Healthcare practitioners' personal and professional values.

Personal and professional values of healthcare practitioners influence their clinical decisions. Understanding these values for individuals and across healthcare professions can help improve patient-centred decision-making by individual practitioners and interprofessional teams, respectively. We aimed to identify these values and integrate them into a single framework using Schwartz's values model. We searched Medline, Embase, PsycINFO, CINAHL and ERIC databases for articles on personal and professional values of healthcare practitioners and students. We extracted values from included papers and synthesized them into a single framework using Schwartz's values model. We summarised the framework within the context of healthcare practice. We identified 128 values from 50 included articles from doctors, nurses and allied health professionals. A new framework for the identified values established the following broad healthcare practitioner values, corresponding to Schwartz values (in parentheses): authority (power); capability (achievement); pleasure (hedonism); intellectual stimulation (stimulation); critical-thinking (self-direction); equality (universalism); altruism (benevolence); morality (tradition); professionalism (conformity); safety (security) and spirituality (spirituality). The most prominent values identified were altruism, equality and capability. This review identified a comprehensive set of personal and professional values of healthcare practitioners. We integrated these into a single framework derived from Schwartz's values model. This framework can be used to assess personal and professional values of healthcare practitioners across professional groups, and can help improve practitioners' awareness of their values so they can negotiate more patient-centred decisions. A common values framework across professional groups can support shared education strategies on values and help improve interprofessional teamwork and decision-making.

Two-Color, Two-Photon Imaging at Long Excitation Wavelengths Using a Diamond Raman Laser.

We demonstrate that the second-Stokes output from a diamond Raman laser, pumped by a femtosecond Ti:Sapphire laser, can be used to efficiently excite red-emitting dyes by two-photon excitation at 1,080 nm and beyond. We image HeLa cells expressing red fluorescent protein, as well as dyes such as Texas Red and Mitotracker Red. We demonstrate the potential for simultaneous two-color, two-photon imaging with this laser by using the residual pump beam for excitation of a green-emitting dye. We demonstrate this for the combination of Alexa Fluor 488 and Alexa Fluor 568. Because the Raman laser extends the wavelength range of the Ti:Sapphire laser, resulting in a laser system tunable to 680-1,200 nm, it can be used for two-photon excitation of a large variety and combination of dyes.

Label-free imaging of thick tissue at 1550 nm using a femtosecond optical parametric generator.

We have developed a simple wavelength-tunable optical parametric generator (OPG), emitting broadband ultrashort pulses with peak wavelengths at 1530-1790 nm, for nonlinear label-free microscopy. The OPG consists of a periodically poled lithium niobate crystal, pumped at 1064 nm by a ultrafast Yb:fiber laser with high pulse energy. We demonstrate that this OPG can be used for label-free imaging, by third-harmonic generation, of nuclei of brain cells and blood vessels in a >150 µm thick brain tissue section, with very little decay of intensity with imaging depth and no visible damage to the tissue at an incident average power of 15 mW.

Values add value: an online tool enhances postgraduate evidence-based practice learning.

BACKGROUND: To better prepare practitioners for the complex world of clinical decision-making, teaching evidence-based practice needs to move beyond its focus on skills and knowledge to give students an experience and understanding of applying evidence in practice. AIM: To explore whether incorporating an online values-based tool enhanced learning in a post graduate epidemiology course. METHODS: Having completed a critical appraisal of an epidemiological study, students were asked to then respond to a case scenario, using the analytical frameworks of the Values-Exchange, a software tool that highlights ethical domains in decision-making. The student experience of the Values-Exchange was evaluated using focus groups. Sessions were audiotaped and transcribed. In total, 613 responses were analysed by two independent coders to identify emergent themes. RESULTS: Three main themes emerged: (1) the Values-Exchange exposed students to new concepts and ideas relating to healthcare decision-making; (2) the diversity of other student values broadened their perspectives and (3) the experience brought reality to what it means to apply evidence in practice. CONCLUSION: Adding an online values-based tool to clinical epidemiology teaching was highly valued by students and enabled new understandings of empirical evidence and its application in practice.

An evaluation of multi-excitation-wavelength standing-wave fluorescence microscopy (TartanSW) to improve sampling density in studies of the cell membrane and cytoskeleton.

Conventional standing-wave (SW) fluorescence microscopy uses a single wavelength to excite fluorescence from the specimen, which is normally placed in contact with a first surface reflector. The resulting excitation SW creates a pattern of illumination with anti-nodal maxima at multiple evenly-spaced planes perpendicular to the optical axis of the microscope. These maxima are approximately 90 nm thick and spaced 180 nm apart. Where the planes intersect fluorescent structures, emission occurs, but between the planes are non-illuminated regions which are not sampled for fluorescence. We evaluate a multi-excitation-wavelength SW fluorescence microscopy (which we call TartanSW) as a method for increasing the density of sampling by using SWs with different axial periodicities, to resolve more of the overall cell structure. The TartanSW method increased the sampling density from 50 to 98% over seven anti-nodal planes, with no notable change in axial or lateral resolution compared to single-excitation-wavelength SW microscopy. We demonstrate the method with images of the membrane and cytoskeleton of living and fixed cells.

Does food supplementation really enhance productivity of breeding birds?

Food availability influences multiple stages of the breeding cycle of birds, and supplementary feeding has helped in its understanding. Most supplementation studies have reported advancements of laying, whilst others, albeit less numerous, have also demonstrated fitness benefits such as larger clutches, shorter incubation periods, and greater hatching success. Relatively few studies, however, have investigated the effects of supplementary feeding for protracted periods across multiple stages of the breeding cycle. These effects are important to understand since long-term food supplementation of birds is recommended in urban habitats and is used as a tool to increase reproductive output in endangered species. Here, we compare the breeding phenology and productivity of blue tits Cyanistes caeruleus and great tits Parus major breeding in food-supplemented and non-supplemented blocks in a broadleaf woodland in central England over three seasons (2006-2008). Supplementation was provided continuously from several weeks pre-laying until hatching, and had multiple significant effects. Most notably, supplementation reduced brood size significantly in both species, by half a chick or more at hatching (after controlling for year and hatching date). Reduced brood sizes in supplemented pairs were driven by significantly smaller clutches in both species and, in blue tits, significantly lower hatching success. These are novel and concerning findings of food supplementation. As expected, supplementary feeding advanced laying and shortened incubation periods significantly in both species. We discuss the striking parallels between our findings and patterns in blue and great tit reproduction in urban habitats, and conclude that supplementary feeding may not always enhance the breeding productivity of birds.

The State of Quality Improvement Teaching in Medical Schools: A Systematic Review.

INTRODUCTION: While teaching patient safety and quality improvement (QI) skills to medical students is endorsed as being important, best practice for achieving learner outcomes in QI is particularly unclear. We systematically reviewed QI curricula for medical students to identify approaches to QI training that are associated with positive learner outcomes. METHODS: We searched databases (Medline, EMBASE, and Scopus) and article bibliographies for studies published from 2009 to 2018. Studies evaluating QI teaching for medical students in any setting and reporting learner outcomes were included. Educational content, teaching format, achievement of learning outcomes, and methodological features were abstracted. Outcomes assessed were learners' satisfaction, attitudes, knowledge and skills, changes in behavior and clinical processes, and benefits to patients. RESULTS: Twenty of 25 curricula targeted medical students exclusively. Most curricula were well accepted by students (11/13 studies), increased their confidence in QI (9/11) and led to knowledge acquisition (17/20). Overall, positive learner outcomes (Kirkpatrick Levels 1 to 4A) were demonstrated across a range of curricular content and teaching modalities. In particular, 2 curricula demonstrated positive changes in learners' behavior (Kirkpatrick Level 3), both incorporating a clinical audit or QI project based in hospitals, and supplemented by didactic lectures. Seven curricula were associated with improvements in processes of care (Kirkpatrick Level 4A) all of which were set in a clinical setting and supplemented by didactic lectures and/or small group sessions. None of the curricula evaluated patient benefits (Kirkpatrick Level 4B). CONCLUSIONS: Whilst there is heterogeneity in educational content and teaching methods, most curricula are well accepted and led to learners' knowledge acquisition. Although there is limited evidence for the impact of QI curricula on learner behavior and benefit to patients, and for interprofessional QI curricula, teaching QI in the clinical setting leads to better learner outcomes with location being potentially a surrogate for clinical experience.

Three-dimensional in situ morphometrics of Mycobacterium tuberculosis infection within lesions by optical mesoscopy and novel acid-fast staining.

Tuberculosis (TB) preclinical testing relies on in vivo models including the mouse aerosol challenge model. The only method of determining colony morphometrics of TB infection in a tissue in situ is two-dimensional (2D) histopathology. 2D measurements consider heterogeneity within a single observable section but not above and below, which could contain critical information. Here we describe a novel approach, using optical clearing and a novel staining procedure with confocal microscopy and mesoscopy, for three-dimensional (3D) measurement of TB infection within lesions at sub-cellular resolution over a large field of view. We show TB morphometrics can be determined within lesion pathology, and differences in infection with different strains of Mycobacterium tuberculosis. Mesoscopy combined with the novel CUBIC Acid-Fast (CAF) staining procedure enables a quantitative approach to measure TB infection and allows 3D analysis of infection, providing a framework which could be used in the analysis of TB infection in situ.

Emergency department case-finding for high-risk older adults: the Brief Risk Identification for Geriatric Health Tool (BRIGHT).

OBJECTIVE: The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment. METHODS: This was a cross-sectional study in which 139 persons > or = 75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A "yes" response to at least 3 of the 11 BRIGHT items was considered "positive." Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL). RESULTS: The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p < 0.01); cognitive deficit (35% prevalence) sensitivity of 0.78, specificity of 0.54, and ROC of 0.66 (95% CI = 0.55 to 0.76, p = 0.006); and ADL deficit (29% prevalence) sensitivity of 0.83, specificity of 0.53, and ROC of 0.64 (95% CI = 0.53 to 0.75, p = 0.020). Positive likelihood ratios (LR+) for the three outcomes of interest were 3.6, 1.7, and 1.8, respectively. Negative likelihood ratios (LR-) were 0.3, 0.4, and 0.3. CONCLUSIONS: The 11-item BRIGHT successfully identifies older adults in the ED with decreased function and may be useful in differentiating elder patients in need of comprehensive assessment.

The BRIGHT tool.

OBJECTIVE: the size of the burden of unmet needs of older people living in the community is unknown. We aim to validate a brief postal questionnaire, the Brief Risk Identification of Geriatric Health Tool (BRIGHT) questionnaire, to find cases of older people with disabilities (case-finding) living in the community. METHODS: community-dwelling patients over the age of 75 years were invited from two general practitioners in Auckland, New Zealand. Participants completed the 11-item BRIGHT questionnaire twice and were assessed at home using the Minimum Dataset for Home Care (MDS-HC) comprehensive geriatric assessment tool by a trained gerontology nurse. Retest reliability of the BRIGHT was assessed with a correlation coefficient, and receiver operator characteristic (ROC) curves were used to assess the utility of the tool against standard outputs from the MDS-HC reflecting level of disability; the instrumental activities of daily living clinical assessment protocol (IADL CAP), and the MAPle score for dependency. RESULTS: 101 participants completed both the BRIGHT questionnaires and the comprehensive MDS-HC assessment. Test-retest reliability was modest with a correlation of 0.77. A sensitivity of 0.86 and specificity of 0.86 were observed for a score of 3 or more on the questionnaire in relationship to the IADL CAP. A sensitivity of 0.65 and specificity of 0.84 were observed when BRIGHT questionnaire score of 3+ was related to the MAPLe score from the MDS-HC assessment. CONCLUSIONS: the BRIGHT questionnaire has acceptable utility in identifying community-dwelling older people with disability, and excellent utility in ruling them out of needing further assessment. This tool may be useful as part of an intervention process to detect unmet needs and to improve systematic surveillance of primary care populations.

PEGylation of polypropylenimine dendrimers: effects on cytotoxicity, DNA condensation, gene delivery and expression in cancer cells.

Diaminobutyric polypropylenimine (DAB) dendrimers have been shown to be highly efficient non-viral gene delivery systems for cancer therapy. However, their cytotoxicity currently limits their applications. To overcome this issue, PEGylation of DAB dendrimer, using various PEG molecular weights and dendrimer generations, has been attempted to decrease the cytotoxicity and enhance the DNA condensation, size and zeta potential, cellular uptake and transfection efficacy of these dendriplexes. Among all the PEGylated dendrimers synthesized, generation 3- and generation 4-DAB conjugated to low molecular weight PEG (2 kDa) at a dendrimer: DNA ratio of 20:1 and 10:1 resulted in an increase in gene expression on almost all tested cancer cells lines (by up to 3.2-fold compared to unmodified dendrimer in A431 cells). The highest level of ß-galactosidase gene expression (10.07 × 10-3 ± 0.09 × 10-3 U/mL) was obtained following treatment of B16F10-Luc cells with G4-dendrimer PEGylated with PEG2K at a dendrimer: DNA ratio of 20:1. These delivery systems significantly decreased cytotoxicity on B16F10-Luc cells, by more than 3.4-fold compared to unmodified dendrimer. PEGylated generations 3- and 4-DAB dendrimers are therefore promising gene delivery systems for cancer therapy, combining low cytotoxicity and high transfection efficacy.

The state of quality improvement and patient safety teaching in health professional education in New Zealand.

AIM: To investigate how quality and patient safety domains are being taught in the pre-registration curricula of health profession education programmes in New Zealand. METHODS: All tertiary institutions providing training for medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, dietetics and 11 other allied health professions in New Zealand were contacted and a person with relevant curriculum knowledge was invited to participate. Interviews were conducted using a semi-structured interview guide to explore nine quality and safety domains; improvement science, patient safety, quality and safety culture, evidence-based practice, patient-centred care, teamwork and communication, leadership for change, systems thinking and use of information technology (IT). Transcribed data were extracted and categorised by discipline and domain. Two researchers independently identified and categorised themes within each domain, using a general inductive approach. RESULTS: Forty-nine institutions were contacted and 43 (88%) people were interviewed. The inclusion and extent of quality and safety teaching was variable. Evidence-based practice, patient-centred care and teamwork and communication were the strongest domains and well embedded in programmes, while leadership, systems thinking and the role of IT were less explicitly included. Except for two institutions, improvement science was absent from pre-registration curricula. Patient safety teaching was focused mainly around incident reporting, and to a lesser extent learning from adverse events. Although a 'no blame' culture was articulated as important, the theme of individual accountability was still apparent. While participants agreed that all domains were important, the main barriers to incorporating improvement science and patient safety concepts into existing programmes included an 'already stretched curriculum' and having faculty with limited expertise in these areas. CONCLUSIONS: Although the building blocks for improving the quality and safety of healthcare are present, this national study of multiple health professional pre-registration education programmes has identified teaching gaps in patient safety and improvement science methods and tools. Failure to address these gaps will compromise the ability of new graduates to successfully implement and sustain improvements.

Medication-related patient harm in New Zealand hospitals.

AIM: The purpose of this study is to identify patterns of medication-related harm from a national perspective, and to use this information to inform decisions on where to focus medication safety efforts. This study updates a 2013 study using the same methodology. METHOD: District health boards (DHBs) still actively using either the Adverse Drug Event (ADE) Trigger Tool (TT) or the Global Trigger Tool (GTT), submitted two years of anonymised ADE data (1 July 2013-30 June 2015) to the Health Quality & Safety Commission (the Commission) using a standard template. Analyses were conducted using aggregated data only. RESULTS: Of eight DHBs who submitted data, six datasets were included, representing a total of 2,659 chart reviews. From these reviews, 923 harms were identified in 751 patients, with 28% of patients experiencing one or more harms. Harms occurred at a rate of 34.7 per 100 admissions, 42.5 per 1,000 bed days and 28% of patients experienced one or more medication-related harms. Those harmed were more likely to be older, female and have an increased length of stay. Most harms (65%) occurred during an inpatient stay, however, a substantial number (29%) originated in the community and precipitated an admission. Across all levels of severity, the most common types of medication harm were constipation, hypotension and bleeding. In the more serious harm categories, bleeding, hypotension and delirium/confusion/over-sedation were most common. Six groups of medicines caused the greatest amount of harm: opioids (including tramadol), anticoagulants/antiplatelet agents, antibiotics, antianginals (beta-blockers, nitrates, calcium channel blockers and others), diuretics and other cardiovascular medicines (angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARBs), centrally acting agents and statins). Opioids and anticoagulants/antiplatelet agents not only accounted for 40% of all harm, they were implicated in the most severe harm. CONCLUSION: This paper confirms earlier work that medication-related harms are common, occur both in hospitals and in the community, and are a substantial burden for patients and our healthcare system. Work is underway at local and national levels to decrease this harm, with a focus on the high-risk medicines most commonly implicated.

Teaching quality improvement to medical students: over a decade of experience.

AIM: To describe how we incorporate experiential quality improvement (QI) learning at the University of Auckland by integrating a clinical audit project into the Year 6 obstetrics and gynaecology clinical attachment. METHODS: Students gain insight into the relevance of QI while engaged in day-to-day clinical work. Students work with a clinical supervisor to identify an area for potential improvement, set a standard of care, measure current practice, investigate reasons for deviation from the standard and make real-world suggestions to close the gap between best evidence and observed practice. RESULTS: Since 2004, over 1,250 projects have been completed, and two journal articles published. Many of the student projects result in actual improvements to clinical processes of care, and lead to strengthening of academic and service provider learning networks and partnerships. CONCLUSIONS: Performing a hands-on project within the constraints and context of a busy women's health service is a feasible and effective method of teaching QI. Medical schools have an integral role to play in ensuring future healthcare professionals are equipped with QI knowledge, skills and attitudes. Experiential QI learning enhances clinical teaching and training, and is important in preparing future clinicians to incorporate QI into their daily practice.

Widefield Two-Photon Excitation without Scanning: Live Cell Microscopy with High Time Resolution and Low Photo-Bleaching.

We demonstrate fluorescence imaging by two-photon excitation without scanning in biological specimens as previously described by Hwang and co-workers, but with an increased field size and with framing rates of up to 100 Hz. During recordings of synaptically-driven Ca(2+) events in primary rat hippocampal neurone cultures loaded with the fluorescent Ca(2+) indicator Fluo-4 AM, we have observed greatly reduced photo-bleaching in comparison with single-photon excitation. This method, which requires no costly additions to the microscope, promises to be useful for work where high time-resolution is required.

Enhanced gene expression in the brain following intravenous administration of lactoferrin-bearing polypropylenimine dendriplex.

The possibility of using gene therapy for the treatment of brain diseases such as brain cancer, Alzheimer's and Parkinson's diseases, is currently hampered by the lack of gene delivery systems able to cross the blood-brain barrier and deliver DNA to the brain following intravenous administration. On the basis that lactoferrin can effectively reach the brain by using specific receptors for crossing the blood-brain barrier, we propose to investigate if a lactoferrin-bearing generation 3-diaminobutyric polypropylenimine (DAB) dendrimer would allow the transport of plasmid DNA to the brain after intravenous administration. In this work, we demonstrated that the conjugation of lactoferrin to the dendrimer led to an enhanced DNA uptake by 2.1-fold in bEnd.3 murine brain capillary endothelial cells compared to the unmodified dendriplex in vitro. In vivo, the intravenous administration of lactoferrin-bearing DAB dendriplex resulted in a significantly increased gene expression in the brain, by more than 6.4-fold compared to that of DAB dendriplex, while decreasing gene expression in the lung and the kidneys. Gene expression in the brain was significantly higher than in any other major organs of the body. Lactoferrin-bearing generation 3 polypropylenimine dendrimer is therefore a highly promising delivery system for systemic gene delivery to the brain.

Subterranean sympatry: an investigation into diet using stable isotope analysis.

In the Western Cape three species of mole-rat occur in sympatry, however, little is known about differences in their dietary preferences. Dietary composition of the three species; the common mole-rat (Cryptomys hottentotus hottentotus), the Cape mole-rat (Georychus capensis) and the Cape dune mole-rat (Bathyergus suillus) were examined using stable isotope analysis. Blood, fur and claw samples were collected from 70 mole-rats, in addition to several potential food items, to assess food selection of the three species under natural conditions. Overall there was a significant difference in the isotopic composition (δ(13)C and δ(15)N) between all three species and significant differences in their diet composition. There were also significant differences between tissues in all three species suggesting temporal variation in diet. The small size and colonial lifestyle of C. h. hottentotus allows it to feed almost 100% on bulbs, while the solitary and larger species G. capensis and B. suillus fed to a greater extent on other resources such as grasses and clover. B. suillus, the largest of the species, had the most generalized diet. However, overall all species relied most heavily upon geophytes and consumed the same species suggesting competition for resources could exist. We also showed a high level of individual variation in diet choices. This was most pronounced in B. suillus and G. capensis and less so in C. h. hottentotus. We demonstrate that stable isotope analysis can successfully be applied to examine dietary patterns in subterranean mammals and provide insights into foraging patterns and dietary variation at both the inter and intra population level.

A multi-faceted approach to the physiologically unstable patient.

BACKGROUND: Patients on general hospital wards who deteriorate clinically are often not recognised as needing an escalation in care, and effective interventions are delayed. This study reviews a multifaceted approach to the identification and management of these patients in a large metropolitan hospital in Auckland, New Zealand. STRATEGIES FOR CHANGE: Four interventions were combined into the Physiologically Unstable Patient (PUP) programme. These were: (1) redesign of the vital sign observation chart; (2) introduction of an early warning scoring system; (3) deployment of a nurse-led rapid response team; and (4) a comprehensive ward-based education programme. KEY MEASURES FOR IMPROVEMENT: Completeness and accuracy of routine observations; actions taken in accordance with the algorithm; impact on medical emergency team callouts, cardiac arrest calls and unplanned intensive care unit admissions. EFFECTS OF CHANGE: The PUP programme was implemented in 16 wards over 15 months. Vital sign recording improved, and the PUP score became a recognised metric for prioritising patients for review. Consistent with others' experience, there was a reluctance to call for help. Raised PUP scores prompted action around 30% of the time on average. Medical emergency team calls increased significantly from a median of 27.5 calls per month to 70.5. There was no significant change in unplanned transfers to intensive care unit or in cardiac arrest calls. LESSONS LEARNT: A multifaceted programme to identify physiologically unstable patients on general wards can be introduced and can improve the recognition of such patients, but there are still barriers to ensuring that these patients receive the extra care that they require. These systemic failings need to be investigated and addressed for real change to occur.

Measuring the safety culture in a hospital setting: a concept whose time has come?

AIM: Getting the right 'patient safety culture' is thought to be an important component in improving patient safety in hospitals, however there is a lack of clarity in how best to measure and improve it, and whether such improvement actually translates to better patient outcomes. This paper reflects on the Counties Manukau District Health Board (CMDHB) experience with a patient safety survey and attempts to answer questions other organisations may ask when deciding whether to invest in such survey. METHODS: A literature search was undertaken to identify valid and reliable patient safety culture survey tools. These were reviewed with respect to how best to interpret and use the results. RESULTS: If hospitals decide to undertake a patient safety culture survey, the recommended survey tools are the Safety Attitudes Questionnaire (SAQ) and the Hospital Survey on Patient Safety (HSOPS). Both have been widely used and have sound and comprehensive psychometrics. Only the SAQ has established links with patient safety outcomes such as reduced healthcare associated infections. CONCLUSION: Surveys can provide some insights into the patient safety culture within an organisation, but the opportunity costs of undertaking a survey should be carefully considered. Much of their value lies in raising the profile of patient safety and promoting conversations; making patient safety 'the way we do business around here'.

Summary of an evidence-based guideline on soft tissue shoulder injuries and related disorders--Part 1: Assessment.

AIM: To provide a succinct summary of the diagnosis of soft tissue injuries to the shoulder for primary health care practitioners based on the New Zealand guideline. METHODS: A multidisciplinary team developed the guideline by critically appraising and grading retrieved literature using the Graphic Appraisal Tool for Epidemiology (GATE). Recommendations were derived from resulting evidence tables. RESULTS: Diagnostic ultrasound is a valid tool for the diagnosis of a full thickness rotator cuff tear. If a significant tear is suspected, referral for diagnostic ultrasound is recommended. There is a paucity of evidence for the diagnosis of soft tissue shoulder injuries and most recommendations are based on the consensus of the guideline team. CONCLUSION: Assessment relies on thorough history-taking and physician examination with appropriate referral where there is evidence of serious damage or the diagnosis remains unclear.