independently of group size; decreasing the group size decreases the E. coli O157:H7 prevalence independently of stocking density; a very high level of barn hygiene reduces the risk; a shorter time between spreading farmyard manure and grazing and an increased background level of E. coli O157:H7 in the model increases the risk. The background level could be influenced by the presence of wild animals carrying the organism. The parameters to which the model is most sensitive are those related to transmission from grass and enclosures to animals, pathogen survival on grass, in slurry and in barns and contact between animals.

The value of metals bioavailability and speciation information for ecological risk assessment in arid soils.

When evaluating the risk chemicals may pose to mammals and birds in ecological risk assessments (ERAs), it is common practice to conservatively assume that all (100%) of a chemical in an environmental medium is bioavailable to receptors. This assumption often leads to overestimating ecological risk and may ultimately result in costly and unnecessary risk management actions. While effects of bioavailability and speciation of metals such as arsenic (As) and lead (Pb) have been considered in human health risk assessment, these effects are rarely taken into consideration when assessing risks to mammals and birds. An ERA was conducted at the former Col-Tex refinery site in Colorado City, Texas, USA, to characterize risks to select wildlife species from exposure to chromium (Cr) and Pb found in soils. The focus on these metals was based on results of a screening-level ERA that found that Cr and Pb were posing ecological risks at the site. Soils were analyzed for total Cr and Pb, trivalent Cr (CrIII), hexavalent Cr (CrVI), organic Pb, and the bioavailability and speciation of Pb. Results for Pb and Cr indicated that >94% of the Cr was present as the less toxic and immobile Cr(III) and that >99% of the Pb in soils was present as inorganic Pb. Lead bioaccessibility measured by in vitro testing ranged from 8% to 77.8%, depending on location of individual soil samples. Results demonstrated that Pb and Cr bioavailability and speciation information can raise soil cleanup concentrations while being protective of ecological receptors. The costs of performing the ERA were de minimus compared to the reduction in remediation costs at the site. The refined hazard estimates allowed informed decision making in the management and segregation of soils, allowing for effective risk management at the site.

Doppler ultrasonographic assessment of closure of the ductus venosus in neonatal Irish wolfhounds.

The normal appearance and closure time of the ductus venosus of 22 neonatal Irish wolfhounds from three unrelated litters were determined by repeated two-dimensional, grey-scale and colour-flow Doppler ultrasound examinations. A left intercostal approach was used to identify the ductus venosus, which appeared as a parallel-sided or cone-shaped vessel connecting a left-sided intrahepatic branch of the portal vein with a confluence of veins on the cranial aspect of the liver. Doppler signals indicative of patent ductus venosus were obtained in nine of nine puppies on day 2, 11 of 17 on day 4, five of 22 on day 6, none of nine on day 9 and none of eight on day 10.

An assessment of the microbiological risks involved with egg washing under commercial conditions.

The potential benefits of washing eggs is offset by a historical perception in the European Union that wetted eggs are prone to spoilage and water loss. This study describes the effects of spray jet washing under various processing conditions to shell surface counts of Salmonella and the presence of bacteria in egg contents. Experiments used eggs that were contaminated with Salmonella Enteritidis PT4 or Salmonella Typhimurium DT104 before cuticle hardening. Washing of contaminated eggs under optimum conditions resulted in a more than 5-log reduction of Salmonella counts from the shell surface. Salmonella was not isolated from the yolk or albumen of any egg washed by the optimal protocol, suggesting that when properly controlled, egg washing did not cause Salmonella to enter the contents. However, contamination did arise if strict control was not maintained over the wash and rinse water temperatures. Both Salmonella Enteritidis and Salmonella Typhimurium were shown to enter the egg contents when water temperatures were lowered, indicating that strict temperature control must be maintained in order to prevent the ingress of Salmonella into egg contents. Other washing machine parameters that were investigated did not significantly affect Salmonella entry into the egg contents but influenced shell surface kill levels to varying degrees.

A note on whether spousal caregivers try to control their environment or themselves.

In this study, a two-process model of control (Rothbaum, Weisz, & Snyder, 1982) was used to investigate spousal caregivers' control in stressful situations. According to Rothbaum et al., primary control occurs when individuals retain control by changing their environment (other people, objects, or events), whereas secondary control occurs when individuals retain control by changing their own cognitions or emotions to adapt to the environment. In an exploration of whether caregivers would use primary or secondary control in caring for a spouse with dementia, 32 caregivers described a stressful situation they found difficult to control. Most of the participants used primary control to handle situations that focused on behavioral problems. Additional analyses indicated that most of the caregivers, in fact, used a combination of primary and secondary control.

Computed tomographic scanning and the lumbar spine. Part I: Economic and historic review.

Computed tomography represents one of the most remarkable short-term technical advances ever seen in medicine. Its recent extension to scanning of the lumbar spine promises to become its most significant extra-cranial application. The accusation has been made that CT scanning represents an expensive diagnostic modality whose cost is unjustified by its clinical value. Recent studies indicate that CT scanning is presently cost-effective and promises to become more so in the future, not only by decreasing the cost of instrumentation but also by replacing other diagnostic tests (particularly those of an invasive type) and lessening the need for exploratory surgery. CT scanning is of direct benefit to the patient because it assures that lumbar surgery is performed only after an accurate and complete diagnosis.