Adoption of technology enabled care to support the management of children and teenagers in rheumatology services: a protocol for a mixed-methods systematic review.

INTRODUCTION: COVID-19 catalysed a rapid move to provide care away from the hospital using online communication platforms. Technology enabled care (TEC) continues to be an important driver in progressing future healthcare services. Due to the complex and chronic nature of conditions seen within paediatric rheumatology, TEC may lead to better outcomes. Despite some growth in published literature into the adoption of TEC in paediatric rheumatology, there is limited synthesis. The aim of this review is to provide a comprehensive understanding and evaluation of the adoption of TEC by patients in paediatric rheumatology services, to establish best practices. METHODS AND ANALYSIS: This proposed mixed-methods systematic review will be conducted by searching a wide variety of healthcare databases, grey literature resources and associated charities and societies, for articles reported in English language. Data extraction will include population demographics, technology intervention, factors affecting adoption of intervention and consequent study outcomes. A parallel-results convergent synthesis design is planned, with independent syntheses of quantitative and qualitative data, followed by comparison of the findings of each synthesis using a narrative approach. Normalisation process theory will be used to identify, characterise and explain implementation factors. The quality of included articles will be assessed using the Mixed Methods Appraisal Tool for research papers and the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklist for grey literature. Overall confidence in quality and strength of evidence will be assessed using the Confidence in the Evidence from Reviews of Qualitative Research tool. ETHICS AND DISSEMINATION: Ethical approval is not required due to the nature of this mixed-methods systematic review. The findings will be disseminated via a peer-reviewed journal, relevant conferences and any other methods (eg, via NHS Trust or NIHR YouTube channels) as advised by paediatric rheumatology patients. PROSPERO REGISTRATION NUMBER: CRD42023443058.

Video analysis of communication by physiotherapists and patients in video consultations: a qualitative study using conversation analysis.

OBJECTIVES: To investigate the challenges of doing physical examinations and exercises by video, and the communication strategies used by physiotherapists and patients to overcome them. DESIGN: A qualitative study of talk and social actions, examining the verbal and non-verbal communication practices used by patients and physiotherapists. Video consultations between physiotherapists and patients were video recorded using MS Teams, transcribed and analysed in detail using Conversation Analysis. SETTING: Video consultations were recorded in three specialist settings (long-term pain, orthopaedics, and neuromuscular rehabilitation) across two NHS hospitals. PARTICIPANTS: 15 adult patients (10 female, 5 male; aged 20-77) with a scheduled video consultation. RESULTS: Examinations and exercises retain-->were successfully accomplished in all 15 consultations. Two key challenges were identified for physiotherapists and patients when doing video assessments: (1) managing safety and clinical risk, and (2) making exercises and movements visible. Challenges were addressed by through communication practices that were patient-centred and tailored to the video context (e.g., explaining how to frame the body to the camera or adjust the camera to make the body visible). CONCLUSIONS: Video is being used by physiotherapists to consult with their patients. This can work well, but tailored communication strategies are critical to help participants overcome the challenges of remote physical examinations and exercises. CONTRIBUTION OF THE PAPER: This paper is a first to use video-based analysis to determine the challenges of video consulting for doing remote assessments and exercises in physiotherapy settings. It demonstrates how patients and physiotherapists use communication strategies to raise concerns around safety and visibility and how they overcome these concerns.

Carrying eggs uphill: are costs of reproduction stronger on steeper slopes?

Locomotor impairment during pregnancy is a well-documented cost of reproduction, but most empirical studies have not incorporated ecological complexity, such as locomotion on sloping inclines rather than horizontal surfaces. Biomechanical factors suggest that carrying a heavy burden-including shifts in the body's centre of mass-may impair locomotor ability even more when an animal is running uphill. If so, then measuring costs of reproduction on horizontal racetracks may underestimate these costs in nature for arboreal species. To evaluate this prediction, we measured the pregnancy-induced reduction in speed for jacky dragons (Amphibolurus muricatus) at inclines ranging from 0 to 45°. Both pregnancy and steeper slopes reduced lizard performance, but pregnancy did not exacerbate the locomotor decrement on steeper racetracks. An ability to maintain mobility on steep slopes during pregnancy may be a target of selection in arboreal taxa. To understand the evolutionary context of locomotion-based costs of reproduction, we also need studies on the relationship between organismal performance and ecologically relevant measures such as predation risk.

The patient acceptability of a remotely delivered pain management programme for people with persistent musculoskeletal pain: A qualitative evaluation.

Introduction: Remotely delivered pain management programmes have been offered in place of in-person programmes by many chronic pain services since the onset of the COVID-19 pandemic. There is a lack of evidence regarding the acceptability of these programmes. In this evaluation, we have explored patients' acceptability of a remotely delivered pain management programme for patients with persistent musculoskeletal pain. Methods: Qualitative data were collected using focus groups with participants who had previously attended the remote pain management programme. Data were analysed using abductive analysis. Results: Three focus groups were conducted with a total of 13 participants. The programmme was either entirely acceptable, had some acceptable components or was not acceptable to patients. Factors leading to the programme being acceptable include learning to manage pain from home, receiving high quality care from home, enhancing the potential of rehabilitation using technology, enabling attendance on a pain management programme from home, overcoming social distancing requirements of COVID-19 using technology, and virtual peer support. Factors leading to the programme not being acceptable include having an inappropriate home environment for virtual therapy, communication challenges with virtual therapy, technological issues and concerns regarding the quality of care. Conclusions: There is a spectrum of acceptability with respect to the remote programme. The factors that influence this are dynamic, individual and situational. Hybrid programmes have the potential to enhance access to pain management programmes and improve patient experience and programme outcomes in the future.

Translational framework for implementation evaluation and research: Protocol for a qualitative systematic review of studies informed by Normalization Process Theory (NPT) [version 1; peer review: 2 approved].

Background: Normalization Process Theory (NPT) identifies mechanisms that have been demonstrated to play an important role in implementation processes. It is now widely used to inform feasibility, process evaluation, and implementation studies in healthcare and other areas of work. This qualitative synthesis of NPT studies aims to better understand how NPT explains observed and reported implementation processes, and to explore the ways in which its constructs explain the implementability, enacting and sustainment of complex healthcare interventions. Methods: We will systematically search Scopus, PubMed and Web of Science databases and use the Google Scholar search engine for citations of key papers in which NPT was developed. This will identify English language peer-reviewed articles in scientific journals reporting (a) primary qualitative or mixed methods studies; or, (b) qualitative or mixed methods evidence syntheses in which NPT was the primary analytic framework. Studies may be conducted in any healthcare setting, published between June 2006 and 31 December 2021. We will perform a qualitative synthesis of included studies using two parallel methods: (i) directed content analysis based on an already developed coding manual; and (ii) unsupervised textual analysis using Leximancer® topic modelling software. Other: We will disseminate results of the review using peer reviewed publications, conference and seminar presentations, and social media (Facebook and Twitter) channels. The primary source of funding is the National Institute for Health Research ARC North Thames. No human subjects or personal data are involved and no ethical issues are anticipated.

Environmental conditions and male quality traits simultaneously explain variation of multiple colour signals in male lizards.

Male lizards often display multiple pigment-based and structural colour signals which may reflect various quality traits (e.g. performance, parasitism), with testosterone (T) often mediating these relationships. Furthermore, environmental conditions can explain colour signal variation by affecting processes such as signal efficacy, thermoregulation and camouflage. The relationships between colour signals, male quality traits and environmental factors have often been analysed in isolation, but simultaneous analyses are rare. Thus, the response of multiple colour signals to variation in all these factors in an integrative analysis remains to be investigated. Here, we investigated how multiple colour signals relate to their information content, examined the role of T as a potential mediator of these relationships and how environmental factors explain colour signal variation. We performed an integrative study to examine the covariation between three colour signals (melanin-based black, carotenoid-based yellow-orange and structural UV), physiological performance, parasitism, T levels and environmental factors (microclimate, forest cover) in male common lizards Zootoca vivipara from 13 populations. We found that the three colour signals conveyed information on different aspects of male condition, supporting a multiple message hypothesis. T influenced only parasitism, suggesting that T does not directly mediate the relationships between colour signals and their information content. Moreover, colour signals became more saturated in forested habitats, suggesting an adaptation to degraded light conditions, and became generally brighter in mesic conditions, in contradiction with the thermal melanism hypothesis. We show that distinct individual quality traits and environmental factors simultaneously explain variations of multiple colour signals with different production modes. Our study therefore highlights the complexity of colour signal evolution, involving various sets of selective pressures acting at the same time, but in different ways depending on colour production mechanism.

Les lézards mâles arborent souvent plusieurs signaux colorés de nature pigmentaire et structurale qui reflètent de multiples traits de qualité (e.g. performance, parasitisme), et la testostérone (T) joue souvent un rôle de médiateur dans ces relations. En outre, les conditions environnementales peuvent également expliquer les variations des signaux colorés en influençant des aspects tels que l'efficacité des signaux, la thermorégulation ou le camouflage. Les relations entre signaux colorés, traits de qualité individuelle et facteurs environnementaux ont souvent été analysées séparément, mais rarement de manière simultanée. Ainsi, la réponse de ces multiples signaux colorés aux variations de tous ces facteurs reste à explorer dans le contexte d'une étude intégrative. Ici, nous explorons la relation entre ces multiples signaux colorés et leur contenu informatif, nous examinons le rôle de T comme médiateur potentiel de ces relations et nous recherchons si les conditions environnementales expliquent la variation de ces signaux colorés. Nous avons mené une étude intégrative afin d'examiner la covariation entre trois types de signaux colorés (noir produit par la mélanine, jaune-orange produit par les caroténoïdes et UV produit par des éléments structuraux), la performance physiologique, le parasitisme, les niveaux de T et les conditions environnementales (e.g. microclimat, couverture forestière) chez des mâles du lézard vivipare (Zootoca vivipara) provenant de 13 populations. Nos résultats indiquent que les trois signaux colorés transmettent des informations sur différents aspects de la condition des mâles, en accord avec l'hypothèse de « messages multiples ¼. T influence uniquement le parasitisme, suggérant que T n'agit pas en tant que médiateur des relations entre ces signaux colorés et leur contenu informatif. De plus, les signaux colorés sont plus saturés dans les habitats les plus forestiers, ce qui suggère une adaptation à des conditions lumineuses dégradées. Enfin, les signaux colorés sont plus intenses lorsque les conditions sont mésiques, en contradiction avec l'hypothèse du mélanisme thermal. Nous démontrons que différents traits de qualité individuelle et facteurs environnementaux expliquent de manière simultanée les variations de multiples signaux colorés impliquant différents modes de production. Notre étude souligne ainsi la complexité de l'évolution des signaux colorés, qui implique plusieurs types de pressions de sélection agissant en même temps mais dans des directions différentes selon le mode de production.

Rapid design and implementation of a virtual pain management programme due to COVID-19: a quality improvement initiative.

Background: The COVID-19 pandemic interrupted the delivery of face-to-face pain services including pain management programmes in the United Kingdom with considerable negative impact on patients with chronic musculoskeletal pain. We aimed to develop and implement a remotely delivered pain management programme (PMP) using video-conferencing technology that contains all the core components of a full programme: the 'virtual PMP' (vPMP). By reporting on the process of this development, we endeavour to help address the paucity of literature on the development of remote pain management programmes. Methods: The vPMP was developed by an inter-disciplinary group of professionals as a quality improvement (QI) project. The Model for Improvement Framework was employed with patient involvement at the design phase and at subsequent improvements. Improvement was measured qualitatively with frequent and repeated qualitative data collection leading to programme change. Quantitative patient demographic comparisons were made with a patient cohort who had been on a face-to-face PMP pathway. Results: Sixty-one patients on the PMP waiting list were contacted and 43 met the criteria for the programme. Fourteen patients participated in three vPMP cycles. Patient involvement and comprehensive stakeholder consultation were essential to a robust design for the first vPMP. Continued involvement of patient partners during the QI process led to rapid resolution of implementation problems. The most prominent issues that needed action were technical challenges including training needs, participant access to physical and technological resources, participant fatigue and concerns about adequate communication and peer support. Conclusion: This report demonstrates how a remotely delivered PMP, fully in line with national guidance, was rapidly developed and implemented in a hospital setting for patients with chronic musculoskeletal pain. We also discuss the relevance of our findings to the issues of cost, patient experience, patient preferences and inequities of access in delivering telerehabilitation for chronic pain.

Safety, tolerability and viral kinetics during SARS-CoV-2 human challenge in young adults.

Since its emergence in 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused hundreds of millions of cases and continues to circulate globally. To establish a novel SARS-CoV-2 human challenge model that enables controlled investigation of pathogenesis, correlates of protection and efficacy testing of forthcoming interventions, 36 volunteers aged 18-29 years without evidence of previous infection or vaccination were inoculated with 10 TCID50 of a wild-type virus (SARS-CoV-2/human/GBR/484861/2020) intranasally in an open-label, non-randomized study (ClinicalTrials.gov identifier NCT04865237 ; funder, UK Vaccine Taskforce). After inoculation, participants were housed in a high-containment quarantine unit, with 24-hour close medical monitoring and full access to higher-level clinical care. The study's primary objective was to identify an inoculum dose that induced well-tolerated infection in more than 50% of participants, with secondary objectives to assess virus and symptom kinetics during infection. All pre-specified primary and secondary objectives were met. Two participants were excluded from the per-protocol analysis owing to seroconversion between screening and inoculation, identified post hoc. Eighteen (~53%) participants became infected, with viral load (VL) rising steeply and peaking at ~5 days after inoculation. Virus was first detected in the throat but rose to significantly higher levels in the nose, peaking at ~8.87 log10 copies per milliliter (median, 95% confidence interval (8.41, 9.53)). Viable virus was recoverable from the nose up to ~10 days after inoculation, on average. There were no serious adverse events. Mild-to-moderate symptoms were reported by 16 (89%) infected participants, beginning 2-4 days after inoculation, whereas two (11%) participants remained asymptomatic (no reportable symptoms). Anosmia or dysosmia developed more slowly in 15 (83%) participants. No quantitative correlation was noted between VL and symptoms, with high VLs present even in asymptomatic infection. All infected individuals developed serum spike-specific IgG and neutralizing antibodies. Results from lateral flow tests were strongly associated with viable virus, and modeling showed that twice-weekly rapid antigen tests could diagnose infection before 70-80% of viable virus had been generated. Thus, with detailed characterization and safety analysis of this first SARS-CoV-2 human challenge study in young adults, viral kinetics over the course of primary infection with SARS-CoV-2 were established, with implications for public health recommendations and strategies to affect SARS-CoV-2 transmission. Future studies will identify the immune factors associated with protection in those participants who did not develop infection or symptoms and define the effect of prior immunity and viral variation on clinical outcome.

Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development.

BACKGROUND: Normalisation Process Theory (NPT) is frequently used to inform qualitative research that aims to explain and evaluate processes that shape late-stage translation of innovations in the organisation and delivery of healthcare. A coding manual for qualitative researchers using NPT will facilitate transparent data analysis processes and will also reduce the cognitive and practical burden on researchers. OBJECTIVES: (a) To simplify the theory for the user. (b) To describe the purposes, methods of development, and potential application of a coding manual that translates normalisation process theory (NPT) into an easily usable framework for qualitative analysis. (c) To present an NPT coding manual that is ready for use. METHOD: Qualitative content analysis of papers and chapters that developed normalisation process theory, selection and structuring of theory constructs, and testing constructs against interview data and published empirical studies using NPT. RESULTS: A coding manual for NPT was developed. It consists of 12 primary NPT constructs and conforms to the Context-Mechanism-Outcome configuration of realist evaluation studies. Contexts are defined as settings in which implementation work is done, in which strategic intentions, adaptive execution, negotiating capability, and reframing organisational logics are enacted. Mechanisms are defined as the work that people do when they participate in implementation processes and include coherence-building, cognitive participation, collective action, and reflexive monitoring. Outcomes are defined as effects that make visible how things change as implementation processes proceed and include intervention mobilisation, normative restructuring, relational restructuring, and sustainment. CONCLUSION: The coding manual is ready to use and performs three important tasks. It consolidates several iterations of theory development, makes the application of NPT simpler for the user, and links NPT constructs to realist evaluation methods. The coding manual forms the core of a translational framework for implementation research and evaluation.

What is the content of virtually delivered pain management programmes for people with persistent musculoskeletal pain? A systematic review.

INTRODUCTION: Virtual consultations (VC) have been embraced by healthcare organisations during the COVID-19 pandemic. VC allows continuation of patient care while adhering to government advised restrictions and social distancing measures. Multidisciplinary pain management programmes (PMPs) are a core element of many pain services and utilising virtual methods to deliver PMPs has allowed them to continue to provide care. This systematic review aimed to explore the content of existing virtually delivered PMPs and discuss if and how these findings can be used to guide clinical delivery. METHODS: Eligible studies included adults (aged ⩾18 years) with persistent musculoskeletal pain and any virtually delivered intervention that was described as a PMP or that had components of PMPs. Databases were searched from inception until July 2020. We performed a content analysis comparing existing interventions with established evidence-based clinical guidelines published by the British Pain Society (BPS). Intervention reporting quality was assessed using the Template for Intervention Description and Replication (TIDieR) checklist: an established checklist developed to improve the completeness of the reporting of interventions. RESULTS: Eight studies were included. One intervention included six of the seven components recommended by the BPS; none included all seven. 'Skills training and activity management' was present in all eight interventions; 'education' and 'cognitive therapy methods' were present in six interventions; 'graded activation' and 'methods to enhance acceptance, mindfulness and psychological flexibility' were present in four interventions; 'physical exercise' was present in two interventions and 'graded exposure' was present in one intervention. None of the studies described all 12 items of the TIDieR checklist adequately enough for replication. CONCLUSION: Published virtual PMPs partially meet established clinical guidelines. Future virtual PMPs should be based on evidence-based clinical guidelines, and more research is needed to explore the effectiveness of virtually delivered PMPs and each recommended component.

Patient, clinician and manager experience of the accelerated implementation of virtual consultations following COVID-19: A qualitative study of preferences in a tertiary orthopaedic rehabilitation setting.

AIM: To investigate the experiences of patients, clinicians and managers during the accelerated implementation of virtual consultations (VCs) due to COVID-19. To understand how patient preferences are constructed and organized. METHODS: Semi-structured interviews with patients, clinicians and managerial staff at a single specialist orthopaedic centre in the United Kingdom. The interview schedule and coding frame were based on Normalisation Process Theory. Interviews were conducted over the telephone or by video call. Abductive analysis of interview transcripts extended knowledge from previous research to identify, characterize and explain how patient preferences for VC were formed and arranged. RESULTS: Fifty-five participants were included (20 patients, 20 clinicians, 15 managers). Key mechanisms that contribute to the formation of patient preferences were identified. These were: (a) context for the consultation (normative expectations, relational expectations, congruence and potential); (b) the available alternatives and the implementation process (coherence, cognitive participation, collective action and reflexive monitoring). Patient preferences are mediated by the clinician and organisational preferences through the influence of the consultation context, available alternatives and the implementation process. CONCLUSIONS: This study reports the cumulative analysis of five empirical studies investigating patient preferences for VC before and during the COVID-19 pandemic as VC transitioned from an experimental clinic to a compulsory form of service delivery. This study has identified mechanisms that explain how preferences for VC come about and how these relate to organisational and clinician preferences. Since clinical pathways are shaped by interactions between patient, clinicians and organisational preferences, future service design must strike a balance between patient preferences and the preferences of clinicians and organisations. PATIENT AND PUBLIC CONTRIBUTION: The CONNECT Project Patient and Public Involvement (PPI) group provided guidance on the conduct and design of the research. This took place with remote meetings between the lead researcher and the chair of the PPI group during March and April 2020. Patient information documentation and the interview schedule were developed with the PPI group to ensure that these were accessible.

Prevention of Respiratory Syncytial Virus Infection in Healthy Adults by a Single Immunization of Ad26.RSV.preF in a Human Challenge Study.

BACKGROUND: Respiratory syncytial virus (RSV) is a significant cause of severe lower respiratory tract disease in children and older adults, but has no approved vaccine. This study assessed the potential of Ad26.RSV.preF to protect against RSV infection and disease in an RSV human challenge model. METHODS: In this double-blind, placebo-controlled study, healthy adults aged 18-50 years were randomized 1:1 to receive 1 × 1011 vp Ad26.RSV.preF or placebo intramuscularly. Twenty-eight days postimmunization, volunteers were challenged intranasally with RSV-A (Memphis 37b). Assessments included viral load (VL), RSV infections, clinical symptom score (CSS), safety, and immunogenicity. RESULTS: Postchallenge, VL, RSV infections, and disease severity were lower in Ad26.RSV.preF (n = 27) vs placebo (n = 26) recipients: median VL area under the curve (AUC) quantitative real-time polymerase chain reaction: 0.0 vs 236.0 (P = .012; predefined primary endpoint); median VL-AUC quantitative culture: 0.0 vs 109; RSV infections 11 (40.7%) vs 17 (65.4%); median RSV AUC-CSS 35 vs 167, respectively. From baseline to 28 days postimmunization, geometric mean fold increases in RSV A2 neutralizing antibody titers of 5.8 and 0.9 were observed in Ad26.RSV.preF and placebo, respectively. Ad26.RSV.preF was well tolerated. CONCLUSIONS: Ad26.RSV.preF demonstrated protection from RSV infection through immunization in a human challenge model, and therefore could potentially protect against natural RSV infection and disease. CLINICAL TRIALS REGISTRATION: NCT03334695; CR108398, 2017-003194-33 (EudraCT); VAC18193RSV2002.

Patient preferences for use of virtual consultations in an orthopaedic rehabilitation setting: Results from a discrete choice experiment.

OBJECTIVE: Virtual Consultations may reduce the need for face-to-face outpatient appointments, thereby potentially reducing the cost and time involved in delivering health care. This study reports a discrete choice experiment (DCE) that identifies factors that influence patient preferences for virtual consultations in an orthopaedic rehabilitation setting. METHODS: Previous research from the CONNECT (Care in Orthopaedics, burdeN of treatmeNt and the Effect of Communication Technology) Project and best practice guidance informed the development of our DCE. An efficient fractional factorial design with 16 choice scenarios was created that identified all main effects and partial two-way interactions. The design was divided into two blocks of eight scenarios each, to reduce the impact of cognitive fatigue. Data analysis were conducted using binary logit regression models. RESULTS: Sixty-one paired response sets (122 subjects) were available for analysis. DCE factors (whether the therapist is known to the patient, duration of appointment, time of day) and demographic factors (patient qualifications, access to equipment, difficulty with activities, multiple health issues, travel costs) were significant predictors of preference. We estimate that a patient is less than 1% likely to prefer a virtual consultation if the patient has a degree, is without access to the equipment and software to undertake a virtual consultation, does not have difficulties with day-to-day activities, is undergoing rehabilitation for one problem area, has to pay less than £5 to travel, is having a consultation with a therapist not known to them, in 1 weeks' time, lasting 60 minutes, at 2 pm. We have developed a simple conceptual model to explain how these factors interact to inform preference, including patients' access to resources, context for the consultation and the requirements of the consultation. CONCLUSIONS: This conceptual model provides the framework to focus attention towards factors that might influence patient preference for virtual consultations. Our model can inform the development of future technologies, trials, and qualitative work to further explore the mechanisms that influence preference.

Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning.

PURPOSE: Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. MATERIALS AND METHODS: Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed. RESULTS: Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice. CONCLUSION: This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised.IMPLICATIONS FOR REHABILITATIONRedesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making.Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty.Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice.Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre.

A qualitative investigation into the results of a discrete choice experiment and the impact of COVID-19 on patient preferences for virtual consultations.

OBJECTIVES: To conduct a qualitative investigation on a subset of participants from a previously completed Discrete Choice Experiment (DCE) to understand why factors identified from the DCE are important, how they influenced preference for virtual consultations (VC) and how COVID-19 has influenced preference for VC. METHODS: A quota sample was recruited from participants who participated in our DCE. We specifically targeted participants who were strongly in favour of face-to-face consultations (F2F - defined as choosing all or mostly F2F in the DCE) or strongly in favour of virtual consultations (VC - defined as choosing all or mostly VC consultations in the DCE) to elicit a range of views. Interviews were conducted via telephone or videoconference, audio recorded, transcribed verbatim and uploaded into NVIVO software. A directed content analysis of transcripts was undertaken in accordance with a coding framework based on the results of the DCE and the impact of COVID-19 on preference. RESULTS: Eight F2F and 5 VC participants were included. Shorter appointments were less 'worth' travelling in for than a longer appointment and rush hour travel had an effect on whether travelling was acceptable, particularly when patients experienced pain as a result of extended journeys. Socioeconomic factors such as cost of travel, paid time off work, access to equipment and support in its use was important. Physical examinations were preferable in the clinic whereas talking therapies were acceptable over VC. Several participants commented on how VC interferes with the patient-clinician relationship. VC during COVID-19 has provided patients with the opportunity to access their care virtually without the need for travel. For some, this was extremely positive. CONCLUSIONS: This study investigated the results of a previously completed DCE and the impact of COVID-19 on patient preferences for VC. Theoretically informative insights were gained to explain the results of the DCE. The use of VC during the COVID-19 pandemic provided opportunities to access care without the need for face-to-face social interactions. Many felt that VC would become more commonplace after the pandemic, whereas others were keen to return to F2F consultations as much as possible. This qualitative study provides additional context to the results of a previously completed DCE.

A mixed-methods survey to explore issues with virtual consultations for musculoskeletal care during the COVID-19 pandemic.

OBJECTIVE: To explore orthopaedic and musculoskeletal clinicians' views and experiences of legal, safety, safeguarding and security issues regarding the use of virtual consultations (VC) during the COVID-19 pandemic. A secondary objective was to suggest ways to overcome these issues. METHODS: A mixed method cross-sectional survey was conducted, seeking the views and experiences of orthopaedic and musculoskeletal medically qualified and Allied Health Professionals in the United Kingdom. Descriptive statistical analysis was employed for quantitative data and a qualitative content analysis undertaken for qualitative data. Findings were presented in accordance with the four key issues. RESULTS: Two hundred and ninety professionals (206 physiotherapists, 78 medically qualified professionals, 6 'other' therapists) participated in the survey. Of the 290 participants, 260 (90%) were not using VC prior to the COVID-19 pandemic, 248 respondents (86%) were unsure whether their professional indemnity insurance covered VC, 136 (47%) had considered how they would handle an issue of safeguarding whilst the remainder had not, 126 (43%) had considered what they would do if, during a virtual consultation, a patient suffered an injury (e.g. bang on their head) or a fall (e.g. mechanical or a medical event like syncope) and 158 (54%) reported they felt the current technological solutions are secure in terms of patient data. Qualitative data provided additional context to support the quantitative findings such as validity of indemnification, accuracy of diagnosis and consent using VC, safeguarding issues; and security and sharing of data. Potential changes to practice have been proposed to address these issues. CONCLUSIONS: VC have been rapidly deployed since the onset of the COVID-19 pandemic often without clear guidance or consensus on many important issues. This study identified legal, safeguarding, safety and security issues. There is an urgent need to address these and develop local and national guidance and frameworks to facilitate ongoing safe virtual orthopaedic practice beyond the COVID-19 pandemic.

Factors that influence patient preferences for virtual consultations in an orthopaedic rehabilitation setting: a qualitative study.

OBJECTIVES: To identify, characterise and explain factors that influence patient preferences, from the perspective of patients and clinicians, for virtual consultations in an orthopaedic rehabilitation setting. DESIGN: Qualitative study using semi-structured interviews and abductive analysis. SETTING: A physiotherapy and occupational therapy department situated within a tertiary orthopaedic centre in the UK. PARTICIPANTS: Patients who were receiving orthopaedic rehabilitation for a musculoskeletal problem. Occupational therapists, physiotherapists or therapy technicians involved in the delivery of orthopaedic rehabilitation for patients with a musculoskeletal problem. RESULTS: Twenty-two patients and 22 healthcare professionals were interviewed. The average interview length was 48 minutes. Four major factors were found to influence preference: the situation of care (the ways that patients understand and explain their clinical status, their treatment requirements and the care pathway), the expectations of care (influenced by a patients desire for contact, psychological status, previous care and perceived requirements), the demands on the patient (due to each patients respective social situation and the consequences of choice) and the capacity to allocate resources to care (these include financial, infrastructural, social and healthcare resources). CONCLUSION: This study has identified key factors that appear to influence patient preference for virtual consultations in orthopaedic rehabilitation. A conceptual model of these factors, derived from empirical data, has been developed highlighting how they combine and compete. A series of questions, based on these factors, have been developed to support identification of preferences in a clinical setting.

Influenza A (H3) illness and viral aerosol shedding from symptomatic naturally infected and experimentally infected cases.

BACKGROUND: It has long been known that nasal inoculation with influenza A virus produces asymptomatic to febrile infections. Uncertainty persists about whether these infections are sufficiently similar to natural infections for studying human-to-human transmission. METHODS: We compared influenza A viral aerosol shedding from volunteers nasally inoculated with A/Wisconsin/2005 (H3N2) and college community adults naturally infected with influenza A/H3N2 (2012-2013), selected for influenza-like illness with objectively measured fever or a positive Quidel QuickVue A&B test. Propensity scores were used to control for differences in symptom presentation observed between experimentally and naturally infected groups. RESULTS: Eleven (28%) experimental and 71 (86%) natural cases shed into fine particle aerosols (P < .001). The geometric mean (geometric standard deviation) for viral positive fine aerosol samples from experimental and natural cases was 5.1E + 3 (4.72) and 3.9E + 4 (15.12) RNA copies/half hour, respectively. The 95th percentile shedding rate was 2.4 log10 greater for naturally infected cases (1.4E + 07 vs 7.4E + 04). Certain influenza-like illness-related symptoms were associated with viral aerosol shedding. The almost complete lack of symptom severity distributional overlap between groups did not support propensity score-adjusted shedding comparisons. CONCLUSIONS: Due to selection bias, the natural and experimental infections had limited symptom severity distributional overlap precluding valid, propensity score-adjusted comparison. Relative to the symptomatic naturally infected cases, where high aerosol shedders were found, experimental cases did not produce high aerosol shedders. Studying the frequency of aerosol shedding at the highest observed levels in natural infections without selection on symptoms or fever would support helpful comparisons.

Use of virtual consultations in an orthopaedic rehabilitation setting: how do changes in the work of being a patient influence patient preferences? A systematic review and qualitative synthesis.

OBJECTIVES: To systematically review qualitative studies reporting the use of virtual consultations within an orthopaedic rehabilitation setting and to understand how its use changes the work required of patients. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, we conducted a systematic review of papers to answer the research question 'How do changes in the work of being a patient when using communication technology influence patient preferences?' Electronic databases were searched for studies meeting the inclusion criteria in April 2020. RESULTS: The search strategy identified 2057 research articles from the database search. A review of titles and abstracts using the inclusion criteria yielded 21 articles for full-text review. Nine studies were included in the final analysis. Six studies explored real-time video conferencing and three explored telephone consultations. The use of communication technology changes the work required of patients. Such changes will impact on expectations for care, resources required of patients, the environment of receiving care and patient-clinician interactions. This adjustment of the work required of patients who access orthopaedic rehabilitation using communication technology will impact on their experience of receiving care. It is proposed that changes in the work of being a patient will influence preferences for or against the use of communication technology consultations for orthopaedic rehabilitation. CONCLUSION: We found that the use of communication technology changes the work of being a patient. The change in work required of patients can be both burdensome (it makes it harder for patients to access their care) and beneficial (it makes it easier for patients to access their care). This change will likely to influence preferences. Keeping the concept of patient work at the heart of pathway redesign is likely to be a key consideration to ensure successful implementation. PROSPERO REGISTRATION NUMBER: CRD42018100896.