Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Improves Pain Control in Patients With Rib Fractures.

OBJECTIVES: The serratus anterior plane block (SAPB) is an ultrasound-guided compartment block; limited data suggest that it can decrease pain in patients with rib fractures or chest wall pain. We sought to determine the effect of SAPB on pain and incentive spirometry (IS) maximal vital capacity in adult patients with rib fractures. METHODS: We enrolled a prospective sample of adult patients with at least two unilateral rib fractures who were being admitted for pain control. SAPB was performed by trained emergency physicians. Patients reported pain on an 11-point Numeric Rating Scale at rest and during IS, before, 15, and 60 minutes after SAPB. RESULTS: Mean pain scores decreased by 1.8 (SD 2.17, 95% confidence interval [CI]: 0.79-2.81) at 15 minutes and 2.5 (SD 2.69, 95% CI: 1.24-3.76) at 60 minutes. Compared to pre-block pain scores during IS, mean pain scores decreased by 1.95 (SD 1.99, 95% CI: 1.02-2.88) at 15 minutes and 2.4 (SD 2.42, 95% CI: 1.27-3.53) at 60 minutes. Mean maximum vital capacity increased by 232 mL (SD 406, 95% CI: 36-427) at 60 minutes. Zero SAPB-attributable complications were identified in the 24 hours post-enrollment. CONCLUSIONS: In patients with multiple rib fractures, SAPB reduced pain scores at rest and during IS, and increased maximal vital capacity. The SABP may be a safe and effective modality for pain control in trauma patients with multiple rib fractures.

Indicators of dementia disease progression in primary care: An electronic health record cohort study.

BACKGROUND AND PURPOSE: The objectives were to assess the feasibility and validity of using markers of dementia-related health as indicators of dementia progression in primary care, by assessing the frequency with which they are recorded and by testing the hypothesis that they are associated with recognised outcomes of dementia. The markers, in 13 domains, were derived previously through literature review, expert consensus, and analysis of regional primary care records. METHODS: The study population consisted of patients with a recorded dementia diagnosis in the Clinical Practice Research Datalink, a UK primary care database linked to secondary care records. Incidence of recorded domains in the 36 months after diagnosis was determined. Associations of recording of domains with future hospital admission, palliative care, and mortality were derived. RESULTS: There were 30,463 people with diagnosed dementia. Incidence of domains ranged from 469/1000 person-years (Increased Multimorbidity) to 11/1000 (Home Pressures). An increasing number of domains in which a new marker was recorded in the first year after diagnosis was associated with hospital admission (hazard ratio for ≥4 domains vs. no domains = 1.24; 95% confidence interval = 1.15-1.33), palliative care (1.87; 1.62-2.15), and mortality (1.57; 1.47-1.67). Individual domains were associated with outcomes with varying strengths of association. CONCLUSIONS: Feasibility and validity of potential indicators of progression of dementia derived from primary care records are supported by their frequency of recording and associations with recognised outcomes. Further research should assess whether these markers can help identify patients with poorer prognosis to improve outcomes through stratified care and targeted support.

Markers of dementia-related health in primary care electronic health records.

OBJECTIVES: Identifying routinely recorded markers of poor health in patients with dementia may help treatment decisions and evaluation of earlier outcomes in research. Our objective was to determine whether a set of credible markers of dementia-related health could be identified from primary care electronic health records (EHR). METHODS: The study consisted of (i) rapid review of potential measures of dementia-related health used in EHR studies; (ii) consensus exercise to assess feasibility of identifying these markers in UK primary care EHR; (iii) development of UK EHR code lists for markers; (iv) analysis of a regional primary care EHR database to determine further potential markers; (v) consensus exercise to finalise markers and pool into higher domains; (vi) determination of 12-month prevalence of domains in EHR of 2328 patients with dementia compared to matched patients without dementia. RESULTS: Sixty-three markers were identified and mapped to 13 domains: Care; Home Pressures; Severe Neuropsychiatric; Neuropsychiatric; Cognitive Function; Daily Functioning; Safety; Comorbidity; Symptoms; Diet/Nutrition; Imaging; Increased Multimorbidity; Change in Dementia Drug. Comorbidity was the most prevalent recorded domain in dementia (69%). Home Pressures were the least prevalent domain (1%). Ten domains had a statistically significant higher prevalence in dementia patients, one (Comorbidity) was higher in non-dementia patients, and two (Home Pressures, Diet/Nutrition) showed no association with dementia. CONCLUSIONS: EHR captures important markers of dementia-related health. Further research should assess if they indicate dementia progression. These markers could provide the basis for identifying individuals at risk of faster progression and outcome measures for use in research.

Low back pain: a call for action.

Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.1 Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series,2,3 is a call for action on this global problem of low back pain.

Care for low back pain: can health systems deliver?

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.

Les lombalgies sont la principale cause d'années de vie vécues avec une incapacité dans le monde. En 2018, un groupe de travail international a invité l'Organisation mondiale de la Santé à attirer l'attention sur la charge que représentent les lombalgies et sur la nécessité d'éviter le recours excessif aux solutions médicales. En effet, selon les dernières recommandations cliniques internationales, de nombreux cas de lombalgie ne nécessitent pas ou peu de traitement formel. Lorsqu'un traitement est requis, il est recommandé de limiter la prise d'analgésiques, les injections de stéroïdes et la chirurgie rachidienne, et d'encourager plutôt les thérapeutiques physiques et psychologiques. Très souvent, les systèmes de santé ne sont pas conçus pour appliquer cette approche. Dans cet article, nous abordons les raisons pour lesquelles un changement des systèmes s'impose si l'on veut prendre en charge les lombalgies suivant les recommandations. Nous détaillons les principales difficultés de la prise en charge des lombalgies dans le cadre des systèmes de santé. Il s'agit notamment des intérêts financiers des laboratoires pharmaceutiques, entre autres; des systèmes de paiement obsolètes qui privilégient la prise en charge médicale à l'autogestion par les patients; et de croyances et traditions médicales profondément ancrées parmi les médecins et la population. Nous donnons des exemples internationaux de solutions, de politiques et de pratiques prometteuses pour les systèmes de santé confrontés de plus en plus souvent à une prise en charge inefficace des lombalgies. Nous suggérons des politiques qui, sans incidence sur les coûts, en transférant les ressources allouées aux soins inutiles vers des soins conformes aux recommandations, pourraient avoir un impact considérable. De petits ajustements des politiques de santé ne suffiront cependant pas. Les systèmes des milieux professionnels, les cadres juridiques, les croyances personnelles, les politiques et le contexte sociétal global dans lequel s'inscrit la santé devront également changer.

El dolor lumbar es la causa principal de vivir con discapacidad durante años en todo el mundo. En 2018, un grupo de trabajo internacional pidió a la Organización Mundial de la Salud que prestara más atención a la carga del dolor lumbar y a la necesidad de evitar soluciones excesivamente médicas. De hecho, las principales directrices clínicas internacionales reconocen ahora que muchas personas con dolor lumbar requieren poco o ningún tratamiento formal. Cuando se requiere tratamiento, el enfoque recomendado es desalentar el uso de analgésicos, inyecciones de esteroides y cirugía de la columna vertebral y, en su lugar, promover las terapias físicas y psicológicas. Muchos sistemas de salud no están diseñados para apoyar este enfoque. En este documento, se expone por qué el cuidado del dolor lumbar de acuerdo con las directrices requiere cambios en todo el sistema. Se detallan los retos clave de la atención del dolor lumbar en los sistemas de salud. Estos incluyen los intereses financieros de las compañías farmacéuticas y de otro tipo, los sistemas de pago obsoletos que favorecen la atención médica por encima del autocuidado de los pacientes, así como las tradiciones y las creencias médicas profundamente arraigadas sobre la atención del dolor de espalda entre los médicos y el público general. Se presentan ejemplos internacionales de soluciones prometedoras y de políticas y prácticas para los sistemas de salud que se enfrentan a una carga cada vez mayor de la atención ineficaz para el dolor lumbar. Se sugieren políticas que, al desplazar los recursos de la atención innecesaria a la atención acorde con las directrices para el dolor lumbar, podrían ser neutras en cuanto a costes y tener un impacto generalizado. Sin embargo, los pequeños ajustes en la política sanitaria no funcionarán de forma aislada. Los sistemas del lugar de trabajo, los marcos jurídicos, las creencias personales, la política y el contexto social general en el que vivimos la salud también tendrán que cambiar.

WAMAMI: emergency physicians can accurately identify wall motion abnormalities in acute myocardial infarction.

OBJECTIVE: The ability to identify wall motion abnormalities may be useful for emergency clinicians, but is not typically evaluated in point-of-care echocardiograms. We sought to determine if emergency physicians with basic training in emergency echocardiography could identify regional wall motion abnormalities (RWMA) in patients admitted with ST-elevation myocardial infarction (STEMI). METHODS: We prospectively enrolled patients with admitted with STEMI. Resident physicians with basic training in emergency ultrasound, blinded to other patient data, performed a point-of-care echocardiogram to evaluate for RWMA. If present, they also recorded the suspected territory of the RWMA. We calculated test performance characteristics and compared the agreement between point-of-care and comprehensive echocardiogram for RWMA and territory. RESULTS: 75 patients with STEMI were enrolled, and 62% had a RMWA. RWMA were identified with excellent test performance characteristics (sensitivity 88% (95% CI 75-96); specificity 92% (95% CI 75-99)). There was substantial agreement between the point-of-care echocardiogram and reference standard (K = 0.79; 95% CI: 0.64-0.94). CONCLUSIONS: Emergency physicians with core training in point-of-care echocardiography can accurately identify RMWA.

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis.

Objectives: The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care. Methods: An incremental cost-utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves. Results: Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by -0.28 (95% CI: -0.55, -0.06). The cost-utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £-13.11 (95% CI: -81.09 to 54.85) and an incremental quality adjusted life year (QALY) of -0.003 (95% CI: -0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm. Conclusion: Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.

Secular trends in work disability and its relationship to musculoskeletal pain and mental health: a time-trend analysis using five cross-sectional surveys (2002-2010) in the general population.

OBJECTIVES: International evidence suggests that rates of inability to work because of illness can change over time. We hypothesised that one reason for this is that the link between inability to work and common illnesses, such as musculoskeletal pain and mental illness, may also change over time. We have investigated this in a study based in one UK district. METHODS: Five population surveys (spanning 2002-2010) of working-age people aged >50 years and ≤65 years were used. Work disability was defined as a single self-reported item 'not working due to ill-health'. Presence of moderate-severe depressive symptoms was identified from the Mental Component Score of the Short Form-12, and pain from a full-body manikin. Data were analysed with multivariable logistic regression. RESULTS: The proportion of people reporting work disability across the surveys declined, from 17.0% in 2002 to 12.1% in 2010. Those reporting work disability, one-third reported regional pain, one-half widespread pain (53%) and two-thirds moderate-severe depressive symptoms (68%). Both factors were independently associated with work disability; their co-occurrence was associated with an almost 20-fold increase in the odds of reporting work disability compared with those with neither condition. CONCLUSIONS: The association of work disability with musculoskeletal pain was stable over time; depressive symptoms became more prominent in persons reporting work disability, but overall prevalence of work disability declined. The frequency and impact of both musculoskeletal pain and depression highlight the need to move beyond symptom-directed approaches towards a more comprehensive model of health and vocational advice for people unable to work because of illness.

Non-disclosure of symptoms in primary care: an observational study.

Background: Symptoms form a major component of patient agendas, with the need for an explanation of symptoms being a prominent reason for consultation. Objectives: To estimate the prevalence of different symptoms pre-consultation, to investigate whether intention to mention a symptom in the consultation varied between patients and across symptoms, and to determine how patients' intended agendas for mentioning symptoms compared with what was discussed. Method: We videorecorded consultations of an unselected sample of people aged 45 and over consulting their GP in seven different practices in UK primary care. A pre-consultation questionnaire recorded the patient's agenda for the consultation, current symptoms and symptoms the patient intended to discuss with their GP. The videorecorded consultation was viewed and all patient agendas and 'symptoms with intention to discuss' were compared with the actual topics of discussion. Results: Totally, 190 patients participated. Eighty-one (42.6%) were female and the mean age was 68 (range 46-93). Joint pain was the most commonly reported symptom. One hundred thirty-nine (81.8% of those reporting symptoms) patients reported intention to discuss a symptom. In 43 (22.6%) consultations, 67 symptoms (27.2%), where an intention to discuss had been expressed, remained undisclosed. Tiredness and sleeping difficulty were more likely to be withheld than other symptoms after an intention to discuss had been expressed. Of the more physically located symptoms, joint pain was the most likely to remain undisclosed. Conclusion: This study suggests that the extent of symptom non-disclosure varies between patients, physicians and symptoms. Further work needs to explore the consequences of non-disclosure.

Enhancing delivery of osteoarthritis care in the general practice consultation: evaluation of a behaviour change intervention.

BACKGROUND: Professionally-focussed behaviour change intervention (BCI) workshops were utilised in the Management of OsteoArthritis in Consultations (MOSAICS) trial investigating the feasibility of implementing the National Institute for Health and Care Excellence (NICE) Osteoarthritis (OA) Guideline in general practice. The workshops aimed to implement the general practitioner (GP) component of the trial intervention: an enhanced consultation for patients presenting with possible OA. This study presents an evaluation of the BCI workshops on GP competency in conducting these enhanced consultations. METHODS: A before-and-after evaluation of the workshops, delivered to GPs participating in the intervention arm of the MOSAICS trial, using video-recorded GP consultations with simulated OA patients. GPs attended four workshops, which had been developed using an implementation framework. Videos were undertaken at three time-points (before workshops and at one- and five-months after) and were assessed by independent observers, blinded to time points, for GP competency in undertaking 14 predetermined consultation tasks. RESULTS: Videos of 15 GPs were assessed. GP competency increased from a median of seven consultation tasks undertaken by each GP at baseline to 11 at both time-points after the workshops. Specific tasks which were undertaken more frequently after the workshops related to explaining that OA is treatable and not inevitably progressive, eliciting and addressing patient expectations of the consultation, and providing written OA information. However, the use of the word "osteoarthritis" in giving the diagnosis of OA was not enhanced by the workshops. CONCLUSIONS: BCI workshops can enhance GP competency in undertaking consultations for OA. Further initiatives to implement the NICE OA Guideline and enhance the care of people with OA in primary care can be informed by the content and delivery of the workshops evaluated in this study.

Change in physical activity level and clinical outcomes in older adults with knee pain: a secondary analysis from a randomised controlled trial.

BACKGROUND: Exercise interventions improve clinical outcomes of pain and function in adults with knee pain due to osteoarthritis and higher levels of physical activity are associated with lower severity of pain and higher levels of physical functioning in older adults with knee osteoarthritis in cross-sectional studies. However, to date no studies have investigated if change in physical activity level during exercise interventions can explain clinical outcomes of pain and function. This study aimed to investigate if change in physical activity during exercise interventions is associated with future pain and physical function in older adults with knee pain. METHODS: Secondary longitudinal data analyses of a three armed exercise intervention randomised controlled trial. Participants were adults with knee pain attributed to osteoarthritis, over the age of 45 years old (n = 514) from Primary Care Services in the Midlands and Northwest regions of England. Crude and adjusted associations between absolute change in physical activity from baseline to 3 months (measured by the self-report Physical Activity Scale for the Elderly (PASE)) and i) pain ii) physical function (Western Ontario and McMaster Universities Osteoarthritis Index) and iii) treatment response (OMERACT-OARSI responder criteria) at 3 and 6 months follow-up were investigated using linear and logistic regression. RESULTS: Change in physical activity level was not associated with future pain, function or treatment response outcomes in crude or adjusted models at 3 or 6 months (P > 0.05). A 10 point increase in PASE was not associated with pain ß = - 0.01 (- 0.05, 0.02), physical function ß = - 0.09 (- 0.19, 0.02) or likelihood (odds ratio) of treatment response 1.02 (0.99, 1.04) at 3 months adjusting for sociodemographics, clinical covariates and the trial intervention arm. Findings were similar for 6 month outcome models. CONCLUSIONS: Change in physical activity did not explain future clinical outcomes of pain and function in this study. Other factors may be responsible for clinical improvements following exercise interventions. However, the PASE may not be sufficiently responsive to measure change in physical activity level. We also recommend further investigation into the responsiveness of commonly used physical activity measures. TRIAL REGISTRATION: ( ISRCTN93634563 ). Registered 29th September 2011.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care.

BACKGROUND: This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes. METHODS AND FINDINGS: We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]). CONCLUSIONS: In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group. TRIAL REGISTRATION: ISRCTN registry ISRCTN40721988.

Self-management of musculoskeletal hand pain and hand problems in community-dwelling adults aged 50 years and older: results from a cross-sectional study in a UK population.

BACKGROUND: Musculoskeletal pain is common in adults, with the hand being frequently affected. Healthcare services have the potential to be of benefit to adults with hand pain and problems, through promotion and facilitation of self-management. METHODS: This paper explores existing self-management in a UK population of community-dwelling adults aged 50 years and over using data from surveys and a nested clinical cohort study. Self-management of hand problems was considered in three ways: self-directed treatment approaches used, adaptation behaviours adopted and choice to consult with a healthcare professional. RESULTS: The treatment approaches most commonly used were 'exercise/movement' (n = 151, 69 %) and 'resting' the hands (n = 139, 69 %). The use of adaptation behaviour was widespread: 217 (99 %) people reported using one or more adaptation behaviours. Under half of survey respondents who reported hand pain (n = 783, 43 %) had consulted a healthcare professional about their problem during the last year: the lowest rate of consultation was for occupational therapy (n = 60, 3 %). CONCLUSIONS: Self-directed treatment and adaptation behaviours were widespread in adults aged 50 years and over with hand problems, but consultation with a healthcare professional was low.