Floor and ceiling effects in the Oxford Shoulder Score : an analysis from the National Joint Registry.

AIMS: The main objective of this study was to examine whether the Oxford Shoulder Score (OSS) demonstrated floor or ceiling effects when used to measure outcomes following shoulder arthroplasty in a large national cohort. Secondary objectives were to assess its pain and function subscales, and to identify independent predictors for patients achieving a postoperative ceiling score following shoulder arthroplasty. METHODS: Secondary database analysis of the National Joint Registry (NJR), which included 48,270 patients undergoing shoulder arthroplasty, was conducted. The primary outcome measure was the OSS. Secondary outcome measures were the OSS-Function Component Subscale and OSS-Pain Component Subscale. Floor and ceiling effects were considered to be present if > 15% of patients scored either the lowest or highest possible score. Logistic regression analysis was used to identify independent predictors for scoring the highest possible OSS score postoperatively. RESULTS: Preoperatively, 1% of patients achieved the lowest possible OSS score (0) and 0.4% of patients achieved the highest possible score (48). Postoperatively, < 1% of patients achieved the lowest score at all timepoints, but the percentage achieving the highest score at six months was 8.3%, at three years 16.9%, and at five years 17%. Male patients, those aged between 60 and 89 years, and those undergoing an anatomical total shoulder arthroplasty (ATSA) were more likely to contribute to the ceiling effect seen in the OSS questionnaire. Pain and function subscales exhibited greater ceiling effects at three years and five years when compared with the overall OSS questionnaire. Logistic regression analysis showed that sex, procedure type, and preoperative OSS score were independent predictors for scoring the highest possible OSS at years. CONCLUSION: Based on NJR patient-reported outcome measures data, the OSS does not exhibit a ceiling effect at six months, but does at three years and five years, in part due to outcome scores of ATSA. Preoperative OSS, age, male sex, and ATSA are independent predictors of achieving a ceiling score. Cite this article: Bone Joint J 2021;103-B(11):1717-1724.

Does the Clinical Frailty Scale at Triage Predict Outcomes From Emergency Care for Older People?

STUDY OBJECTIVE: We determine whether the Clinical Frailty Scale applied at emergency department (ED) triage is associated with important service- and patient-related outcomes. METHODS: We undertook a single-center, retrospective cohort study examining hospital-related outcomes and their associations with frailty scores assessed at ED triage. Participants were aged 65 years or older, registered on their first ED presentation during the study period at a single, centralized ED in the United Kingdom. Baseline data included age, sex, Clinical Frailty Scale score, National Early Warning Score-2 and the Charlson Comorbidity Index score; outcomes included length of stay, readmissions (any future admissions), and mortality (inhospital or out of hospital) up to 2 years after ED presentation. Survival analysis methods (standard and competing risks) were applied to assess associations between ED triage frailty scores and outcomes. Unadjusted incidence curves and adjusted hazard ratios are presented. RESULTS: A total of 52,562 individuals representing 138,328 ED attendances were included; participants' mean age was 78.0 years, and 55% were women. Initial admission rates generally increased with frailty. Mean length of stay after 30- or 180-day follow-up was relatively low; all Clinical Frailty Scale categories included patients who experienced zero days' length of stay (ie, ambulatory care) and patients with relatively high numbers of inhospital days. Overall, 46% of study participants were readmitted by the 2-year follow-up. Readmissions increased with Clinical Frailty Scale score up until a score of 6 and then attenuated. Mortality rates increased with increasing frailty; the adjusted hazard ratio was 3.6 for Clinical Frailty Scale score 7 to 8 compared with score 1 to 3. CONCLUSION: Frailty assessed at ED triage (with the Clinical Frailty Scale) is associated with adverse outcomes in older people. Its use in ED triage might aid immediate clinical decisionmaking and service configuration.

Is perception of quality more important than technical quality in patient video cases?

BACKGROUND: The use of video cases to demonstrate key signs and symptoms in patients (patient video cases or PVCs) is a rapidly expanding field. The aims of this study were to evaluate whether the technical quality, or judgement of quality, of a video clip influences a paediatrician's judgment on acuity of the case and assess the relationship between perception of quality and the technical quality of a selection of video clips. METHODS: Participants (12 senior consultant paediatricians attending an examination workshop) individually categorised 28 PVCs into one of 3 possible acuities and then described the quality of the image seen. The PVCs had been converted into four different technical qualities (differing bit rates ranging from excellent to low quality). RESULTS: Participants' assessment of quality and the actual industry standard of the PVC were independent (333 distinct observations, spearmans rho = 0.0410, p = 0.4564). Agreement between actual acuity and participants' judgement was generally good at higher acuities but moderate at medium/low acuities of illness (overall correlation 0.664). Perception of the quality of the clip was related to correct assignment of acuity regardless of the technical quality of the clip (number of obs = 330, z = 2.07, p = 0.038). CONCLUSIONS: It is important to benchmark PVCs prior to use in learning resources as experts may not agree on the information within, or quality of, the clip. It appears, although PVCs may be beneficial in a pedagogical context, the perception of quality of clip may be an important determinant of an expert's decision making.

Getting rhythm: how do babies do it?

OBJECTIVES: To investigate the emergence of biological rhythms in the first months of life in human infants, by measuring age-related changes in core body temperature during night-time sleep, hormones (cortisol and 6-sulfatoxymelatonin) and the expression of a clock-controlled gene H3f3b in oral epithelial cells. DESIGN: Observational longitudinal study. SETTING: We measured overnight core body temperature, actigraphy, day-night urinary cortisol and 6-sulfatoxymelatonin, as well as circadian gene expression, in infants at home from March 2007 to July 2008 in Leicester. PARTICIPANTS: We recruited 35 healthy Caucasian infants who were born at term. They were monitored from 6 to 18 weeks of age. RESULTS: At 8 weeks of age the day-night rhythm of cortisol secretion was the first to appear followed by 6-sulfatoxymelatonin 1 week later; at the same time that night-time sleep was established. At 10 weeks, the maximum fall in deep body temperature occurred with the onset of night-time sleep, followed at 11 weeks by the rhythmical expression of the H3f3b gene. CONCLUSIONS: In human infants, there is a clear sequential pattern for the emergence of diurnal biological rhythms between 6 and 18 weeks of postnatal age, led by the secretion of cortisol and linked with the establishment of consolidated night-time sleep. It is likely that this represents part of a maturation and adaption process as infants gain equilibrium with their external environment after birth.

What aspects of primary care predict emergency admission rates? A cross sectional study.

BACKGROUND: From 2004 to 2009 there was almost a 12% rise in emergency admissions in England. This can be explained partly by an aging population and other socio-demographic characteristics, but much cannot be explained by these factors. We explored aspects of care, in addition to known demographic characteristics in general practice, that are associated with emergency admissions. METHODS: A cross-sectional design employing hospital admission data from 76 general practices in Northamptonshire, England for 2006-08, including demographic data, quality and outcomes framework points and GP patient survey outcomes. RESULTS: There were statistically significant associations between emergency admissions and age, gender, distance from hospital and proportion classified as white. There was also a statistically significant relationship between emergency admissions and being able to book an appointment with a preferred doctor; this relationship was stronger in less deprived communities. CONCLUSIONS: Enabling patients to book with a preferred doctor, particularly those in less deprived communities could have an impact on reducing emergency admissions. It is possible that being able to consult a preferred GP gives patient's confidence to avoid an emergency admission or it facilitates consistent clinical management that helps prevent the need for admission. However the findings only explained some of the variation.

Grip strength characteristics using force-time curves in rheumatoid hands.

The use of force-time curves in rheumatoid hands was investigated to assess peak force, average force, total grip time, area under the curve, and variability of the plateau region of the curves to identify the impact of different rheumatoid hand deformities on grip strength. We studied 43 patients - 10 men and 33 women - with established rheumatoid arthritis affecting their hands. Mean age was 61 years and mean duration of hand involvement was 13 years. Of the 86 hands, 38 had no finger deformity, eight had metacarpophalangeal joint ulnar deviation without any additional finger deformities, 16 had swan neck deformities, and 10 had boutonnière deformities. Fourteen hands had a combination of deformities. The hands with combined deformities were the weakest, had poor grip strength (34.7 N, SE 8), and were able to sustain grip for only a short time (22 sec, SE 3). Swan neck deformity also profoundly affects the magnitude (49.8 N, SE 7) and sustainability of grip (15 sec, SE 2). Even when only one finger had a swan neck deformity the mean strength was poor at 45 N. Swan neck deformity causes greater loss of strength than boutonnière deformity (82.7 N, SE 15). The strongest rheumatoid hands were those with only ulnar deviation deformities (90.8 N, SE 14). The area under the curve best predicted disability assessed using the Patient Evaluation Measure.

Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies.

INTRODUCTION: Scaphoid fractures with displacement have a higher incidence of nonunion that can cause pain and reduced movement, strength and function. The aim of this study was to review the evidence available and establish the risk of nonunion associated with management of displaced fractures of the waist of the scaphoid. METHODS: Electronic databases were searched using the Medical Subject Headings (MeSH) controlled vocabulary (scaphoid fractures, AND'd with displaced, or nonunion, or non-healing or cast immobilisation, or plaster or surgery). At present, there are no randomised, controlled trials or studies comparing fixation to plaster cast treatment of displaced fractures of the scaphoid. The search was therefore limited to observational studies of displaced fractures of the scaphoid treated in a plaster cast (non-operative group) or fixed surgically (operative group). The criterion for displacement was limited to gap or step of more than 1 mm. In the non-operative group, we compared the outcome of displaced and undisplaced fractures of the waist of the scaphoid treated in a plaster cast. In the operative group, contingency table analysis was used to calculate the odds ratio of nonunion with plaster treatment compared to surgery. RESULTS: In the non-operative group, seven studies were included in a meta-analysis with a total of 1401 scaphoids. Ninety-three percent (1311 scaphoids) of these scaphoid fractures healed in a plaster cast. A total of 207 (15%) of all scaphoid fractures showed displacement of at least 1 mm (gap/step) between fracture fragments. Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast. The pooled relative risk of fracture nonunion was 4.4 (95% confidence interval (CI): 2.3-8.7; p=0.00; I(2)=54.3%). In the surgical group, we identified six observational studies in which 157 'displaced' fractures of the scaphoid were surgically fixed. Only two of these fractures did not heal. The odds of nonunion were 17 times higher with plaster cast treatment than surgery. CONCLUSIONS: Displaced fractures of scaphoid have a four times higher risk of nonunion than undisplaced fractures when treated in a plaster cast, and the patients should be advised of this risk. Nonunion is more likely if a displaced fracture of the scaphoid is treated in a plaster cast.

Screening for the metabolic syndrome using simple anthropometric measurements in south Asian and white Europeans: a population-based screening study. The Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) Study.

AIMS: To estimate the prevalence of metabolic syndrome in a general population sample of south Asians and white Europeans and compare predictors of metabolic syndrome, using ethnic specific definitions of obesity. METHODS: 3099 participants (71.4% white European, 28.6% south Asian) aged 40-75 years were screened using a 75 g oral glucose tolerance test. Metabolic syndrome was defined using National Cholesterol Education Programme and International Diabetes Federation definitions. We compared sensitivity, specificity and area under the curve of waist circumference, body mass index and waist-hip ratio. RESULTS: The prevalence of metabolic syndrome using the definitions above was 29.9% (29.2% south Asian, 30.2% white European), and 34.4% (34.2% south Asian, 34.5% white European), respectively. Using the National Cholesterol Education Programme definition, waist circumference was significantly more predictive of metabolic syndrome than body mass index or waist-hip ratio. The area under the curve for waist circumference was 0.75 (95% CI: 0.69-0.80) and 0.76 (0.72-0.81) for south Asian men and women; 0.83 (0.80-0.85) and 0.80 (0.77-0.82) for white European men and women. CONCLUSIONS: The prevalence of metabolic syndrome is high in both south Asian and white European populations. Waist circumference is a simple and effective measure for predicting metabolic syndrome in different populations.

The prevalence of depression in white-European and South-Asian people with impaired glucose regulation and screen-detected type 2 diabetes mellitus.

BACKGROUND: There is a clear relationship between depression and diabetes. However, the directionality of the relationship remains unclear and very little research has considered a multi-ethnic population. The aim of this study was to determine the prevalence of depression in a White-European (WE) and South-Asian (SA) population attending a community diabetes screening programme, and to explore the association of depression with screen-detected Type 2 diabetes mellitus (T2DM) and impaired glucose regulation (IGR). METHODOLOGY/PRINCIPAL FINDINGS: Participants were recruited from general practices in Leicestershire (United Kingdom) between August 2004 and December 2007. 4682 WE (40-75 years) and 1327 SA participants (25-75 years) underwent an Oral Glucose Tolerance Test, detailed history, anthropometric measurements and completed the World Health Organisation-Five (WHO-5) Wellbeing Index. Depression was defined by a WHO-5 wellbeing score < or =13. Unadjusted prevalence of depression for people in the total sample with T2DM and IGR was 21.3% (21.6% in WE, 20.6% in SA, p = 0.75) and 26.0% (25.3% in WE, 28.9% in SA, p = 0.65) respectively. For people with normal glucose tolerance, the prevalence was 25.1% (24.9% in WE, 26.4% in SA, p = 0.86). Age-adjusted prevalences were higher for females than males. Odds ratios adjusted for age, gender, and ethnicity, showed no significant increase in prevalent depression for people with T2DM (OR = 0.95, 95%CI 0.62 to 1.45) or IGR (OR = 1.17, 95%CI 0.96 to 1.42). CONCLUSIONS: Prior to the knowledge of diagnosis, depression was not significantly more prevalent in people with screen detected T2DM or IGR. Differences in prevalent depression between WE and SA people were also not identified. In this multi-ethnic population, female gender was significantly associated with depression.

Diabetes: glycaemic control in type 2.

INTRODUCTION: Diabetes mellitus is now seen as a progressive disorder of glucose metabolism, affecting about 5% of the population worldwide, over 85% of whom have type 2 diabetes. Type 2 diabetes may occur with obesity, hypertension and dyslipidaemia (the metabolic syndrome), which are powerful predictors of CVD. Blood glucose levels rise progressively over time in people with type 2 diabetes regardless of treatment, causing microvascular and macrovascular complications. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions in adults with type 2 diabetes? We searched: Medline, Embase, The Cochrane Library and other important databases up to October 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 69 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: combined oral drug treatment, diet, education, insulin (continuous subcutaneous infusion), insulin, intensive treatment programmes, meglitinides (nateglinide, repaglinide), metformin, monotherapy, blood glucose self-monitoring (different frequencies), and sulphonylureas (newer or older).

Patients' perceptions of written consent: questionnaire study.

OBJECTIVE: To examine patients' understanding of the status, function, and remit of written consent to surgery. DESIGN: Prospective questionnaire study. Questionnaires were sent to patients within one month of surgery. Responses were analysed with frequencies and single variable analyses. SETTING: Large teaching hospital. PARTICIPANTS: 732 patients who had undergone surgery in obstetrics and gynaecology over a six month period. MAIN OUTCOME MEASURES: Patients' awareness of the legal implications of written consent and their views on the function and remit of the consent form. RESULTS: Patients had limited understanding of the legal standing of written consent. Nearly half (46%, 95% confidence interval 43% to 50%) of patients believed the primary function of consent forms was to protect hospitals and 68% (65% to 71%) thought consent forms allowed doctors to assume control. Only 41% (37% to 44%) of patients believed consent forms made their wishes known. CONCLUSIONS: Many patients seem to have limited awareness of the legal implications of signing or not signing consent forms, and they do not recognise written consent as primarily serving their interests. Current consent procedures seem inadequate as a means for the expression of autonomous choice, and their ethical standing and credibility can be called into question.

Interobserver reproducibility and application of the ISN/RPS classification of lupus nephritis-a UK-wide study.

We sought to assess the interobserver variation of the new International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification of lupus nephritis when compared with the previous World Health Organization classification, when used by pathologists throughout the UK. We also sought differences in how the 2 classifications were applied to a single set of biopsies. Twenty unselected renal biopsies showing lupus nephritis were circulated to pathologists in the UK National Renal Pathology External Quality Assessment Scheme, before the ISN/RPS scheme was published, with a request to apply the World Health Organization classification. The same slides were recirculated approximately 1 year later with a request to apply the ISN/RPS classification. A significant improvement in interobserver reproducibility was demonstrated by the new classification (kappa 0.53 vs. 0.44, P = 0.002). The reproducibility of the assessment of disease activity and chronicity remains suboptimal (kappa = 0.33). The new classification tends to produce more diagnoses of Class IV lupus nephritis, with fewer diagnoses of Classes III and V. The improvement in interobserver reproducibility indicates that an important aim of the new classification has been achieved. Further work is needed to determine whether the increase in diagnosis of Class IV nephritis represents an improvement in biopsy interpretation or a divergence from the previous classification, as the latter could undermine attempts to relate results from the new system to treatment strategies based on clinical trials which used the old.

Informed consent for elective and emergency surgery: questionnaire study.

OBJECTIVES: To evaluate women's experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures. DESIGN: A prospective questionnaire study. SETTING: A large teaching hospital. POPULATION: 1006 consecutive patients undergoing elective or emergency surgery in obstetrics and gynaecology. METHODS: Questionnaires were administered to women who had given consent to surgery following the introduction of national guidelines and consent form. Differences in responses between elective and emergency patients were assessed using frequencies, single and multivariable analyses. MAIN OUTCOME MEASURES: Patients' experience and recall of the consent process, their overall satisfaction and their views on what is important for adequate consent. RESULTS: There were significant differences between patients undergoing elective or emergency surgery. Patients undergoing emergency surgery were less likely to have read (OR 0.22) or understood (OR 0.40) the consent form, and were more likely to report feeling frightened by signing it (OR 2.52). They were more likely to report they felt they had no choice about signing the consent form (OR 2.11), and that they would have signed regardless of its content (OR 3.14). Overall, significantly more patients undergoing elective (80%) or emergency (63%) surgery reported satisfaction with the consent process. Patients were more likely to report satisfaction if they read (OR 1.80) and agreed with (OR 3.49) the consent form, and if someone checked that they understood (OR 3.09). CONCLUSION: Patients' needs may not be adequately addressed by current guidelines for consent to treatment, particularly in emergency circumstances. The introduction of more complex forms and procedures appears to conflict with patients' need for personal communication and advocacy. The implications on the ethical and legal standing of consent are considerable.

Randomised comparison of distension media for outpatient hysteroscopy.

OBJECTIVE: To compare saline with and without added lignocaine and carbon dioxide distension for out patient hysteroscopy with regards to patient discomfort and hysteroscopic view. DESIGN: Single blind prospective randomised controlled trial. SETTING: Specialist out patient clinics in a large teaching hospital. POPULATION: Women undergoing out patient hysteroscopy and endometrial biopsy for abnormal uterine bleeding. METHOD: Out patient hysteroscopy using carbon dioxide, saline or saline with lignocaine. MAIN OUTCOME MEASURES: Visual analogue score (VAS) for pain and present pain intensity (PPI) as assessed by patients and the quality of hysteroscopic view as assessed by the operator. RESULTS: Of the 305 women approached, 300 women were randomised into the study. The mean [SD] VAS for pain in the carbon dioxide group was 2.9 [2.3] and in the saline group was 3.1 [2.6], the difference was not statistically significant (P= 0.49). The mean [SD] VAS for pain in the saline plus lignocaine group was 3.2 [2.4]. This was not significantly different from the saline group (P= 0.72). There was a statistically significant difference between the confidence rating for the hysteroscopic view for the carbon dioxide compared with the saline group; mean [SD] was 8.3 [2.1] and 9.6 [1.1], respectively (P= 0.001). CONCLUSION: Carbon dioxide and saline as distension media are comparable in terms of overall patient discomfort and satisfaction, but saline provides better views and increases confidence in diagnosis. Adding lignocaine to the saline distension medium does not confer any additional benefit.

The long-term effectiveness of endometrial laser ablation: a survival analysis.

OBJECTIVES: To assess the long-term effectiveness of endometrial laser ablation and factors that predict long-term outcome. SETTING: A university teaching hospital. STUDY DESIGN: Postal questionnaires were sent to all women who underwent endometrial laser ablation between 1992 and 1998. RESULTS: Of 215 patients who underwent endometrial laser ablation, 174 (80.9%) returned the questionnaire. Duration of follow-up was 1.5-9 years. The procedure was reported as a success by 138 (79.3%) and a failure by 36 (20.7%). Twenty-four patients (13.8%) subsequently underwent hysterectomy for excessive bleeding. Using survival curve estimates the percentage that remained free of failure was 95.3% at 1 year and 76.2% at 4 years. Increasing patient age was significantly associated with reduced risk of failure (hazard ratio 0.91 for every year increase in age). An inexperienced operator significantly increased the hazard of failure. CONCLUSION: Endometrial laser ablation is effective in the long-term in the majority (76.2%) of patients. Older women can expect to have a lower risk of failure.

Carbonic anhydrase IX expression, a novel surrogate marker of tumor hypoxia, is associated with a poor prognosis in non-small-cell lung cancer.

PURPOSE: To evaluate carbonic anhydrase (CA) IX as a surrogate marker of hypoxia and investigate the prognostic significance of different patterns of expression in non-small-cell lung cancer (NSCLC). METHODS: Standard immunohistochemical techniques were used to study CA IX expression in 175 resected NSCLC tumors. CA IX expression was determined by Western blotting in A549 cell lines grown under normoxic and hypoxic conditions. Measurements from microvessels to CA IX positivity were obtained. RESULTS: CA IX immunostaining was detected in 81.8% of patients. Membranous (m) (P =.005), cytoplasmic (c) (P =.018), and stromal (P <.001) CA IX expression correlated with the extent of tumor necrosis (TN). The mean distance from vascular endothelium to the start of tumor cell positivity was 90 micro m, which equates to an oxygen pressure of 5.77 mmHg. The distance to blood vessels from individual tumor cells or tumor cell clusters was greater if they expressed mCA IX than if they did not (P <.001). Hypoxic exposure of A549 cells for 16 hours enhanced CA IX expression in the nuclear and cytosolic extracts. Perinuclear (p) CA IX (P =.035) was associated with a poor prognosis. In multivariate analysis, pCA IX (P =.004), stage (P =.001), platelet count (P =.011), sex (P =.027), and TN (P =.035) were independent poor prognostic factors. CONCLUSION: These results add weight to the contention that mCA IX is a marker of tumor cell hypoxia. The absence of CA IX staining close to microvessels suggests that these vessels are functionally active. pCA IX expression is representative of an aggressive phenotype.

Environmental factors predicting nephritis in systemic lupus erythematosus

OBJECTIVES - To evaluate social class, ethnic origin, and various endocrine variables as potential risk factors in the development of nephritis in patients with systemic lupus erythematosus (SLE). METHODS - A cross-sectional survey was carried out of all outpatients with SLE attending the lupus clinic of St Thomas's Hospital from March to October 1992 using retrospective survival data. The main outcome measure was to duration of SLE before the onset of nephritis. RESULTS - Two hundred and ninety six women and 11 men were studied; the male patients were excluded from the analysis. Univariate analysis showed an increased risk of nephritis in patients with SLE of West Indian origin with 54 v 19 percent with nephritis at five years, in patients of lower social class, in patients who did not drink alcohol and in those with a history of fetal loss after the onset of lupus. No significant effect of the age of onset of SLE, use of oral contraceptives, normal pregnancy, or smoking was seen. Multivariate analysis showed that ethnic origin did not infulence the risk of nephritis independently of social class. CONCLUSIONS - Factors associated with socioeconomic deprivation may increase disease severity in patients with SLE (AU)