Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness.

BACKGROUND: It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions. METHODS: We used citation searches of Web of Science (date of 'parent publication' for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018). RESULTS: Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility. CONCLUSIONS: In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

The (Under)Use of Eye-Tracking in Evolutionary Ecology.

To survive and pass on their genes, animals must perform many tasks that affect their fitness, such as mate-choice, foraging, and predator avoidance. The ability to make rapid decisions is dependent on the information that needs to be sampled from the environment and how it is processed. We highlight the need to consider visual attention within sensory ecology and advocate the use of eye-tracking methods to better understand how animals prioritise the sampling of information from their environments prior to making a goal-directed decision. We consider ways in which eye-tracking can be used to determine how animals work within attentional constraints and how environmental pressures may exploit these limitations.

Operating list composition and surgical performance.

BACKGROUND: Recent reviews suggest that the way in which surgeons prepare for a procedure (warm up) can affect performance. Operating lists present a natural experiment to explore this phenomenon. The aim was to use a routinely collected large data set on surgical procedures to understand the relationship between case list order and operative performance. METHOD: Theatre lists involving the 35 procedures performed most frequently by senior surgeons across 38 private hospitals in the UK over 26 months were examined. A linear mixed-effects model and matched analysis were used to estimate the impact of list order and the cost of switching between procedures on a list while controlling for key prognosticators. The influence of procedure method (open versus minimally invasive) and complexity was also explored. RESULTS: The linear mixed-effects model included 255 757 procedures, and the matched analysis 48 632 pairs of procedures. Repeating the same procedure in a list resulted in an overall time saving of 0·98 per cent for each increase in list position. Switching between procedures increased the duration by an average of 6·48 per cent. The overall reduction in operating time from completing the second procedure straight after the first was 6·18 per cent. This pattern of results was consistent across procedure method and complexity. CONCLUSION: There is a robust relationship between operating list composition and surgical performance (indexed by duration of operation). An evidence-based approach to structuring a theatre list could reduce the total operating time.

A systematic examination of preoperative surgery warm-up routines.

BACKGROUND: Recent evidence indicates that a preoperative warm-up is a potentially useful tool in facilitating performance. But what factors drive such improvements and how should a warm-up be implemented? METHODS: In order to address these issues, we adopted a two-pronged approach: (1) we conducted a systematic review of the literature to identify existing studies utilising preoperative simulation techniques; (2) we performed task analysis to identify the constituent parts of effective warm-ups. We identified five randomised control trials, four randomised cross-over trials and four case series. The majority of these studies reviewed surgical performance following preoperative simulation relative to performance without simulation. RESULTS: Four studies reported outcome measures in real patients and the remainder reported simulated outcome measures. All but one of the studies found that preoperative simulation improves operative outcomes-but this improvement was not found across all measured parameters. While the reviewed studies had a number of methodological issues, the global data indicate that preoperative simulation has substantial potential to improve surgical performance. Analysis of the task characteristics of successful interventions indicated that the majority of these studies employed warm-ups that focused on the visual motor elements of surgery. However, there was no theoretical or empirical basis to inform the design of the intervention in any of these studies. CONCLUSIONS: There is an urgent need for a more rigorous approach to the development of "warm-up" routines if the potential value of preoperative simulation is to be understood and realised. We propose that such interventions need to be grounded in theory and empirical evidence on human motor performance.

A three dimensional view of stereopsis in dentistry.

Stereopsis and its role in dental practice has been a topic of debate in recent editions of this Journal. These discussions are particularly timely as they come at a point when virtual reality simulators are becoming increasingly popular in the education of tomorrow's dentists. The aim of this article is to discuss the lack of robust empirical evidence to ascertain the relationship (if any) between stereopsis and dentistry and to build a case for the need for further research to build a strong evidence base on the topic.

Clustering of pain and its associations with health in people aged 50†years and older: cross-sectional results from the North Staffordshire Osteoarthritis Project.

OBJECTIVE: Most pain in patients aged ≥50 years affects multiple sites and yet the predominant mode of presentation is single-site syndromes. The aim of this study was to investigate if pain sites form clusters in this population and if any such clusters are associated with health factors other than pain. SETTING: Six general practices in North Staffordshire, UK. DESIGN: Cross-sectional, postal questionnaire, study. PARTICIPANTS: Community-dwelling adults aged ≥50 years registered at the general practices. MAIN OUTCOMES MEASURES: Number of pain sites was measured by asking participants to shade sites of pain lasting ≥1 day in the past 4 weeks on a blank body manikin. Health factors measured included anxiety and depression (Hospital and Anxiety Depression Scale), cognitive complaint (Sickness Impact Profile) and sleep. Pain site clustering was investigated using latent class analysis. Association of clusters with health factors, adjusted for age, sex, body mass index and morbidities, was analysed using multinomial regression models. RESULTS: 13 986 participants (adjusted response 70.6%) completed a questionnaire, of whom 12 408 provided complete pain data. Four clusters of participants were identified: (1) low number of pain sites (36.6%), (2) medium number of sites with no back pain (31.5%), (3) medium number of sites with back pain (17.9%) and (4) high number of sites (14.1%). Compared to Cluster 1, other clusters were associated with poor health. The strongest associations (relative risk ratios, 95% CI) were with Cluster 4: depression (per unit change in score) 1.11 (1.08 to 1.14); cognitive complaint 2.60 (2.09 to 3.24); non-restorative sleep 4.60 (3.50 to 6.05). CONCLUSIONS: These results indicate that in a general population aged ≥50 years, pain forms four clusters shaped by two dimensions-number of pain sites (low, medium, high) and, within the medium cluster, the absence or presence of back pain. The usefulness of primary care treatment approaches based on this simple classification should be investigated.

Inconsistent reporting of minimally invasive surgery errors.

INTRODUCTION: Minimally invasive surgery (MIS) is a complex task requiring dexterity and high level cognitive function. Unlike surgical 'never events', potentially important (and frequent) manual or cognitive slips ('technical errors') are underresearched. Little is known about the occurrence of routine errors in MIS, their relationship to patient outcome, and whether they are reported accurately and/or consistently. METHODS: An electronic survey was sent to all members of the Association of Surgeons of Great Britain and Ireland, gathering demographic information, experience and reporting of MIS errors, and a rating of factors affecting error prevalence. RESULTS: Of 249 responses, 203 completed more than 80% of the questions regarding the surgery they had performed in the preceding 12 months. Of these, 47% reported a significant error in their own performance and 75% were aware of a colleague experiencing error. Technical skill, knowledge, situational awareness and decision making were all identified as particularly important for avoiding errors in MIS. Reporting of errors was variable: 15% did not necessarily report an intraoperative error to a patient while 50% did not consistently report at an institutional level. Critically, 12% of surgeons were unaware of the procedure for reporting a technical error and 59% felt guidance is needed. Overall, 40% believed a confidential reporting system would increase their likelihood of reporting an error. CONCLUSION: These data indicate inconsistent reporting of operative errors, and highlight the need to better understand how and why technical errors occur in MIS. A confidential 'no blame' reporting system might help improve patient outcomes and avoid a closed culture that can undermine public confidence.

A new tool for assessing head movements and postural sway in children.

Current methods of measuring gross motor abilities in children involve either high-cost specialist apparatus that is unsuitable for use in schools, or low-cost but nonoptimal observational measures. We describe the development of a low-cost system that is capable of providing high-quality objective data for the measurement of head movements and postural sway. This system is based on off-the-shelf components available for the Nintendo Wii: (1) The infrared cameras in a pair of WiiMotes are used to track head movements by resolving the position of infrared-emitting diodes in three dimensions, and (2) center-of-pressure data are captured using the WiiFit Balance board. This allows the assessment of children in school settings, and thus provides a mechanism for identifying children with neurological problems affecting posture. In order to test the utility of the system, we installed the apparatus in two schools to determine whether we could collect meaningful data on hundreds of children in a short time period. The system was successfully deployed in each school over a week, and data were collected on all of the children within the school buildings at the time of testing (N = 269). The data showed reliable effects of age and viewing condition, as predicted from previous small-scale studies that had used specialist apparatus to measure childhood posture. Thus, our system has the potential to allow screening of children for gross postural deficits in a manner that has never previously been possible. It follows that our system opens up the possibility of conducting large-scale behavioral studies concerning the development of posture.

Social participation restriction among US adults with arthritis: a population-based study using the International Classification of Functioning, Disability and Health.

OBJECTIVE: To examine arthritis impact among US adults with self-reported doctor-diagnosed arthritis using the International Classification of Functioning, Disability and Health (ICF) framework (including the impairments, activity limitations, environmental, and personal factors domains and social participation restriction [SPR] as the outcome) overall and among those with and without SPR, and to identify the correlates of SPR. METHODS: Cross-sectional 2009 National Health Interview Survey data were analyzed to examine the distribution of the ICF domain components. Unadjusted and multivariable-adjusted prevalence ratios (PRs) and 95% confidence intervals (95% CIs) were estimated to identify the correlates of SPR. Analyses using SAS, version 9.2 survey procedures accounted for the complex sample design. RESULTS: SPR prevalence was 11% of adults with arthritis (5.7 million). After initial multivariable adjustment by ICF domain, serious psychological distress (impairments domain; PR 2.5 [95% CI 2.0-3.2]), ≥5 medical office visits (environmental domain; PR 3.4 [95% CI 2.5-4.4]), and physical inactivity (personal domain; PR 4.8 [95% CI 3.6-6.4]) were most strongly associated with SPR. A combined measure (key limitations [walking, standing, or carrying]; PR 31.2 [95% CI 22.3-43.5]) represented the activity limitations domain. After final multivariable adjustment incorporating all ICF domains simultaneously, the strongest associations with SPR were key limitations (PR 24.3 [95% CI 16.8-35.1]), ≥9 hours of sleep (PR 1.6 [95% CI 1.3-2.0]), and income-to-poverty ratio <2.00 and severe joint pain (PR 1.4 [95% CI 1.2-1.6] for both). CONCLUSION: SPR affects 1 of 9 adults with arthritis. This study is the first to use the ICF framework in a population-based sample to identify specific functional activities, pain, sleep, and other areas as priorities for intervention to reduce negative arthritis impacts on disability, including SPR. Increased use of existing clinical and public health interventions is warranted.

Involving children in the development of assistive technology devices.

PURPOSE: To investigate the implementation of a web-based survey for involving children in the design of assistive technology devices within the primary school environment. METHOD: Children were recruited within their normal school environment. They completed tasks within the survey that sought to gather their personal preferences about assistive technology devices. From six primary schools, 257 children (mean age = 9 years and 8 months, SD = 1.51; 123 males, 134 females) including children with cerebral palsy (N = 11), varying levels of deafness (N = 7), global developmental delay (N = 2) and Down's syndrome (N = 1) participated. Observations were taken whilst the children completed the survey tasks. RESULTS: All children were able to complete the tasks from the survey, although children with disabilities had higher completion times and most required a form of assistance from support assistants and/or sign language interpreters. CONCLUSIONS: The use of the web-based survey provided a novel means with which to involve children with and without disabilities in the design of assistive technology devices within a primary school environment. In order for the survey to be utilised more widely, issues that arose when involving children with disabilities need to be addressed.

Is tracing or copying better when learning to reproduce a pattern?

Learning to write requires the repeated manual production of spatial patterns. It remains unclear whether tracing or copying provides better training: tracing provides accurate and immediate performance feedback, whereas copying may require greater use of memory and recall during training. We asked sixteen adults to copy or trace novel patterns then reproduce these from memory using a stylus and tablet PC. A week later, a retention test was performed. Sophisticated analyses indexed the extent to which participants had learned the dimensions and shape of patterns. We found that participants: (a) showed better shape and dimensional accuracy when tracing; (b) had better shape and dimensional retention immediately after tracing; (c) showed no differences between copying and tracing in their ability to redraw the pattern (shape or dimensions) 1 week later. Our methods provide a useful starting point for examining training and feedback on the generation and recall of spatial patterns.

Using vision to control locomotion: looking where you want to go.

Looking at the inside edge of the road when steering a bend seems to be a well-established strategy linked to using a feature called the tangent point. An alternative proposal suggests that the gaze patterns observed when steering result from looking at the points in the world through which one wishes to pass. In this explanation fixation on or near the tangent point results from trying to take a trajectory that cuts the corner. To test these accounts, we recorded gaze and steering when taking different paths along curved roadways. Participants could gauge and maintain their lateral distance, but crucially, gaze was predominantly directed to the region proximal to the desired path rather than toward the tangent point per se. These results show that successful control of high-speed locomotion requires fixations in the direction you want to steer rather than using a single road feature like the tangent point.

The impact of musculoskeletal hand problems in older adults: findings from the North Staffordshire Osteoarthritis Project (NorStOP).

OBJECTIVES: Hand problems are common in older people, but their impact on everyday life is not clear. The aim of this study was to investigate the impact of hand problems in community-dwelling older adults and how this varies with age and gender. METHODS: Analysis was performed in 7878 subjects who responded to a baseline questionnaire. Participants defined as having hand problems were sent a second questionnaire, which included questions about hand pain and disability. Severe disability was defined as a score of 4 or more points on a validated hand and finger function scale. Estimates of 1-month period prevalence of hand pain and severe disability were calculated for the total responder population, by age and gender. RESULTS: 2113 persons with hand problems completed Stage 2 (78.6% response). One-year period prevalence of hand problems was 47% and estimated 1-month period prevalence of hand pain was 30.8%. These figures varied little with age. Severe hand-related disability affected 12.3% (95% confidence interval 11.3-13.3%) of this sample, was significantly more common in females than males, and increased in prevalence to the oldest age-groups. CONCLUSIONS: Musculoskeletal hand problems are common in the population aged over 50 yrs. Most are painful, and have a significant impact on everyday life. Women and the very old appear especially vulnerable to the effect of hand problems on their daily activities.

Measuring the consequences of osteoarthritis and joint pain in population-based studies: can existing health measurement instruments capture levels of participation?

OBJECTIVE: To identify health measurement instruments to investigate levels of participation associated with joint pain in a population survey questionnaire. METHOD: A comprehensive electronic search of the published literature was performed to identify potential instruments that could measure participation. All items from identified instruments were assessed for the ability to measure participation by 2 experienced and 2 inexperienced assessors. Agreement was determined in terms of actual agreement (%) and agreement beyond chance (kappa). RESULTS: Twenty-seven instruments (912 items) were identified. Agreement between the experienced assessors occurred in 86% of items (kappa = 0.70, 95% confidence interval [95% CI] 0.65-0.75) and between the inexperienced assessors in 72% (kappa = 0.40, 95% CI 0.34-0.46). The greatest proportion of participation items in one instrument was 82%. CONCLUSION: None of the identified instruments consisted entirely of participation items. The concept of participation and its translation into measurement for use in the general population is likely to need further development.

Life-threatening autoimmunity with diabetes: management with an insulin pump.

A 2-yr-old boy presented initially with type 1 diabetes (T1D). Over the next 9 yrs, he developed multiple autoimmune conditions including Evans' syndrome, alopecia, and autoimmune bowel disease. Autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy (APECED) syndrome was considered, but no mutations were found in the autoimmune regulator-1 (AIRE-1) gene, making this diagnosis unlikely, and he did not fulfill the clinical criteria for immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome. We describe the challenges created by the combination of these diseases and how introduction of insulin pump therapy revolutionized his care.

Measurement of the consistency of patellar-tendon-bearing cast rectification.

The quality of fit of a trans-tibial patellar-tendon-bearing (PTB) socket may be influenced by consistency in casting, rectification or alignment. This paper quantifies, for the first time, the variations in the rectified casts between two experienced prosthetists and the variation between the rectified casts of each individual prosthetist. Prosthetists A and B observed the hand casting of a typical trans-tibial amputee. Each prosthetist was supplied with 5 previously measured duplicated plaster models. The two prosthetists rectified the supplied plaster models based on their own interpretation of basic rectification guidelines. Both prosthetists operated in isolation. The re-measured rectified plaster model data was compared with the unrectified data. The extent of rectification at each of 1800 locations per plaster model was calculated. In zones of major rectification, the mean difference between prosthetists was quantified as 2mm and the standard deviation (SD) about that mean was +/- 1mm for each prosthetist. The co-ordinates of the apex of the fibular head for the 10 modified casts indicated that the maximum variation was in the axial direction with a SD of 4.3mm for prosthetist A and a SD of 2.8mm for prosthetist B. The lengths of the 5 plaster models rectified by prosthetist A indicated a SD of 0.2mm whereas the lengths of the 5 plaster models rectified by prosthetist B indicated a SD of 2.9mm.

Cytokine release by ovine macrophages following infection with Chlamydia psittaci.

Chlamydia psittaci is an obligate intracellular pathogen that causes abortion in both sheep and humans. The disease in sheep (but not humans) is characterized by a long-term persistent phase that appears to be under the control of interferon-gamma. However, nothing is known about cytokine induction that precedes the persistent phase in sheep. Primary alveolar lavage cells recovered from normal adult sheep were used to study cytokine production in the first 72 h of infection with C. psittaci. These cells were phenotypically characteristic of macrophages, being adherent, phagocytic, CD14+ and staining positive for non-specific esterase. In vitro infection of the macrophages with C. psittaci resulted in the release of IL-1beta, IL-8 and granulocyte-macrophage colony-stimulating factor (GM-CSF) as measured by ovine-specific ELISAs. Heat-treated chlamydiae (1 h at 65 degrees C) did not induce the release of IL-1beta, but the release of IL-8 was similar to that induced by untreated organisms. The cells from different sheep varied most notably in their patterns of GM-CSF release in response to heat-treated and untreated organisms.

Randomised controlled trial of respiratory system compliance measurements in mechanically ventilated neonates.

AIM: To determine whether outcomes of neonatal mechanical ventilation could be improved by regular pulmonary function testing. METHODS: Two hundred and forty five neonates, without immediately life threatening congenital malformations, were mechanically ventilated in the newborn period. Infants were randomly allocated to conventional clinical management (control group) or conventional management supplemented by regular measurements of static respiratory system compliance, using the single breath technique, with standardised management advice based on the results. RESULTS: Fifty five (45%) infants in each group experienced one or more adverse outcomes. The median (quartile) durations of ventilation and oxygen supplementation were 5 (2-12) and 6 (2-34) days for the control group, and 4 (2-9) and 6 (3-36) days for the experimental group (not significant). On post-hoc secondary analysis, control group survivors were ventilated for 1269 days with a median (quartile) of 5 (2-13) days, and experimental group survivors were ventilated for 775 days with a median (quartile) duration of 3 (2-8) days (p = 0.03). CONCLUSIONS: Although primary analysis did not show any substantial benefit associated with regular measurement of static respiratory system compliance, this may reflect a type II error, and a moderate benefit has not been excluded. Larger studies are required to establish the value of on-line monitoring techniques now available with neonatal ventilators.

Decreased muscle cell proliferation in chicks with a deletion in the GH receptor gene.

The increase in muscle weight in neonatal animals is a consequence of increased protein accretion and DNA content. GH increases protein accretion but direct effects of GH on myogenic cell proliferation have not been demonstrated. Sex-linked dwarfism in the chick is caused by mutation or deletion in the GH receptor gene and has provided a useful model to study the physiological consequences of GH insensitivity. This study determined the consequences of GH receptor gene mutation on muscle cell proliferation in vivo. Northern and Southern blotting and PCR analysis revealed restriction fragment length polymorphism patterns and a 1.7 kb deletion of the intracellular domain of the GH receptor gene in commercial dwarf broiler chicks, similar to the Connecticut strain in which there is a dysfunctional GH receptor. Cell proliferation was measured in muscle sections from normal and dwarf chicks after incorporation of 5-bromo-2'-deoxyuridine (BrdU; 25 mg/kg) in vivo at 2, 5 and 13 days of age. Incorporation of BrdU into nuclei was measured in frozen sections, counterstained with propidium iodide to estimate the total number of nuclei by quantitative image analysis, and the labelling index was calculated. Paraffin-embedded sections of breast muscle were stained using an anti-human IGF-I polyclonal antibody. Expression of IGF-I mRNA in muscle from each genotype at 5 days of age was measured by RNAse protection assay. The labelling index was similar in 2-day-old chicks from both genotypes (normal, 20.14 +/- 2.39%; dwarf, 19.79 +/- 5.83%). By day 5 the labelling index had decreased but was significantly higher (P < 0.02) in normal (12.53 +/- 3.36%) compared with the dwarf (6.25 +/- 1.39%). By 13 days of age, there was a further decrease in labelling index but no difference between the groups (normal, 4.92 +/- 1.28%; dwarf, 4.96 +/- 1.51%). IGF-I mRNA was expressed and IGF-I peptide was identified in muscle sections but there was no difference between genotypes. The results show that cell division in breast muscle in vivo is high in neonatal chicks but it declines with increasing age. The absence of a functional GH receptor in the dwarf is associated with a greater decline in DNA synthesis and suggests that GH may directly affect a proportion of cells, since there was no difference in IGF-I mRNA or peptide.