Anthropogenic modification of forests means only 40% of remaining forests have high ecosystem integrity.

Many global environmental agendas, including halting biodiversity loss, reversing land degradation, and limiting climate change, depend upon retaining forests with high ecological integrity, yet the scale and degree of forest modification remain poorly quantified and mapped. By integrating data on observed and inferred human pressures and an index of lost connectivity, we generate a globally consistent, continuous index of forest condition as determined by the degree of anthropogenic modification. Globally, only 17.4 million km2 of forest (40.5%) has high landscape-level integrity (mostly found in Canada, Russia, the Amazon, Central Africa, and New Guinea) and only 27% of this area is found in nationally designated protected areas. Of the forest inside protected areas, only 56% has high landscape-level integrity. Ambitious policies that prioritize the retention of forest integrity, especially in the most intact areas, are now urgently needed alongside current efforts aimed at halting deforestation and restoring the integrity of forests globally.

Leadership capabilities of physiotherapy leaders in Ireland: Part 2. Clinical specialists and advanced physiotherapy practitioners.

Background: Investigation of the leadership capabilities of physiotherapy managers found that they report predominantly demonstrating capabilities associated with the human resource and structural frames. However, little is known about the leadership capabilities of clinical specialists and advanced physiotherapy practitioners (APPs) who also are identified as having responsibility for leadership. Objective: To explore clinical specialists´ and APPs' perceptions of their leadership capabilities and compare them with the reported leadership capabilities of physiotherapy managers. Methods: Semi-structured interviews were conducted with a purposive sample of 17 physiotherapy clinical specialists and APPs from a range of practice settings across Ireland. The interviews were analyzed using template analysis and the coding template was based on the Bolman and Deal Leadership framework. Results: The participants described demonstrating leadership capabilities associated with each of the four leadership frames. However, the language used by the clinical specialists/APPs suggested that they work predominantly through the human resource frame. Structural frame capabilities were reported by the clinical specialists/APPs and there were some differences to those reported by the managers. In keeping with the reported leadership capabilities of the physiotherapy managers, the employment of capabilities associated with the political frame varied between participants and symbolic frame capabilities were underused. Conclusion: There are many similarities in the self-reported leadership capabilities of managers and clinical specialists/APPs. However, differences were also noted. Both cohorts of physiotherapy leaders may benefit from specific development programs to develop leadership capabilities associated with the political and symbolic frames.

Randomized trial of near-infrared spectroscopy for personalized optimization of cerebral tissue oxygenation during cardiac surgery.

BACKGROUND: We assessed whether a near-infrared spectroscopy (NIRS)-based algorithm for the personalized optimization of cerebral oxygenation during cardiopulmonary bypass combined with a restrictive red cell transfusion threshold would reduce perioperative injury to the brain, heart, and kidneys. METHODS: In a randomized controlled trial, participants in three UK centres were randomized with concealed allocation to a NIRS (INVOS 5100; Medtronic Inc., Minneapolis, MN, USA)-based 'patient-specific' algorithm that included a restrictive red cell transfusion threshold (haematocrit 18%) or to a 'generic' non-NIRS-based algorithm (standard care). The NIRS algorithm aimed to maintain cerebral oxygenation at an absolute value of > 50% or at > 70% of baseline values. The primary outcome for the trial was cognitive function measured up to 3 months postsurgery. RESULTS: The analysis population comprised eligible randomized patients who underwent valve or combined valve surgery and coronary artery bypass grafts using cardiopulmonary bypass between December 2009 and January 2014 ( n =98 patient-specific algorithm; n =106 generic algorithm). There was no difference between the groups for the three core cognitive domains (attention, verbal memory, and motor coordination) or for the non-core domains psychomotor speed and visuo-spatial skills. The NIRS group had higher scores for verbal fluency; mean difference 3.73 (95% confidence interval 1.50, 5.96). Red cell transfusions, biomarkers of brain, kidney, and myocardial injury, adverse events, and health-care costs were similar between the groups. CONCLUSIONS: These results do not support the use of NIRS-based algorithms for the personalized optimization of cerebral oxygenation in adult cardiac surgery. CLINICAL TRIAL REGISTRATION: http://www.controlled-trials.com , ISRCTN 23557269.

Are lower levels of red blood cell transfusion more cost-effective than liberal levels after cardiac surgery? Findings from the TITRe2 randomised controlled trial.

OBJECTIVE: To assess the incremental cost and cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery. DESIGN: A within-trial cost-effectiveness analysis with a 3-month time horizon, based on a multicentre superiority randomised controlled trial from the perspective of the National Health Service (NHS) and personal social services in the UK. SETTING: 17 specialist cardiac surgery centres in UK NHS hospitals. PARTICIPANTS: 2003 patients aged >16 years undergoing non-emergency cardiac surgery with a postoperative haemoglobin of <9 g/dL. INTERVENTIONS: Restrictive (transfuse if haemoglobin <7.5 g/dL) or liberal (transfuse if haemoglobin <9 g/dL) threshold during hospitalisation after surgery. MAIN OUTCOME MEASURES: Health-related quality of life measured using the EQ-5D-3L to calculate quality-adjusted life years (QALYs). RESULTS: The total costs from surgery up to 3 months were £17 945 and £18 127 in the restrictive and liberal groups (mean difference is -£182, 95% CI -£1108 to £744). The cost difference was largely attributable to the difference in the cost of red blood cells. Mean QALYs to 3 months were 0.18 in both groups (restrictive minus liberal difference is 0.0004, 95% CI -0.0037 to 0.0045). The point estimate for the base-case cost-effectiveness analysis suggested that the restrictive group was slightly more effective and slightly less costly than the liberal group and, therefore, cost-effective. However, there is great uncertainty around these results partly due to the negligible differences in QALYs gained. CONCLUSIONS: We conclude that there is no clear difference in the cost-effectiveness of restrictive and liberal thresholds for red blood cell transfusion after cardiac surgery. TRIAL REGISTRATION NUMBER: ISRCTN70923932; Results.

Ability of physiotherapists to undertake evidence-based practice steps: a scoping review.

BACKGROUND: Evidence-based practice (EBP) is promoted to ensure quality of care. However, analysis of the skill of physiotherapists in undertaking the steps of EBP, or the impact of EBP on the work of physiotherapists is limited. OBJECTIVES: To conduct a scoping review into physiotherapists performing the steps of EBP. DATA SOURCE: Literature concerning the skill of physiotherapists in EBP between 1990 and June 2013 was searched using AMED, Academic Search Complete, CINAHL, PubMed, ERIC, PEDRO and EMBASE databases. STUDY SELECTION: Twenty-five studies (six qualitative, one mixed methods and 18 quantitative) were selected. DATA EXTRACTION AND SYNTHESIS: Quantitative and qualitative data were extracted using two appraisal tools to analyse each of the five steps of EBP. RESULTS: Limited evidence exists to show that physiotherapists undertake the full EBP process. Despite formulating clinical questions and acquiring literature-based evidence, the drivers for conducting literature or evidence searches have not been clarified. The critical appraisal step was mainly assessed in the form of recognition of statistical terms. Only examples of guideline usage support the reflective final assessment step. Physiotherapists report using their peers and other trusted sources in preference to literature, primarily due to time but also due to divergence between the literature-based evidence and other evidence that they use and value (tacit knowledge). A positive impact of EBP on patient outcomes is lacking. CONCLUSIONS: Understanding the information needs of physiotherapists may be necessary before adoption of the EBP process. The use of professional networks may offer a better means to identify knowledge gaps and translate acquired knowledge into practice, rather than focusing on individual skills in EBP.

Towards improving service delivery in screening and intervention services in community pharmacies: a case study of an alcohol IBA service.

BACKGROUND: Previous studies have demonstrated positive outcomes from a range of pharmacy public health services, but barriers to delivery remain. This paper explores the processes of delivering an alcohol screening and intervention service, with a view to improving service delivery. METHODS: A mixed-methods, multi-perspective approach was used, comprising in-pharmacy observations and recording of service provision, follow-up interviews with service users and interactive feedback sessions with service providers. RESULTS: Observations and recordings indicate that staff missed opportunities to offer the service and that both availability and delivery of the service were inconsistent, partly owing to unavailability of trained staff and service restrictions. Most service users gave positive accounts of the service and considered pharmacies to be appropriate places for this service. Respondents also described positive impacts, ranging from thinking more about alcohol consumption generally to substantial reductions in consumption. Key facilitators to service provision included building staff confidence and service champions. Barriers included commissioning issues and staff perception of alcohol as a sensitive topic. CONCLUSIONS: Findings support expansion of pharmacies' role in delivering public health services and highlight benefits of providing feedback to pharmacy staff on their service provision as a possible avenue for service improvement.

Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial.

OBJECTIVES: Data on costs associated with acute upper gastrointestinal bleeding (AUGIB) are scarce. We provide estimates of UK healthcare costs, indirect costs and health-related quality of life (HRQoL) for patients presenting to hospital with AUGIB. SETTING: Six UK university hospitals with >20 AUGIB admissions per month, >400 adult beds, 24 h endoscopy, and on-site access to intensive care and surgery. PARTICIPANTS: 936 patients aged ≥18 years, admitted with AUGIB, and enrolled between August 2012 and March 2013 in the TRIGGER trial of AUGIB comparing restrictive versus liberal red blood cell (RBC) transfusion thresholds. PRIMARY AND SECONDARY OUTCOME MEASURES: Healthcare resource use during hospitalisation and postdischarge up to 28  days, unpaid informal care, time away from paid employment and HRQoL using the EuroQol EQ-5D at 28  days were measured prospectively. National unit costs were used to value resource use. Initial in-hospital treatment costs were upscaled to a UK level. RESULTS: Mean initial in-hospital costs were £2458 (SE=£216) per patient. Inpatient bed days, endoscopy and RBC transfusions were key cost drivers. Postdischarge healthcare costs were £391 (£44) per patient. One-third of patients received unpaid informal care and the quarter in paid employment required time away from work. Mean HRQoL for survivors was 0.74. Annual initial inhospital treatment cost for all AUGIB cases in the UK was estimated to be £155.5 million, with exploratory analyses of the incremental costs of treating hospitalised patients developing AUGIB generating figures of between £143 million and £168 million. CONCLUSIONS: AUGIB is a large burden for UK hospitals with inpatient stay, endoscopy and RBC transfusions as the main cost drivers. It is anticipated that this work will enable quantification of the impact of cost reduction strategies in AUGIB and will inform economic analyses of novel or existing interventions for AUGIB. TRIAL REGISTRATION NUMBER: ISRCTN85757829 and NCT02105532.

Spatiotemporal trends of illegal activities from ranger-collected data in a Ugandan national park.

Within protected areas, biodiversity loss is often a consequence of illegal resource use. Understanding the patterns and extent of illegal activities is therefore essential for effective law enforcement and prevention of biodiversity declines. We used extensive data, commonly collected by ranger patrols in many protected areas, and Bayesian hierarchical models to identify drivers, trends, and distribution of multiple illegal activities within the Queen Elizabeth Conservation Area (QECA), Uganda. Encroachment (e.g., by pastoralists with cattle) and poaching of noncommercial animals (e.g., snaring bushmeat) were the most prevalent illegal activities within the QECA. Illegal activities occurred in different areas of the QECA. Poaching of noncommercial animals was most widely distributed within the national park. Overall, ecological covariates, although significant, were not useful predictors for occurrence of illegal activities. Instead, the location of illegal activities in previous years was more important. There were significant increases in encroachment and noncommercial plant harvesting (nontimber products) during the study period (1999-2012). We also found significant spatiotemporal variation in the occurrence of all activities. Our results show the need to explicitly model ranger patrol effort to reduce biases from existing uncorrected or capture per unit effort analyses. Prioritization of ranger patrol strategies is needed to target illegal activities; these strategies are determined by protected area managers, and therefore changes at a site-level can be implemented quickly. These strategies should also be informed by the location of past occurrences of illegal activity: the most useful predictor of future events. However, because spatial and temporal changes in illegal activities occurred, regular patrols throughout the protected area, even in areas of low occurrence, are also required.

Addition of motivational interventions to exercise and traditional physiotherapy: a review and meta-analysis.

BACKGROUND: Incontestable epidemiological trends indicate that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases. International guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. Motivational interventions to increase adherence and physical activity are not part of traditional physiotherapy for any condition. OBJECTIVE: To evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions. DATA SOURCES: A literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database using keywords and subject headings. STUDY SELECTION: Only randomised controlled trials comparing two or more arms, with one arm focused on motivational interventions influencing exercise and one control arm, were included. The search identified 493 titles, of which 14 studies (comprising 1504 participants) were included. DATA EXTRACTION: The principal investigator extracted data that were reviewed independently by another author. Methodological quality was assessed independently by two authors using the Cochrane Risk of Bias tool and the PEDro scale. Outcomes were measured at the level of impairment, activity limitation and participation restriction. The standardised mean difference between the control and intervention groups at follow-up time points was used as the mode of analysis. I2≤50% was used as the cut-off point for acceptable heterogeneity, above which a random effects model was applied. RESULTS: Exercise attendance was measured in six studies (n=378), and the results indicate that there was no significant difference in exercise attendance between the groups (Random effects model, standardised mean difference 0.33, 95% confidence interval -0.03 to 0.68, I2 62%). Perceived self-efficacy results were pooled from six studies (n=722), and a significant difference was found between the groups in favour of the interventions (Fixed effects model, standardised mean difference 0.71, 95% confidence interval 0.55 to 0.87, I2 41%). The results for levels of activity limitation were pooled (n=550), and a significant difference was found between the groups in favour of the interventions (REM, standardised mean difference -0.37, 95% confidence interval -0.65 to -0.08, I(2) 61%). LIMITATIONS: The majority of the included studies were of medium quality, and four studies were of low quality. Data were pooled from a wide variety of different populations and settings, increasing the assortment of study characteristics. CONCLUSIONS: Motivational interventions can help adherence to exercise, have a positive effect on long-term exercise behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory choice and the most beneficial length and type of intervention have not been defined, although all interventions showed benefits. There is a need to determine how practising physiotherapists currently optimise adherence, and their current levels of knowledge about motivational interventions. IMPLICATIONS OF KEY FINDINGS: The results indicate that motivational interventions are successful for increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice.

Direct access and patient/client self-referral to physiotherapy: a review of contemporary practice within the European Union.

BACKGROUND: Direct access refers to service users being able to refer themselves to physiotherapy without a third-party referral. It represents a model of practice supported globally by the profession, growing research evidence and health policy in some health systems. To the authors' knowledge, no research has been reported to ascertain the extent to which direct access is available within the physiotherapy profession within the European Union (EU). OBJECTIVES: To survey member organisations of the World Confederation for Physical Therapy (WCPT); establish the number of member states within the EU where it is possible for individuals seeking physiotherapy services to self-refer; describe the legislative/regulatory and reimbursement contexts in which physiotherapy services are delivered; examine if physiotherapy practice is different in member states where direct access is permitted compared with member states where direct access is not permitted; and to describe the barriers and facilitators to direct access perceived by member organisations of the WCPT. DESIGN: Cross-sectional, online survey using a purposive sample. PARTICIPANTS: Member organisations of the WCPT in the EU. RESULTS: Direct access is not available in all member states of the EU, despite the majority having legislation to regulate the profession, and entry-level education programmes that produce graduates with the requisite competencies. Key barriers perceived are those that can influence policy development, including the views of the medical profession and politicians. Support of service users and politicians, as well as professional autonomy, are seen as key facilitators. CONCLUSION: These results represent the first report of a comprehensive mapping of direct access to physiotherapy and contexts within the EU. In over half of member states, service users can self-refer to physiotherapists. These results provide insights to further individuals' understanding about the similarities and differences in working practices and service delivery factors, such as reimbursement across and within EU member states. The synergies between barriers and facilitators indicate the importance of targeted advocacy strategies in the introduction of direct access/self-referral to physiotherapy.

Randomised controlled trial of the efficacy of a high-fluoride gel self-applied by toothbrushing in children at high caries risk.

The primary objective of this clinical trial was to assess the caries-preventive efficacy of 2 years of twice weekly supervised brushing with a self-applied gel containing 12,500 ppm fluoride on schooldays compared with weekly supervised use in children at high caries risk (with prior caries experience on first permanent molars). The secondary objective was to assess efficacy compared with similar children who continued with their usual oral hygiene care. This was a single-centre, single-blind, randomised, parallel-groups trial comprising two test groups and one untreated control group. 1,075 pupils aged 12-13 years at baseline received a baseline and final examination 2 years later. For all children completing the trial no significant difference was found between groups. For children compliant with study protocol no significant difference was found in the primary outcome (D(1)FS caries increment), but significant differences were found between the three groups overall in the secondary outcome, D(3)FT caries increment, with a significant pairwise difference between control and twice per week gel brushing (29%, p = 0.023 D(3)FT visual + fibre-optic transillumination). Analysis of the relationship between number of gel applications and caries showed that children who brushed with the gel at least 60 times over a 2-year period developed significantly fewer carious lesions into dentine than children who followed their usual oral hygiene routine. Some caution is needed as greatest benefit was shown by compliant children. Where schools are co-operative, it is recommended that the gel be used twice a week within a school-based programme over a 2-year period.

Assessing the effectiveness of robot facilitated neurorehabilitation for relearning motor skills following a stroke.

A growing awareness of the potential for machine-mediated neurorehabilitation has led to several novel concepts for delivering these therapies. To get from laboratory demonstrators and prototypes to the point where the concepts can be used by clinicians in practice still requires significant additional effort, not least in the requirement to assess and measure the impact of any proposed solution. To be widely accepted a study is required to use validated clinical measures but these tend to be subjective, costly to administer and may be insensitive to the effect of the treatment. Although this situation will not change, there is good reason to consider both clinical and mechanical assessments of recovery. This article outlines the problems in measuring the impact of an intervention and explores the concept of providing more mechanical assessment techniques and ultimately the possibility of combining the assessment process with aspects of the intervention.

Reported analgesic and anaesthetic administration to rodents undergoing experimental surgical procedures.

A structured literature review was carried out to assess recent trends in the administration of analgesics and anaesthetics to laboratory rats and mice undergoing surgical procedures. The ScienceDirect database was used to systematically identify studies published in peer-reviewed journals over two periods (2000-2001 and 2005-2006), 86 studies from each time period were included in the review. The total number of animals that underwent surgery, species used, type of procedure, anaesthetic regimen and analgesic administration were noted for each study. There was an increase in the reported administration of systemic analgesics from 10% in 2000-2001 to 20% in 2005-2006. Buprenorphine was the most commonly reported analgesic in both periods (2000-2001: 78%, 2005-2006: 35%) and reporting the use of non-steroidal anti-inflammatory drugs increased from 11% to 53%. There was also a change in reported anaesthetic practices, notably a decrease in the use of pentobarbital and an increase in the use of isoflurane and ketamine/xylazine. Although reported administration of analgesics has increased and there has been some refinement in the selection of anaesthetic agents used, the findings of this review suggest that there is still significant scope for improvement with respect to the perioperative care of laboratory rodents.

The right to remain silent: a qualitative study of the medical and social ramifications of pregnancy disclosure for Gambian women.

OBJECTIVES: Control of infectious diseases in developing countries often requires using drugs that are contraindicated during pregnancy. Avoiding inadvertent exposure to drugs involves women (a) recognising pregnancy early, (b) disclosing the pregnancy to health workers and (c) using medicines in an informed manner. We explored these factors to inform and improve the process by which health workers provide care and treatment to pregnant women. DESIGN: Qualitative study. SETTING: The Gambia. POPULATION: Rural women and men. METHODS: We conducted 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants (TBAs). MAIN OUTCOME MEASURE: Pregnancy disclosure. RESULTS: Most women recognised early signs and symptoms of pregnancy and believed other people could easily do so. To avoid gossip, women hid their pregnancies and delayed antenatal care, even though husbands and TBAs insisted on attendance. Women acutely ill in early pregnancy hoped health workers would recognise pregnancy without explicit disclosure. Women said that they knew, and sought to avoid, some contraindicated drugs, but their knowledge was rudimentary. Health workers stressed the benefits, not the risks of prescribed drugs. CONCLUSIONS: Despite public health and clinical benefits of preventing and treating pregnancy infections, women were ill informed and pressurised into taking drugs. These ethical issues should be more widely addressed.

An economic evaluation of three physiotherapy treatments for non-specific neck disorders alongside a randomized trial.

OBJECTIVES: Cost-effectiveness and cost-utility analyses were conducted to compare advice and exercise plus manual therapy (MT) and advice and exercise plus pulsed shortwave diathermy (PSWD) with advice and exercise alone (A&E) in the treatment of non-specific neck disorders by experienced physiotherapists. METHODS: Between July 2000 and June 2002, 350 participants with neck disorders from 15 physiotherapy departments were randomized to: A&E (n = 115); MT (n = 114) and PSWD (n = 121). Outcome and resource-use data were collected using physiotherapist case report forms and participant self-complete questionnaires. Outcome measures were the Northwick Park Neck Pain Questionnaire (NPQ) and EuroQoL EQ-5D [used to derive quality-adjusted-life-year (QALY) utility scores]. Two economic viewpoints were considered (health care and societal). Cost-effectiveness acceptability curves were used to assess the probabilities of the interventions being cost-effective at different willingness-to-pay threshold values. RESULTS: Mean improvement in NPQ at 6 months was 11.5 in the A&E group, 10.2 in the MT group and 10.3 in the PSWD group; mean QALY scores were 0.362, 0.342 and 0.360, respectively. Mean health care costs were pound sterling105, pound sterling119 and pound sterling123 in the A&E, MT and PSWD groups, respectively. Mean societal costs were pound sterling373, pound sterling303 and pound sterling 338 in each group, respectively. Depending on the viewpoint and the outcome measure, A&E or MT were most likely to be the cost-effective interventions. PSWD was consistently the least cost-effective intervention. CONCLUSIONS: The cost-effective intervention is likely to be A&E or MT, depending on the economic perspective and preferred outcome, but not PSWD.

A dental workforce review for a Midlands Strategic Health Authority.

OBJECTIVE: To explore opportunities for workforce development in NHS general dental services (GDS) in Shropshire and Staffordshire. METHOD: Secondary data sources were supplemented with a primary survey of GDS practices to build up a profile of the existing GDS workforce and its current capacity. Attitudes and perceptions on current workforce issues and potential solutions were gathered using a second survey and explored further through other qualitative techniques including interviews and a focus group discussion. RESULTS: The results confirm that there is a shortage of dentists in the area, fuelled by multiple factors including the move from NHS to private work, the decision to retire early and a growing disillusionment with NHS policies and remuneration. Modelling of alternate approaches to future dental clinical needs highlighted the opportunity for meeting the consequent workforce demands through increased involvement of hygienists and therapists. CONCLUSIONS: This study has provided local evidence to inform dental service development in Shropshire and Staffordshire. It has provided a starting point for exploring new ways of working and will contribute towards a more effective implementation of new and evolving service strategies.

Determining Liverpool adolescents' beliefs and attitudes in relation to oral health.

Poor oral health is an important public health issue. Adolescents represent a challenging group in terms of oral health because they have vulnerable permanent teeth erupting at a time when they are establishing their independence from parental influence. Preventing oral disease by attempting to influence the behaviours that impact adversely on oral health requires an understanding of the attitudes and beliefs that underpin those behaviours. Very few studies have investigated adolescents' attitudes and beliefs in relation to dental issues. This study aimed to examine the attitudes and beliefs of adolescents towards dentistry and oral disease in order to inform future health promotion interventions. Data were collected through focus groups involving 22 13- to 14-year olds from selected secondary schools in Liverpool. A thematic analysis was applied to the data. The themes identified illustrated the attitudes and beliefs of adolescents in relation to oral health and demonstrated how adolescents justify and personally operationalize these attitudes and beliefs. A need to encourage this group to take action to perform oral health behaviours was demonstrated.

A cost consequences analysis of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care.

OBJECTIVE: Local steroid injections and community-based physiotherapy have been shown to be of similar benefit for treating shoulder pain presenting to primary care. This paper presents a cost consequences analysis of a prospective economic evaluation, conducted alongside a randomized clinical trial (RCT) of corticosteroid injections versus physiotherapy for new episodes of unilateral shoulder pain, to determine the economic implications of injection versus physiotherapy. METHODS: A pragmatic RCT with 207 patients randomized to either physiotherapy (n = 103) or local steroid injection (n = 104) was conducted. The resource inputs required were identified for each treatment arm in terms of capital, staff and consumables. These were measured for the period up to 6 months post-randomization. Outcome measures included shoulder disability, shoulder pain, global assessment of health change and the EQ5D, all at 6 months. A sensitivity analysis was performed around the general practitioner minor surgical fee. RESULTS: Analysis is presented on the 199 patients for which the general practice record review (101 physiotherapy, 98 injection) was available. The total mean costs, per patient, were 71.28 pound sterling for the injection group and 114.60 pound sterling for the physiotherapy group. The difference in average total cost per patient was 43.32 pound sterling (95% bootstrap confidence interval: 16.21 pound sterling, 68.03 pound sterling ). This is a statistically significant difference in cost. Outcome was similar in both groups across all measures following intervention. Smaller mean differences in cost were observed between the treatment groups in the sensitivity analysis, but the difference remained in favour of injection over physiotherapy. CONCLUSIONS: This study has shown, given similar clinical outcomes across the treatment groups, that corticosteroid injections were the cost-effective option for patients presenting with new episodes of unilateral shoulder pain in primary care.

Hip protectors--a survey of practice in Ireland.

When used appropriately and worn by the user, it has been established that hip protectors can reduce the risk of femoral fractures in older people who fall. While hip protectors receive increasing interest in the scientific literature, it is not clear how widely and appropriately they are being used in Ireland. This national survey aimed to investigate this practice. The survey yielded 185 responses from a variety of settings, response rate of 53%. It noted that only 18% of respondents actually used hip protectors for their clients/patients, despite the fact that the many of the participants in this survey were from nursing homes, where the evidence supports their use. It clearly identifies that a lack of knowledge about hip protectors is one barrier to their use, with 54% of participants reporting they were not aware of hip protectors and their value; but other factors, such as the suitability and compliance of older clients/patients and financial issues also impact on their use. In excess of 70% of respondents reported that financial restrictions influenced their prescription practice. While the majority of the participants were nurses, it is of note that the professional group most frequently involved in prescribing the use of hip protectors was physiotherapists and not nurses or doctors. National guidelines which both educate and advise on the use of hip protectors would lead to optimal use in the context of both clinical and cost effectiveness.