Technology acceptance of digital devices for home use: Qualitative results of a mixed methods study.

Objective: Digital devices have demonstrated benefits to patients with chronic and neurodegenerative diseases. But when patients use medical devices in their homes, the technologies have to fit into their lives. We investigated the technology acceptance of seven digital devices for home use. Methods: We conducted 60 semi-structured interviews with participants of a larger device study on their views on the acceptability of seven devices. Transcriptions were analysed using qualitative content analysis. Results: Based on the unified theory of acceptance and use of technology, we evaluated effort, facilitating conditions, performance expectancy and social influence of each device.In the effort category, five themes emerged: (a) the hassle to use the device; (b) its usability; (c) comfort; (d) disturbance to daily life; and (e) problems during usage. Facilitating conditions consisted of five themes: (a) expectations regarding a device; (b) quality of the instructions; (c) insecurities with usage; (d) possibilities of optimization; and (e) possibilities to use the device longer. Regarding performance expectancy, we identified three themes: (a) insecurities with the performance of a device; (b) feedback; and (c) motivation for using a device. In the social influence category, three themes emerged: (a) reactions of peers; (b) concerns with the visibility of a device; and (c) concerns regarding data privacy. Conclusions: We identify key factors that determine the acceptability of medical devices for home use from the participants' perspective. These include low effort of use, minor disruptions to their daily lives and good support from the study team.

Variation of implant use in A1 and A2 trochanteric hip fractures : a study from the National Hip Fracture Database of England and Wales.

AIMS: Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. METHODS: We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. RESULTS: We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. CONCLUSION: Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity.Cite this article: Bone Jt Open 2022;3(10):741-745.

Factors that influence mental health of university and college students in the UK: a systematic review.

BACKGROUND: Worsening mental health of students in higher education is a public policy concern and the impact of measures to reduce transmission of COVID-19 has heightened awareness of this issue. Preventing poor mental health and supporting positive mental wellbeing needs to be based on an evidence informed understanding what factors influence the mental health of students. OBJECTIVES: To identify factors associated with mental health of students in higher education. METHODS: We undertook a systematic review of observational studies that measured factors associated with student mental wellbeing and poor mental health. Extensive searches were undertaken across five databases. We included studies undertaken in the UK and published within the last decade (2010-2020). Due to heterogeneity of factors, and diversity of outcomes used to measure wellbeing and poor mental health the findings were analysed and described narratively. FINDINGS: We included 31 studies, most of which were cross sectional in design. Those factors most strongly and consistently associated with increased risk of developing poor mental health included students with experiences of trauma in childhood, those that identify as LGBTQ and students with autism. Factors that promote wellbeing include developing strong and supportive social networks. Students who are prepared and able to adjust to the changes that moving into higher education presents also experience better mental health. Some behaviours that are associated with poor mental health include lack of engagement both with learning and leisure activities and poor mental health literacy. CONCLUSION: Improved knowledge of factors associated with poor mental health and also those that increase mental wellbeing can provide a foundation for designing strategies and specific interventions that can prevent poor mental health and ensuring targeted support is available for students at increased risk.

Regional variation in the provision of major trauma services for the older injured patient.

INTRODUCTION: The establishment of national trauma networks have resulted in significant benefits to injured patients. Older people are the majority of major trauma patients and there is need to study variations in care and performance against clinical metrics for them. We aim to describe this patient group in terms of injury, demographics, episode of care assessment and variation between component regions of the Major Trauma Network of England and Wales. METHOD: The Trauma Audit and Research Network (TARN) database was analysed from April 2017 to March 2019. Patients aged 65 years and above with injury severity score (ISS) greater than eight were selected for analysis. Patients were compared by care pathway in terms of first and second treating hospitals and by demographics, injury mechanism, severity, physiology at arrival to hospital (including Glasgow Coma Score (GCS)) and mortality, where known, at discharge. RESULTS: Fifty-three thousand three hundred and forty-seven older injured patients (median age 82.5 years and 58.2% female), were treated in 165 hospitals within the 17 regional trauma networks over the two-year study period. Aside from GCS and gender, all other patient characteristics were significantly different between networks and specifically, a large variation between the network with the highest proportion of older patients (60.4%) and that with a preponderance of younger patients (40.2%) is seen. 84% of cases were due to a fall <2 m and 36.7% of cases had a brain injury. 73.5% of cases had one or more comorbidities. DISCUSSION: We have increased the understanding of how older patients contribute to and are managed by a national trauma service. We have demonstrated variation in numbers and patient characteristics throughout regional trauma networks. We have detailed the whole patient episode, allowing us to comment on disparities in management such as senior review and access to specialist clinical care settings. Older patients dominate United Kingdom major trauma and considerable variations and shortfalls have been identified. Work is needed to focus on the whole clinical episode for these patients both to improve outcome and patient experience but to also to ensure sustainable clinical care in a resource deplete era.

Internal fixation implants for intracapsular hip fractures in older adults.

BACKGROUND: Hip fractures are a major healthcare problem, presenting a huge challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. The majority of hip fractures are treated surgically. This review evaluates evidence for types of internal fixation implants used in joint-preserving surgery for intracapsular hip fractures. OBJECTIVES: To determine the relative effects (benefits and harms) of different implants for the internal fixation of intracapsular hip fractures in older adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Proquest Dissertations and Theses, and National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing implants used for internal fixation of fragility intracapsular proximal femoral fractures in older adults. Types of implants were smooth pins (these include pins with fold-out hooks), screws, or fixed angle plates. We excluded studies in which all or most fractures were caused by specific pathologies other than osteoporosis or were the result of a high energy trauma. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. One review author extracted data and assessed risk of bias which was checked by a second review author. We collected data for seven outcomes: activities of daily living (ADL), delirium, functional status, health-related quality of life (HRQoL), mobility, mortality (reported within four months of surgery as early mortality, and at 12 months since surgery), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE. MAIN RESULTS: We included 38 studies (32 RCTs, six quasi-RCTs) with 8585 participants with 8590 intracapsular fractures. The mean ages of participants in the studies ranged from 60 to 84 years; 73% were women, and 38% of fractures were undisplaced. We report here the findings of the four main comparisons, which were between different categories of implants. We downgraded the certainty of the outcomes for imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide), study limitations (e.g. high or unclear risks of bias), and inconsistency (when we noted substantial levels of statistical heterogeneity). Smooth pins versus fixed angle plate (four studies, 1313 participants) We found very low-certainty evidence of little or no difference between the two implant types in independent mobility with no more than one walking stick (1 study, 112 participants), early mortality (1 study, 383 participants), mortality at 12 months (2 studies, 661 participants), and unplanned return to theatre (3 studies, 736 participants). No studies reported on ADL, delirium, functional status, or HRQoL. Screws versus fixed angle plates (11 studies, 2471 participants) We found low-certainty evidence of no clinically important differences between the two implant types in functional status using WOMAC (MD -3.18, 95% CI -6.35 to -0.01; 2 studies, 498 participants; range of scores from 0 to 96, lower values indicate better function), and HRQoL using EQ-5D (MD 0.03, 95% CI 0.00 to 0.06; 2 studies, 521 participants; range -0.654 (worst), 0 (dead), 1 (best)). We also found low-certainty evidence showing little or no difference between the two implant types in mortality at 12 months (RR 1.04, 95% CI 0.83 to 1.31; 7 studies, 1690 participants), and unplanned return to theatre (RR 1.10, 95% CI 0.95 to 1.26; 11 studies, 2321 participants). We found very low-certainty evidence of little or no difference between the two implant types in independent mobility (1 study, 70 participants), and early mortality (3 studies, 467 participants). No studies reported on ADL or delirium. Screws versus smooth pins (seven studies, 1119 participants) We found low-certainty evidence of no or little difference between the two implant types in mortality at 12 months (RR 1.07, 95% CI 0.85 to 1.35; 6 studies, 1005 participants; low-certainty evidence). We found very low-certainty evidence of little or no difference between the two implant types in early mortality (3 studies, 584 participants) and unplanned return to theatre (5 studies, 862 participants). No studies reported on ADL, delirium, functional status, HRQoL, or mobility. Screws or smooth pins versus fixed angle plates (15 studies, 3784 participants) In this comparison, we combined data from the first two comparison groups. We found low-certainty evidence of no or little difference between the two groups of implants in mortality at 12 months (RR 1.04, 95% CI.083 to 1.31; 7 studies, 1690 participants) and unplanned return to theatre (RR 1.02, 95% CI 0.88 to 1.18; 14 studies, 3057 participants). We found very low-certainty evidence of little or no difference between the two groups of implants in independent mobility (2 studies, 182 participants), and early mortality (4 studies, 850 participants). We found no additional evidence to support the findings for functional status or HRQoL as reported in 'Screws versus fixed angle plates'. No studies reported ADL or delirium. AUTHORS' CONCLUSIONS: There is low-certainty evidence that there may be little or no difference between screws and fixed angle plates in functional status, HRQoL, mortality at 12 months, or unplanned return to theatre; and between screws and pins in mortality at 12 months. The limited and very low-certainty evidence for the outcomes for which data were available for the smooth pins versus fixed angle plates comparison, as well as the other outcomes for which data were available for the screws and fixed angle plates, and screws and pins comparisons means we have very little confidence in the estimates of effect for these outcomes. Additional RCTs would increase the certainty of the evidence. We encourage such studies to report outcomes consistent with the core outcome set for hip fracture, including long-term quality of life indicators such as ADL and mobility.

Too Cool? Hip Fracture Care and Maintaining Body Temperature.

INTRODUCTION: Patients with hip fractures can become cold during the perioperative period despite measures applied to maintain warmth. Poor temperature control is linked with increasing complications and poorer functional outcomes. There is generic evidence for the benefits of maintaining normothermia, however this is sparse where specifically concerning hip fracture. We provide the first comprehensive review in this population. SIGNIFICANCE: Large studies have revealed dramatic impact on wound infection, transfusion rates, increased morbidity and mortality. With very few studies relating to hip fracture patients, this review aimed to capture an overview of available literature regarding hypothermia and its impact on outcomes. RESULTS: Increased mortality, readmission rates and surgical site infections are all associated with poor temperature control. This is more profound, and more common, in older frail patients. Increasing age and lower BMI were recognized as demographic factors that increase risk of hypothermia, which was routinely identified within modern day practice despite the use of active warming. CONCLUSION: There is a gap in research related to fragility fractures and how hypothermia impacts outcomes. Inadvertent intraoperative hypothermia still occurs routinely, even when active warming and cotton blankets are applied. No studies documented temperature readings postoperatively once patients had been returned to the ward. This is a point in the timeline where patients could be hypothermic. More studies need to be performed relating to this area of surgery.

Age and the distribution of major injury across a national trauma system.

BACKGROUND: Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution. OBJECTIVES: There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between. METHODS: The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England. RESULTS: About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs. CONCLUSIONS: Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures.

INTRODUCTION: Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population. METHOD: Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients. RESULTS: We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications. DISCUSSION: There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture. CONCLUSION: Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient's nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Nutrition in Hip Fracture Units: Contemporary Practices in Preoperative Supplementation.

INTRODUCTION: Patients with hip fractures pose a significant burden on health services. Malnutrition, frailty, and cognitive impairment are common, and key to addressing the needs of this vulnerable patient group is nutrition optimization, including reduction in arbitrary nil by mouth (NBM) perioperative regimens. In order to understand current practices, we characterize preoperative nutrition in a regional hip fracture population. METHODS: Prospective data were submitted to the National Hip Fracture Database by 6 hospitals in the north east of England over a 6-month period. Patients were stratified by preoperative nutritional intake, frailty, and cognitive function. RESULTS: In all, 24.2% (n = 205) patients received no oral intake at all preoperatively; 15.3% of NBM patients were at risk of malnutrition; and 6.9% were malnourished at the time of assessment. Median time to surgery for NBM patients was 16.75 hours, and 6.34% of patients were fasted with no intake for >36 hours. In all, 6.5% (n = 44) of patients with an Abbreviated Mental Test Score (AMTS) of 8 or above were deemed to be at risk of malnutrition at admission, compared to 11.3% (n = 50) of patients with an AMTS of 7 or below. The NBM patients had similar mean Rockwood (4.97) and AMTS (6.51) scores to patients given oral nutrition. CONCLUSION: We have demonstrated contemporary preoperative nutritional practices in the management of over 800 hip fracture patients. Contrary to perception, nutrition practices vary little when stratified for age, cognition frailty, or comorbid burden. We have identified widespread prolonged NBM fasting and undersupplementation in patients sustaining hip fracture across a region. This work suggests a need to focus less on patient factors and more on systematic practices.

Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol.

INTRODUCTION: As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented. MATERIALS AND METHODS: Systematic review of preoperative IVP administration in patients presenting with a hip fracture. RESULTS: Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia. DISCUSSION: The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.