Assistive technologies and strategies to support the medication management of individuals with hearing and/or visual impairment: A scoping review.

BACKGROUND: Individuals with sensory impairment (visual and/or hearing) experience health inequalities and increased the risk of medication-related iatrogenic disease compared with the general population. Assistive technologies and tailored strategies could support medication management for individuals with sensory impairment to reduce harm and increase the likelihood of therapeutic benefit. OBJECTIVE: This scoping review identified assistive technologies and strategies to support medication management of/for people with hearing and/or visual impairment. METHODS: Standard scoping review methodology was used to identify studies that evaluated technologies or strategies designed to support people with sensory impairment with independent medicine management. Electronic databases were searched (MEDLINE, Embase, CINAHL, ACM, Cochrane) from inception to 18/07/22. Independent duplicate screening, selection, and data extraction were undertaken. RESULTS: Of 1231 publications identified, 18 were included, reporting 17 studies, 16 of which evaluated technologies to assist people with visual impairment and one study to assist people with hearing impairment. The range of technologies and devices included: applications for android phones (n = 6); eyedrop-assistance devices (n = 5); audio-prescription labelling/reading systems (n = 2); touch-to-speech devices (n = 2); continuous glucose monitoring system (n = 1); magnifying technology (n = 1). Ten studies tested early-stage prototypes. Most participants could operate the technologies effectively and deemed them to be useful. CONCLUSIONS: Despite the increasing number of medicine-related assistive technologies, there has been limited empirical evaluation of their effectiveness for supporting individuals with sensory impairment. Prototypes appear to be useful for people with visual or hearing impairment, however wider 'real-life' testing is needed to confirm the benefits of these technologies.

Optimum length of treatment with systemic antibiotics in adults with dental infections: a systematic review.

Introduction Guidelines on the length of treatment of dental infections with systemic antibiotics vary across different countries. We aimed to determine if short-duration (3-5 days) courses of systemic antibiotics were as effective as longer-duration courses (≥7 days) for the treatment of dental infections in adults in outpatient settings.Methods We searched Ovid Medline, Ovid Embase, Cochrane, trials registries, Google Scholar and forward and backward citations for studies published between database inception and 30 March 2021. All randomised clinical trials (RCT) and non-randomised trials which compared length of treatment with systemic antibiotics for dental infections in adults in outpatient settings published in English were included.Results One small RCT met our defined inclusion criteria. The trial compared three-day versus seven-day courses of amoxicillin in adults with odontogenic infection requiring tooth extraction. There was no significant difference between groups in terms of participant-reported pain or clinical assessment of wound healing.Discussion While a number of observational studies were supportive of shorter-course therapy, only one small RCT concluded that a three-day course of amoxicillin was clinically non-inferior versus seven days for the treatment of odontogenic infection requiring tooth extraction. Limited conclusions on shorter-course therapy can be drawn from this study as all participants commenced amoxicillin two days before tooth extraction which is not common clinical practice. The variability in guidelines for use of antimicrobials in dental infections suggests that guidelines are based on local or national historical practice and indicates the need for further research to determine the optimum length of treatment. RCTs are required to investigate if short-duration courses of antibiotics are effective and to provide evidence to support consistent guidance for dental professionals.

Indications for the use of metronidazole in the treatment of non-periodontal dental infections: a systematic review.

Background: Dental practitioners are the largest prescribers of metronidazole. Antibiotics should only be prescribed when systemic involvement is clear and should be limited to monotherapy with ß-lactams in the first instance. Objectives: To determine whether metronidazole used as monotherapy or in addition to a ß-lactam antibiotic offers any additional benefit over ß-lactam monotherapy in non-periodontal dental infections. Methods: Searches of Ovid Medline, Ovid Embase, Cochrane library and trials registries, forward and backward citations, for studies published between database inception and 2 August 2021. All randomized clinical trials (RCTs) and non-randomized trials comparing either systemic metronidazole monotherapy or metronidazole combined with a ß-lactam with ß-lactam monotherapy for the treatment of non-periodontal dental infections in adults or children in outpatient settings were included. Results: Four publications reporting three RCTs comparing metronidazole with a ß-lactam antibiotic were recovered. Studies were conducted in the 1970s-80s and aimed to demonstrate metronidazole was as effective as penicillin for the treatment of acute pericoronitis or acute apical infections with systemic involvement. Meta-analysis of results was not possible due to differences in measurement of infection signs. All studies concluded that metronidazole and penicillin are equally effective for the treatment of non-periodontal dental infections with systemic involvement. Conclusions: Metronidazole does not provide superior clinical outcomes (alone or in combination with a ß-lactam) when compared with a ß-lactam antibiotic alone for the treatment of non-periodontal dental infections in general dental practice. Guidelines should reinforce the importance of surgical interventions and if appropriate the use of a single agent narrow-spectrum ß-lactam.

Tackling antimicrobial resistance in practice: dental students' evaluation of university teaching supplemented by an online course.

Background: Antimicrobial resistance (AMR) presents a global threat to public health. Engaging all healthcare professionals including undergraduates in efforts to tackle AMR is vital. Sharing and spreading good practice in teaching on AMR and antimicrobial stewardship (AMS) is a key ambition in Scotland. In 2020, the University of Glasgow Dental School supplemented teaching with mandatory completion by final year undergraduates of an online education programme on the essential role of dental teams in reducing AMR. Objectives: To evaluate final year dental students' knowledge and experience of utilizing an online international educational, interactive resource to supplement university teaching: Tackling Antibiotic Resistance: What Should Dental Teams Do? Methods: Cross-sectional qualitative evaluation using a self-administered questionnaire with open questions about course content, learning and personal action planning. Data were thematically analysed using NVivo12 Pro software. Results: A total of 88 students completed a questionnaire, which indicated online training had increased their understanding of AMR and AMS from a global perspective and confirmed these topics were an integral part of their undergraduate education programme. Their action plans demonstrated enthusiasm for creating an AMS culture in clinical practice and an understanding of the need for ongoing education of themselves, their colleagues and patients. Conclusions: Education delivery using a variety of media to support teaching and learning in Glasgow Dental School was effective in ensuring that students understand their role in tackling AMR. Students were positive about the addition of an online education programme to supplement university teaching. This approach may be beneficial for other undergraduate dentistry programmes.

Safety and efficacy of de-labelling penicillin allergy in adults using direct oral challenge: a systematic review.

BACKGROUND: Approximately 10% of people have an unverified penicillin allergy, with multiple personal and public health consequences. OBJECTIVES: To assess the efficacy and safety of direct oral challenge, without prior skin testing, in this population. METHODS: MEDLINE, EMBASE, CINAHL, the Cochrane Library and Google Scholar were searched from inception to 28 June 2020 (updated November 2020) to find published and unpublished studies that reported direct oral challenge for the purpose of removal of penicillin allergy labels. Population weighted mean was used to calculate the proportion of patients who developed an immediate or delayed reaction to direct oral challenge across the studies. RESULTS: Thirteen studies were included in the review, with a sample size of 1202 (range 7-328). Studies included inpatient and outpatient cohorts assessed as low risk for true allergy. In pooled analysis of all 13 studies there were 41/1202 (3.41%) mild immediate or delayed reactions to direct oral challenge. The population-weighted mean incidence of immediate or delayed reaction to an oral challenge across studies was also 3.41% (95% CI: 2.38%-4.43%). There were no reports of serious adverse reactions, 96.5% of patients could be de-labelled and many were subsequently successfully treated with penicillin. CONCLUSIONS: Direct oral challenge is safe and effective for de-labelling patients assessed as low risk for true allergy. Non-specialist clinicians competent in using an assessment algorithm can offer evaluation of penicillin allergy labels using direct oral challenge in appropriate patients. These measures will facilitate optimal infection treatment for patients, support antimicrobial stewardship, and minimize antimicrobial resistance.

Antibiotic prescribing for respiratory tract infection in patients with suspected and proven COVID-19: results from an antibiotic point prevalence survey in Scottish hospitals.

BACKGROUND: Bacterial co-infection is infrequently observed with SARS-CoV-2/COVID-19 infection outside of critical care, however, antibiotics are commonly prescribed. OBJECTIVES: To examine factors associated with antibiotic prescribing for suspected respiratory tract infection (RTI) and evaluate the nature and dynamics of prescribing in hospitalized patients with suspected and proven COVID-19 infection. METHODS: An antibiotic point prevalence survey in hospitalized adult patients was conducted in designated COVID-19 clinical areas (including critical care) in 15 Scottish hospitals. Antibiotics prescribed for RTI and factors associated with prescribing were investigated. RESULTS: Of 820 surveyed patients, 272 (prevalence 33.3%) received antibiotics for suspected RTI on the survey day and 58.8% were SARS-CoV-2 positive. Antibiotics were empirical in 91.9% and amoxicillin (24.6%), doxycycline (20.5%) and co-amoxiclav (15%) were most frequently prescribed. Oral antibiotics were prescribed in 54.5% and duration was recorded in 76.7% on wards for a median of 5 days. IV to oral switch occurred after a median of 2 days. Prescribing for RTI was independently and positively associated with COPD/chronic lung disease, purulent/bloody sputum, abnormal chest X-ray, and CRP ≥ 100 mg/L. Probable and definite hospital-acquired COVID-19 and diabetes were associated with a lower odds of receiving an antibiotic for RTI. CONCLUSIONS: Antibiotic prescribing for suspected RTI was commonly observed and predominantly empirical in suspected or proven COVID-19. Initiatives to reinforce stewardship principles including clinical review, effective use of microbiological diagnostics and better understanding of the role of biomarkers are central to further limit unnecessary antibiotic therapy in COVID-19.

Antibiotic use towards the end of life: development of good practice recommendations.

OBJECTIVES: Development of evidence-based good practice recommendations for clinicians considering the use of antibiotics in patients towards the end of life. DESIGN: A multiprofessional group of experts in end-of-life care and antimicrobial stewardship was convened. Findings from a scoping review of the literature and a consultation of clinicians were triangulated. Expert discussion was used to generate consensus on how to approach decision-making. SETTING: Representatives from hospital and a range of community health and care settings. PARTICIPANTS: Medical, pharmacy and nursing professionals. MAIN OUTCOME MEASURES: Good practice recommendations based on published evidence and the experience of prescribers in Scotland. RESULTS: The findings of 88 uncontrolled, observational studies of variable quality were considered alongside a survey of over 200 prescribers. No national or international guidelines were identified. Antibiotic use towards the end of life was common but practice was highly variable. The potential harms associated with giving antibiotics tended to be less well considered than the potential benefits. Antibiotics often extended the length of time to death but this was sometimes at the cost of higher symptom burden. There was strong consensus around the importance of effective communication with patients and their families and making treatment decisions aligned to a patient's goals and priorities. CONCLUSIONS: Good practice recommendations were agreed with focus on three areas: making shared decisions about future care; agreeing clear goals and limits of therapy; reviewing all antibiotic prescribing decisions regularly. These will be disseminated widely to support optimal care for patients towards the end of life. A patient version of the recommendations has also been produced to support implementation.

Antimicrobial use at the end of life: a scoping review.

OBJECTIVE: To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance. DESIGN: Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020. STUDY SELECTION: Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group. RESULTS: Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care. CONCLUSIONS: Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.

Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals.

BACKGROUND: Concern regarding bacterial co-infection complicating SARS-CoV-2 has created a challenge for antimicrobial stewardship. Following introduction of national antibiotic recommendations for suspected bacterial respiratory tract infection complicating COVID-19, a point prevalence survey of prescribing was conducted across acute hospitals in Scotland. METHODS: Patients in designated COVID-19 units were included and demographic, clinical and antimicrobial data were collected from 15 hospitals on a single day between 20th and 30th April 2020. Comparisons were made between SARS-CoV-2 positive and negative patients and patients on non-critical care and critical care units. Factors associated with antibiotic prescribing in SARS-CoV-2 positive patients were examined using Univariable and multivariable regression analyses. FINDINGS: There were 820 patients were included, 64.8% were SARS-CoV-2 positive and 14.9% were managed in critical care, and 22.1% of SARS-CoV-2 infections were considered probable or definite nosocomial infections. On the survey day, antibiotic prevalence was 45.0% and 73.9% were prescribed for suspected respiratory tract infection. Amoxicillin, doxycycline and co-amoxiclav accounted for over half of all antibiotics in non-critical care wards and meropenem, piperacillin-tazobactam and co-amoxiclav accounted for approximately half prescribed in critical care. Of all SARS-CoV-2 patients, 38.3% were prescribed antibiotics. In a multivariable logistic regression analysis, COPD/chronic lung disease and CRP ≥ 100 mg/l were associated with higher odds and probable or confirmed nosocomial COVID-19, diabetes and management on an elderly care ward had lower odds of an antibiotic prescription. Systemic antifungals were prescribed in 9.8% of critical care patients and commenced a median of 18 days after critical care admission. INTERPRETATION: A relatively low prevalence of antibiotic prescribing in SARS-CoV-2 hospitalised patients and low proportion of broad spectrum antibiotics in non-critical care settings was observed potentially reflecting national antimicrobial stewardship initiatives. Broad spectrum antibiotic and antifungal prescribing in critical care units was observed indicating the importance of infection prevention and control and stewardship initiatives in this setting. FUNDING: The Scottish Antibiotic Prescribing Group is funded by Scottish Government.

Impact of the COVID-19 pandemic on community antibiotic prescribing in Scotland.

BACKGROUND: Following concerns about increased antibiotic use during the COVID-19 pandemic, trends in community antibiotic prescriptions in Scotland were evaluated. METHODS: The primary care prescription electronic messaging system used in GP practices with NHS contracts provided near real-time data analysis of national data. The main outcome measures were the weekly number of prescriptions for antibiotics generated by prescribers in GP practices in 2020 compared with 2019. RESULTS: At end of Week 12 2020 (22 March), after a sharp increase, the number of prescriptions commonly used for respiratory infections was 44% higher than the corresponding week in 2019. The number of prescriptions for respiratory antibiotics reduced through April and May 2020, with 34% fewer prescriptions issued by end of Week 22 (31 May) than in the corresponding week in 2019. Reductions were pronounced in all age groups but particularly apparent for prescriptions for children aged 0-4 years. These data were compared with weekly prescriptions for a selection of non-respiratory antibiotics and no difference was seen between 2020 and 2019. CONCLUSIONS: Trends in antibiotic prescription data show that after an initial surge, and following 'lockdown' in Scotland, the total number of prescriptions for antibiotics commonly used for respiratory infections fell. We believe this is the first published national evaluation of the impact of COVID-19 on community use of antibiotics. Further analysis of national data is planned to provide a greater understanding of the reasons behind these trends.

Antimicrobial point prevalence surveys in two Ghanaian hospitals: opportunities for antimicrobial stewardship.

BACKGROUND: Improved knowledge regarding antimicrobial use in Ghana is needed to reduce antimicrobial resistance (AMR). This includes point prevalence studies (PPSs) in hospitals. Objectives were to: (i) provide baseline data in two hospitals [Keta Municipal Hospital (KMH) and Ghana Police Hospital (GPH)] and identify priorities for improvement; (ii) assess the feasibility of conducting PPSs; and (iii) compare results with other studies. METHODS: Standard PPS design using the Global PPS paper forms, subsequently transferred to their template. Training undertaken by the Scottish team. Quality indicators included: rationale for use; stop/review dates; and guideline compliance. RESULTS: Prevalence of antibiotic use was 65.0% in GPH and 82.0% in KMH. Penicillins and other ß-lactam antibiotics were the most frequently prescribed in both hospitals, with third-generation cephalosporins mainly used in GPH. Antibiotic treatment was mainly empirical and commonly administered intravenously, duration was generally short with timely oral switching and infections were mainly community acquired. Encouragingly, there was good documentation of the indications for antibiotic use in both hospitals and 50.0%-66.7% guideline compliance (although for many indications no guideline existed). In addition, almost all prescribed antibiotics had stop dates and there were no missed doses. The duration of use for surgical prophylaxis was generally more than 1 day (69.0% in GPH and 77.0% in KMH). CONCLUSIONS: These two hospitals were the first in Ghana to use the Global PPS system. We found the PPS was feasible, relatively rapid and achieved with limited training. Targets for improvement identified included reduction of broad-spectrum antibiotics and duration of treatment.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis.

BACKGROUND: The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work. METHODS: MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted. RESULTS: This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis. CONCLUSIONS: There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Supporting antimicrobial stewardship in Ghana: evaluation of the impact of training on knowledge and attitudes of healthcare professionals in two hospitals.

BACKGROUND: A Commonwealth Partnership for Antimicrobial Stewardship was created between the Scottish Antimicrobial Prescribing Group (SAPG), Ghana Police Hospital and Keta Municipal Hospital. During a scoping visit, requirements for implementing antimicrobial stewardship (AMS), areas for improvement and training needs were identified. METHODS: A multidisciplinary team from SAPG and health psychologists from The Change Exchange developed and delivered multi-professional evidence-based teaching incorporating behavioural science, supported by partner pharmacists in each hospital. Four sessions were delivered over 2 days to 60 participants across both sites. Before and after the sessions, participants were asked to complete a knowledge quiz and a behaviours survey. Results were analysed using t-tests. RESULTS: Comparison of the participants' pre- and post-test quiz scores (Keta Municipal Hospital 9.4 and 10.9, Ghana Police Hospital 9.2 and 11.1, respectively) demonstrated statistically significant improvement in knowledge of antimicrobial resistance and appropriate use of antibiotics. Comparison of survey responses before and after the education sessions indicated that the education had a positive impact on participants' attitudes towards the issue of antimicrobial resistance, their role in AMS and confidence in using the Ghana Standard Treatment Guidelines. Participants were also more likely to question colleagues about compliance with guidelines. Forty-eight participants (80%) completed a training evaluation and all responded positively. CONCLUSIONS: The education sessions appeared to be successful in improving knowledge and behaviours of hospital staff. Cascade of an abbreviated version of the training by partner pharmacists and AMS teams in Ghana will ensure that all staff have the opportunity to develop skills and knowledge to support AMS.

Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis.

Chronic musculoskeletal pain (CMP) is an urgent global public health concern. Pain neuroscience education (PNE) is an intervention used in the management of CMP aiming to reconceptualize an individual's understanding of their pain as less threatening. This mixed-methods review undertook a segregated synthesis of quantitative and qualitative studies to investigate the clinical effectiveness, and patients' experience of, PNE for people with CMP. Electronic databases were searched for studies published between January 1, 2002, and June 14, 2018. Twelve randomized, controlled trials (n = 755 participants) that reported pain, disability, and psychosocial outcomes and 4 qualitative studies (n = 50 participants) that explored patients experience of PNE were included. The meta-analyzed pooled treatment effects for PNE versus control had low clinical relevance in the short term for pain (-5.91/100; 95% confidence interval [CI], -13.75 to 1.93) and disability (-4.09/100; 95% CI, -7.72 to -.45) and in the medium term for pain (-6.27/100; 95% CI, -18.97 to 6.44) and disability (-8.14/100; 95% CI, -15.60 to -.68). The treatment effect of PNE for kinesiophobia was clinically relevant in the short term (-13.55/100; 95% CI, -25.89 to -1.21) and for pain catastrophizing in the medium term (-5.26/52; 95% CI, -10.59 to .08). A metasynthesis of 23 qualitative findings resulted in the identification of 2 synthesized findings that identified several key components important for enhancing the patient experience of PNE, such as allowing the patient to tell their own story. These components can enhance pain reconceptualization, which seems to be an important process to facilitate patients' ability to cope with their condition. The protocol was published on PROSPERO (CRD42017068436). Perspective: We outline the effectiveness of PNE for the management of pain, disability, and psychosocial outcomes in adults with CMP. Key components that can enhance the patient experience of PNE, such as allowing the patient to tell their own story, are also presented. These components may enhance pain reconceptualization.

Perceptions of adults with overweight/obesity and chronic musculoskeletal pain: An interpretative phenomenological analysis.

AIMS AND OBJECTIVES: To gain insight into the lived experience of adults with overweight/obesity and chronic musculoskeletal pain. Knowledge gained will inform healthcare professionals about the complexity of the weight-pain relationship and enable more effective engagement with this population. BACKGROUND: Quantitative studies show links between weight and pain. Adults with overweight/obesity are more likely to experience comorbidity; however, qualitative research describing the complexities of the relationship is limited. METHODS: A purposive sample of adults with overweight/obesity and chronic musculoskeletal pain participated in face-to-face interviews. Interviews were audio-recorded, transcribed verbatim and analysed using interpretive phenomenological analysis. RESULTS: Eighteen adults (16 female) aged 29-71, body mass index ≥25-46, participated in this study. Three superordinate themes emerged: "pain as a motivator and barrier to weight loss"; "fear of weight causing more damage"; and "activity is positive." Pain motivates some individuals to lose weight while simultaneously inhibiting weight loss efforts. Participants' perception that extra pressure caused by their weight further damaged joints contributed to fear and catastrophising. Fear is often exacerbated by healthcare professionals' descriptions of musculoskeletal damage, or participants' perception of healthcare professionals' attitude towards people with overweight/obesity. Conversely, individuals acknowledged the benefits of increased activity. CONCLUSION: Adults with overweight/obesity and chronic musculoskeletal pain in this study identified a bidirectional relationship between their weight and pain that challenged their weight loss efforts. Overweight/obesity contributed to fear and catastrophising, which resulted in avoidance of exercise that would have assisted their weight loss. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals need to understand the complex relationship between weight and pain, and their patients' understanding of that relationship. Healthcare professionals should use therapeutic communication to reduce the fear of weight causing damage, and thus promote physical activities that will contribute to weight loss. It is also important to ensure that the language used with this patient group does not stigmatise individuals, or cause or exacerbate fear of normal movement.

The association between baseline persistent pain and weight change in patients attending a specialist weight management service.

OBJECTIVE: To quantify the influence of baseline pain levels on weight change at one-year follow-up in patients attending a National Health Service specialist weight management programme. METHODS: We compared one-year follow-up weight (body mass) change between patient sub-groups of none-to-mild, moderate, and severe pain at baseline. A mean sub-group difference in weight change of ≥5kg was considered clinically relevant. RESULTS: Of the 141 complete cases, n = 43 (30.5%) reported none-to-mild pain, n = 44 (31.2%) reported moderate pain, and n = 54 (38.3%) reported severe pain. Covariate-adjusted mean weight loss (95%CI) was similar for those with none-to-mild (8.1kg (4.2 to 12.0kg)) and moderate pain (8.3kg (4.9 to 11.7kg). The mean weight loss of 3.0kg (-0.4 to 6.4kg) for the severe pain group was 5.1kg (-0.6 to 10.7, p = 0.08) lower than the none-to-mild pain group and 5.3kg (0.4 to 10.2kg, p = 0.03) lower than the moderate pain group. CONCLUSIONS: Patients with severe pain upon entry to a specialist weight management service in England achieve a smaller mean weight loss at one-year follow-up than those with none-to-moderate pain. The magnitude of the difference in mean weight loss was clinically relevant, highlighting the importance of addressing severe persistent pain in obese patients undertaking weight management programmes.

Weight-loss interventions for overweight/obese adults with chronic musculoskeletal pain: a mixed methods systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this mixed methods review is to develop an aggregated synthesis of qualitative and quantitative data on weight-loss interventions for overweight/obese adults with chronic musculoskeletal pain in an attempt to derive conclusions and recommendations useful for clinical practice and policy decision making.The objective of the quantitative component of this review is to quantify the effectiveness of weight-loss interventions on weight, pain and physical and/or psychosocial function in overweight/obese adults with chronic musculoskeletal pain.The objectives of the qualitative component of this review are to explore the perceptions and experiences of overweight/obese adults with chronic musculoskeletal pain of the link between their weight and pain, and the effectiveness and appropriateness of weight-loss interventions and sustainability of weight-loss efforts.

Open all hours: a qualitative exploration of open visiting in a hospice.

Over the past 20 years, visiting policies within adult care settings have progressed from strictly enforced times to more flexible arrangements. The Scottish Commission for the Regulation of Care (SCRC, 2003) advocates open visiting in hospices, which allows access at all times of day. However, little research has been carried out to investigate the assumption that an 'open visiting' policy in a hospice benefits patients and carers and improves the quality of care. This article describes the first strand of a qualitative exploratory study designed to evaluate the impact that open visiting has on patients and the multidisciplinary team in a hospice. A purposive sample of ten inpatients was interviewed. Data were analysed thematically. Patients acknowledged the benefits of contact with family and friends, such as maintaining links with the outside world and improvement in mood. However, they also reported that visitors could be intrusive and, depending on the nature of the relationship, were not always sensitive to cues that the patient was tiring or in pain. Patients indicated a need for more control of visiting arrangements, particularly related to timing, visitor numbers and restrictions on who could visit. These data will contribute to the second strand of the study which involves interviewing multidisciplinary team members.

Diagnosis of a rare source of upper extremity symptoms in a healthy woman after weight lifting.

STUDY DESIGN: Resident's case problem. BACKGROUND: The popularity of weight training has increased dramatically during the past 20 years. With the increase in popularity of weight training, the rate of injury has also increased dramatically. The types of injuries range from benign to life threatening. DIAGNOSIS: The patient was a 21-year-old woman originally referred for pelvic pain who presented with new complaints of right upper extremity swelling, discomfort, and cyanosis after recently beginning a comprehensive weight-lifting program. Additional signs, including paresthesias decreased pulses, and venous distension, warranted a timely referral by the physical therapist bavk to the referring physician. DISCUSSION: The primary injury in this case report was hypothesized to have been induced by the recent start of a weight-lifting program, with no other significant contributing risk factors. A comprehensive examination by the physical therapist revealed clinical signs of an upper extremity deep vein thrombosis, leading to a same-day referral back to the referring physician. Further research, resulting in a clinical decision rule for upper extremity deep vein thrombosis or estimates of diagnostic accuracy of clinical signs and symptoms, would improve the diagnostic process.