Integrated clinical pathways for lower limb orthopaedic surgeries: An updated systematic review.

OBJECTIVE: The objective of the study was to comprehensively synthesise the components of integrated clinical pathways (ICPs) and post-operative outcomes of patients undergone total hip and knee arthroplasty (THA & TKA) and hip fracture surgeries. BACKGROUND: Previous systematic reviews examined components and effectiveness of ICPs for lower limb joint replacement and hip fracture surgeries. DESIGN AND METHODS: An updated systematic review guided by the Whittemore and Knafl (2005) framework. Electronic databases, Ovid MEDLINE, EBSCOhost-CINAHL, the Cochrane Reviews and Trails, EMBASE and PubMed, were searched from 2007 to 31 January 2021. Due to the heterogeneity of the methods and data collection tools of included studies, pooling of the quantitative data was not possible. Therefore, the included studies were synthesised and presented narratively under subthemes of arthroplasty and hip fracture surgeries. The PRISMA checklist for systematic reviews was used. RESULTS: Twenty-four studies met selection criteria with 11 examined ICPs for hip fracture and 13 for the THA and TKA. Twenty-one ICPs were reviewed, and 33 components were extracted. The most frequently included components for hip fracture subgroup were 'discharge disposition arrangement' and 'dedicated personnel and resources'. 'Exercise plan' and 'pain management' were for the arthroplasty subgroup. A significant reduction in the length of stay and post-operative complications were associated with the ICPs. Results were mixed for the effectiveness of ICPs in reducing unplanned hospital admissions, mortality rates, post-operative complications and hospital costs. CONCLUSION: The number of ICP components varied across studies. This review could not recommend a one size-fits-all ICP that could be adapted for use for patients undergoing hip fracture and joint replacement surgeries. RELEVANCE FOR CLINICAL PRACTICE: This review identified research evidence-based components considered as essential for the inclusion in ICP's for hip fracture and arthroplasty surgeries. Further research is suggested to determine the patient experience and healthcare providers' acceptance of ICPs.

Consistency of pediatric pain ratings between dyads: an updated meta-analysis and metaregression.

Accurate assessment of pediatric pain remains a challenge, especially for children who are preverbal or unable to communicate because of their health condition or a language barrier. A 2008 meta-analysis of 12 studies found a moderate correlation between 3 dyads (child-caregiver, child-nurse, and caregiver-nurse). We updated this meta-analysis, adding papers published up to August 8, 2021, and that included intraclass correlation/weighted kappa statistics (ICC/WK) in addition to standard correlation. Forty studies (4,628 children) were included. Meta-analysis showed moderate pain rating consistency between child and caregiver (ICC/WK = 0.51 [0.39-0.63], correlation = 0.59 [0.52-0.65], combined = 0.55 [0.48-0.62]), and weaker consistency between child and health care provider (HCP) (ICC/WK = 0.38 [0.19-0.58], correlation = 0.49 [0.34-0.55], combined = 0.45; 95% confidence interval 0.34-0.55), and between caregiver and HCP (ICC/WK = 0.27 [-0.06 to 0.61], correlation = 0.49 [0.32 to 0.59], combined = 0.41; 95% confidence interval 0.22-0.59). There was significant heterogeneity across studies for all analyses. Metaregression revealed that recent years of publication, the pain assessment tool used by caregivers (eg, Numerical Rating Scale, Wong-Baker Faces Pain Rating Scale, and Visual Analogue Scale), and surgically related pain were each associated with greater consistency in pain ratings between child and caregiver. Pain caused by surgery was also associated with improved rating consistency between the child and HCP. This updated meta-analysis warrants pediatric pain assessment researchers to apply a comprehensive pain assessment scale Patient-Reported Outcomes Measurement Information System to acknowledge psychological and psychosocial influence on pain ratings.

Integrating Health Coaching With a Medical Fitness Program to Treat Chronic Health Conditions.

Medical fitness and health/wellness coaching (HWC) are emerging health care trends but potential synergistic effects are yet to be studied. PURPOSE: To determine the impact of integrating HWC within a community-based medical fitness program for patients with chronic health conditions. METHODS: A before and after clinical trial, examining 3 frequency levels of coaching sessions, with Journey-to-Wellness (J2W) participants (N = 1306) who were predominately female (76%), aged 12 to 87 years (mean ± SD = 53.54 ± 14.34 years), and referred by their health care provider. Over 3 months, J2W emphasized HWC, exercise, nutrition counseling, and group/interactive events. HWC averaged 4.4 ± 2.5 sessions and was analyzed at 3 levels (0-3; 4-6; 6+ sessions). Pre-post measures were Patient Health Questionnaire (PHQ-9), Positivity, General Anxiety Disorder (GAD-7), Dartmouth Quality of Life (QoL), Lifestyle Nutrition Behavior (LNB), Pain, exercise minutes, weight, waist circumference, and systolic/diastolic blood pressures. RESULTS: J2W intervention significantly (P < .01) improved all outcomes. Between 20% and 43% improvements were observed for PHQ-9, GAD-7, QoL while LNB improved 7.5%, and biometrics between 1% and 2.2%. Greater frequency of HWC enhanced J2W effect for PHQ-9 and QoL with weight and GAD approaching significance. CONCLUSION: J2W programming produced measurable improvement in health metrics, with greater HWC frequency adding to these beneficial effects, providing a powerful community-based health intervention.

Risk factors associated with paediatric unplanned hospital readmissions: a systematic review.

OBJECTIVE: To synthesise evidence on risk factors associated with paediatric unplanned hospital readmissions (UHRs). DESIGN: Systematic review. DATA SOURCE: CINAHL, EMBASE (Ovid) and MEDLINE from 2000 to 2017. ELIGIBILITY CRITERIA: Studies published in English with full-text access and focused on paediatric All-cause, Surgical procedure and General medical condition related UHRs were included. DATA EXTRACTION AND SYNTHESIS: Characteristics of the included studies, examined variables and the statistically significant risk factors were extracted. Two reviewers independently assessed study quality based on six domains of potential bias. Pooling of extracted risk factors was not permitted due to heterogeneity of the included studies. Data were synthesised using content analysis and presented in narrative form. RESULTS: Thirty-six significant risk factors were extracted from the 44 included studies and presented under three health condition groupings. For All-cause UHRs, ethnicity, comorbidity and type of health insurance were the most frequently cited factors. For Surgical procedure related UHRs, specific surgical procedures, comorbidity, length of stay (LOS), age, the American Society of Anaesthesiologists class, postoperative complications, duration of procedure, type of health insurance and illness severity were cited more frequently. The four most cited risk factors associated with General medical condition related UHRs were comorbidity, age, health service usage prior to the index admission and LOS. CONCLUSIONS: This systematic review acknowledges the complexity of readmission risk prediction in paediatric populations. This review identified four risk factors across all three health condition groupings, namely comorbidity; public health insurance; longer LOS and patients<12 months or between 13-18 years. The identification of risk factors, however, depended on the variables examined by each of the included studies. Consideration should be taken into account when generalising reported risk factors to other institutions. This review highlights the need to develop a standardised set of measures to capture key hospital discharge variables that predict unplanned readmission among paediatric patients.

Diversity and signature of small RNA in different bodily fluids using next generation sequencing.

BACKGROUND: Small RNAs are critical components in regulating various cellular pathways. These molecules may be tissue-associated or circulating in bodily fluids and have been shown to associate with different tumors. Next generation sequencing (NGS) on small RNAs is a powerful tool for profiling and discovery of microRNAs (miRNAs). RESULTS: In this study, we isolated total RNA from various bodily fluids: blood, leukocytes, serum, plasma, saliva, cell-free saliva, urine and cell-free urine. Next, we used Illumina's NGS platform and intensive bioinformatics analysis to investigate the distribution and signature of small RNAs in the various fluids. Successful NGS was accomplished despite the variations in RNA concentrations among the different fluids. Among the fluids studied, blood and plasma were found to be the most promising fluids for small RNA profiling as well as novel miRNA prediction. Saliva and urine yielded lower numbers of identifiable molecules and therefore were less reliable in small RNA profiling and less useful in predicting novel molecules. In addition, all fluids shared many molecules, including 139 miRNAs, the most abundant tRNAs, and the most abundant piwi-interacting RNAs (piRNAs). Fluids of similar origin (blood, urine or saliva) displayed closer clustering, while each fluid still retains its own characteristic signature based on its unique molecules and its levels of the common molecules. Donor urine samples showed sex-dependent differential clustering, which may prove useful for future studies. CONCLUSIONS: This study shows the successful clustering and unique signatures of bodily fluids based on their miRNA, tRNA and piRNA content. With this information, cohorts may be differentiated based on multiple molecules from each small RNA class by a multidimensional assessment of the overall molecular signature.

The development and testing of a skin tear risk assessment tool.

The aim of the present study is to develop a reliable and valid skin tear risk assessment tool. The six characteristics identified in a previous case control study as constituting the best risk model for skin tear development were used to construct a risk assessment tool. The ability of the tool to predict skin tear development was then tested in a prospective study. Between August 2012 and September 2013, 1466 tertiary hospital patients were assessed at admission and followed up for 10 days to see if they developed a skin tear. The predictive validity of the tool was assessed using receiver operating characteristic (ROC) analysis. When the tool was found not to have performed as well as hoped, secondary analyses were performed to determine whether a potentially better performing risk model could be identified. The tool was found to have high sensitivity but low specificity and therefore have inadequate predictive validity. Secondary analysis of the combined data from this and the previous case control study identified an alternative better performing risk model. The tool developed and tested in this study was found to have inadequate predictive validity. The predictive validity of an alternative, more parsimonious model now needs to be tested.

Identification of risk factors associated with the development of skin tears in hospitalised older persons: a case-control study.

To identify the risk factors associated with the development of skin tears in older persons four hundred and fifty three patients (151 cases and 302 controls) were enrolled in a case-control study in a 500-bed metropolitan tertiary hospital in Western Australia between December 2008 and June 2009. Case eligibility was defined by a skin tear on admission, which had occurred in the last 5 days; or, a skin tear developed during hospitalisation. For each case, two controls who did not have a skin tear and had been admitted within 1 day of the case, were also enrolled. Data collected from the nursing staff and inpatient medical records included characteristics known, or hypothesised, to be associated with increased vulnerability to skin tears. Data analysis included a series of multivariate stepwise regressions to identify a number of different potential explanatory models. The most parsimonious model for predicting skin tear development comprised six variables: ecchymosis (bruising); senile purpura; haematoma; evidence of a previously healed skin tear; oedema; and inability to reposition oneself independently. The ability of these six characteristics to predict who among older patients could subsequently develop a skin tear now needs to be determined by a prospective study.

Association between self-report pain ratings of child and parent, child and nurse and parent and nurse dyads: meta-analysis.

AIM: This paper is a report of a meta-analysis to investigate the association between self-report pain ratings for the dyads of child and parent, child and nurse and parent and nurse. BACKGROUND: Existing research has shown conflicting results with regard to agreements of self-report pain ratings between the three dyads. DATA SOURCES: The CINAHL, Medline, Ovid and PsycINFO databases were searched using keyword, such as 'children/adolescents', 'parents/nurses', 'pain assessment', 'pain ratings', 'association' and 'agreement'. Studies published in English in or after 1990 were included. METHODS: Meta-analysis methodology was applied to 12 pain assessment studies published between 1990 and 2007 which met the inclusion criteria. In the 12 studies a common effect size was estimated using the Pearson's correlation coefficient. Therefore, a fixed-effects model was chosen for this meta-analysis. RESULTS: We found moderate summary effect sizes between self-reported pain ratings for the dyad of child and parent (r = 0.64) and the child and nurse dyad (r = 0.58) and a weak summary effect size of r = 0.49 for the dyad of parent and nurse. The summarized effect sizes for each of the three dyads varied across the studies. A test of homogeneity (Q-statistic) indicated that all effect size estimates were not homogeneous. CONCLUSION: Parents' and nurses' perceptions of children's pain should only be considered as estimates rather than expressions of the pain experienced, and not the same as children's self-reports. There is a need for education on selection of appropriate pain assessment scales in relation to the age and development of the child.

Restricted fetal growth and lung development: a morphometric analysis of pulmonary structure.

Intrauterine growth restriction (IUGR) in humans increases the risk of lung disease and impaired function suggesting that adverse intra-uterine conditions can alter lung development. We hypothesized that placental restriction (PR) of fetal growth would alter lung structure in late gestation. PR involved removal of implantation sites in pre-pregnant ewes. Normal (n = 7) and PR (n = 11) fetuses were delivered at day 140 gestation. Lungs were fixed by tracheal infusion, processed and analyzed by morphometry. PR reduced ponderal index (PI) of lambs by 13%, increased lung volume:body weight (BW) (19%), and decreased the proportion of lung volume that comprised parenchyma from 86.5(2.6)% to 76.7(2.1)% with no change in absolute volume of non-parenchyma. Within the parenchyma, PR increased the proportion comprising airspace from 42.0(2.2)% to 55.5(1.7)% with smaller (-13%) more dense (18%) airsacs/alveoli present. The overall effect was a reduction in total gas-exchange surface density (-10%). Lung wet-weight and volume, parenchymal volume, gas-exchange tissue, and airspace volumes and gas-exchange surface area correlated positively with BW and crown-rump length (CRL) for all animals. The relative lung weight and volume correlated negatively with BW, CRL, and lung weight:BW with PI. Lung weight, lung volume, parenchymal volume, airspace perimeter, percent of parenchymal gas-exchange tissue, gas-exchange surface density, and area correlated positively with PI. The results indicate increased sparing of lung growth but with increasing structural changes, predominantly within lung parenchyma, with increasing growth restriction. Structural alterations associated with PR and poor fetal growth may be important in the pathogenesis of impaired lung function associated with IUGR.