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This study assessed Australian clinical practice guidelines for life-limiting index conditions for the extent to which they acknowledged comorbidities and framed management recommendations within the context of older age and reduced life expectancy. A comprehensive search identified current, evidence-based Australian guidelines for chronic life-limiting conditions directed at general practitioners. Guideline content was analysed qualitatively before comorbidity acknowledgements were quantified using a 17-item checklist. Full guidelines were quality appraised using AGREE-II. Ten documents covering chronic obstructive pulmonary disease, heart failure, cancer pain, dementia and palliative care in aged care were identified. Most guidelines addressed one 'comorbid' condition and prompted clinicians to consider patient quality of life and personal preferences. Fewer addressed burden of treatment and half suggested modifying treatments to account for limited life expectancy, age or time horizon to benefit. Half warned of potential adverse drug interactions. Guidelines were of moderate to very high quality. Guidelines naturally prioritised their index condition, directing attention to only the most common comorbidities. However, there may be scope to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the 'guiding principles' approach now emerging internationally from organisations such as the American Geriatrics Society in response to increasing multimorbidity prevalence and evidence limitations. General practitioners provide frontline care for a growing number of patients with multimorbidity, which may involve a life-limiting, progressive condition. Most guidelines for life-limiting conditions acknowledge comorbidity; however, there may be missed opportunities to warn clinicians on the potential for inappropriate polypharmacy, drug–drug interactions, and guideline-imposed treatment burden. Guidelines might consider incorporating 'guiding principles' of multimorbidity care and reframing management in the context of reduced life expectancy. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care. Methods: Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies. Results: Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk. Conclusions: GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient's unique circumstances, and useable knowledge of each individual's capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships. [ABSTRACT FROM AUTHOR]

Chronic lower-limb lymphoedema disrupts physical and mental health and requires labour-intensive therapies. This review synthesised evidence on the impact of exercise therapy on sufferer quality of life and symptom experience, concluding that exercise may improve strength, fitness, function, and decrease fatigue. It might also improve quality of life and subjective symptom scores, or at least have no negative impact. Existing studies are heterogenous in terms of size and exercise type, intensity, and frequency. Larger, more coordinated trials of longer duration are required in the future. [ABSTRACT FROM AUTHOR]

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast‐acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre‐hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base. [ABSTRACT FROM AUTHOR]

Context: The use of peer support as a faculty development technique to improve clinical teaching is uncommon in medical education, despite the benefits of situating learning in the workplace. The authors therefore conducted a broad search seeking theoretical and empirical literature describing peer support strategies for clinical teachers in health care workplaces. This included descriptive and non‐experimental studies that are often excluded from reviews. The review aimed to identify and assess existing initiatives and to synthesise key challenges and benefits. Methods: An integrative literature review was undertaken (2004–2017), based on searches of eight international electronic databases and targeted manual searches. Key concepts, elements and models were mapped using an iterative, constant comparative method. An evaluative framework, drawing on previous research, informed conclusions regarding the quality of evidence. Results: From a pool of 5735 papers, 34 met the inclusion criteria. The majority referred to studies conducted in the USA (59%) and in the medical profession (71%). Analysis revealed a trend towards using a collaborative model (56%), voluntary participation (59%), and direct workplace observation by a peer clinician (68%). Design features of the peer support strategy were commonly reported (65%), with half providing outcome measures (56%). Few papers reported on process evaluation (15%) or evidence of programme sustainability (15%). Despite logistical and time‐associated challenges, benefits accrued to individuals and the workplace, and included improved teaching practices. Embedding the peer support strategy into routine organisational practice proved effective. Conclusions: The results indicated that a workplace‐based peer support model is an acceptable and effective faculty development strategy for health care clinical teachers. Conceptualising workplace‐based peer support via a sociocultural model that acknowledges the significance of educational design, peers as collaborators and the importance of workplace context and culture is emphasised. Future research should focus on clarification studies informed by contemporary models of faculty development, in which factors impacting the health care workplace are considered. By reviewing the literature, Campbell et al. highlight how collaborative relationships and workplace connections with peers offer an under‐utilized resource for effectively improving teaching expertise. [ABSTRACT FROM AUTHOR]

Background: Searching for topics within large biomedical databases can be challenging, especially when topics are complex, diffuse, emerging or lack definitional clarity. Experimentally derived topic search filters offer a reliable solution to effective retrieval; however, their number and range of subject foci remain unknown. Objectives: This systematic scoping review aims to identify and describe available experimentally developed topic search filters. Methods: Reports on topic search filter development (1990‐) were sought using grey literature sources and 15 databases. Reports describing the conception and prospective development of a database‐specific topic search and including an objectively measured estimate of its performance ('sensitivity') were included. Results: Fifty‐four reports met inclusion criteria. Data were extracted and thematically synthesised to describe the characteristics of 58 topic search filters. Discussion: Topic search filters are proliferating and cover a wide range of subjects. Filter reports, however, often lack clear definitions of concepts and topic scope to guide users. Without standardised terminology, filters are challenging to find. Information specialists may benefit from a centralised topic filter repository and appraisal checklists to facilitate quality assessment. Conclusion: Findings will help information specialists identify existing topic search filters and assist filter developers to build on current knowledge in the field. [ABSTRACT FROM AUTHOR]

This systematic review sought to identify whether health care reforms led to improvement in the emergency department (ED) length of stay (LOS) and elective surgery (ES) access in Australia, Canada, New Zealand, and the United Kingdom. The review was registered in the PROSPERO database (CRD42015016343), and nine databases were searched for peer-reviewed, English-language reports published between 1994 and 2014. We also searched relevant ''grey'' literature and websites. Included studies were checked for cited and citing papers. Primary studies corresponding to national and provincial ED and ES reforms in the four countries were considered. Only studies from Australia and the United Kingdom were eventually included, as no studies from the other two countries met the inclusion criteria. The reviewers involved in the study extracted the data independently using standardized forms. Studies were assessed for quality, and a narrative synthesis approach was taken to analyze the extracted data. The introduction of health care reforms in the form of time-based ED and ES targets led to improvement in ED LOS and ES access. However, the introduction of targets resulted in unintended consequences, such as increased pressure on clinicians and, in certain instances, manipulation of performance data. [ABSTRACT FROM AUTHOR]

Background: Reports from patients on seeing or hearing a dead relative or dreaming a highly significant dream at the end of life can be perplexing for health professionals who may wonder how best to respond. Aim: The aim of this study was to systematically review the literature on deathbed phenomena (DBP), and provide suggestions for a clinical response to dying patients’ recounts of these hard-to-explain phenomena. Methods: The authors searched for relevant studies which reported on DBP within a palliative care context. Eligibility criteria were established, a review process was employed and a narrative synthesis approach was used to interpret the data. Results: In total, eight papers met the inclusion criteria. Reported prevalence of DBP ranged from 24–51% with common themes described. Distinguishing between DBP and hallucinations was discussed, requiring very different clinical responses. Phenomena were timed most often in the last hours or days before death. Experiencing a DBP was, in most cases, deeply meaningful, bringing comfort, peace and reassurance. Health professionals were not surprised to hear of a DBP, but were not always well prepared to respond appropriately. Conclusions: Rather than simply dismissing DBP as medication related or the physiological effects of dying, the significance of these events and the comfort afforded by them to patients and carers should be recognised. Disclosure of DBP may enable health professionals to discuss more spiritual and existential concerns, which have the potential to offer hope, meaning and connection. We propose strategies and approaches for strengthening compassionate clinical practice in this area. [ABSTRACT FROM AUTHOR]

Background: Obesity and musculoskeletal pain are strongly related, but there is emerging evidence that body fat, not body weight, may be a better indicator of risk. There is, therefore, a need to determine if body fat is associated with musculoskeletal pain as it may improve management strategies. The aim of this systematic review was to investigate the association between body fat and musculoskeletal pain.Methods: Seven electronic databases were searched from inception to 8th January 2018. Cross-sectional and longitudinal studies investigating the association between measures of body fat and musculoskeletal pain were included. All included articles were assessed for methodological rigour using the Epidemiology Appraisal Instrument. Standardised mean differences (SMDs) and effect estimates were pooled for meta-analysis.Results: A total of 10,221 citations were identified through the database searching, which after abstract and full-text review, yielded 28 unique articles. Fourteen studies were included in the meta-analyses, which found significant cross-sectional associations between total body fat mass and widespread pain (SMD 0.49, 95% CI 0.37-0.61, p < 0.001). Individuals with low-back pain and knee pain had a higher body fat percentage than asymptomatic controls (SMD 0.34, 95% CI 0.17-0.52, p < 0.001 and SMD 0.18, 95% CI 0.05-0.32, p = 0.009, respectively). Fat mass index was significantly, albeit weakly, associated with foot pain (SMD 0.05, 95% CI 0.03-0.06, p < 0.001). Longitudinal studies (n = 8) were unsuitable for meta-analysis, but were largely indicative of elevated body fat increasing the risk of incident and worsening joint pain. There was conflicting evidence for an association between body fat percentage and incident low-back pain (3 studies, follow-up 4-20 years). Increasing knee pain (1 study) and incident foot pain (2 studies) were positively associated with body fat percentage and fat mass index. The percentage of items in the EAI graded as 'yes' for each study ranged from 23 to 85%, indicating variable methodological quality of the included studies.Conclusions: This systematic review and meta-analysis identified positive cross-sectional associations between increased body fat and widespread and single-site joint pain in the low-back, knee and foot. Longitudinal studies suggest elevated body fat may infer increased risk of incident and worsening joint pain, although further high-quality studies are required. [ABSTRACT FROM AUTHOR]