Search

ObjectiveImplementation strategies, such as new models of service delivery, are needed to address evidence practice gaps. This paper describes the process of developing and operationalising a new model of service delivery to implement recommended care for people with knee osteoarthritis (OA) in a primary care setting.MethodsThree development stages occurred concurrently and iteratively. Each stage considered the healthcare context and was informed by stakeholder input. Stage 1 involved the design of a new model of service delivery (PARTNER). Stage 2 developed a behavioural change intervention targeting general practitioners (GPs) using the behavioural change wheel framework. In stage 3, the ‘Care Support Team’ component of the service delivery model was operationalised.ResultsThe focus of PARTNER is to provide patients with education, exercise and/or weight loss advice, and facilitate effective self-management through behavioural change support. Stage 1 model design: based on clinical practice guidelines, known evidence practice gaps in current care, chronic disease management frameworks, input from stakeholders and the opportunities and constraints afforded by the Australian primary care context, we developed the PARTNER service-delivery model. The key components are: (1) an effective GP consultation and (2) follow-up and ongoing care provided remotely (telephone/email/online resources) by a ‘Care Support Team’. Stage 2 GP behavioural change intervention: a multimodal behavioural change intervention was developed comprising a self-audit/feedback activity, online professional development and desktop software to provide decision support, patient information resources and a referral mechanism to the ‘Care Support Team’. Stage 3 operationalising the ‘care support team’—staff recruited and trained in evidence-based knee OA management and behavioural change methodology.ConclusionThe PARTNER model is the result of a comprehensive implementation strategy development process using evidence, behavioural change theory and intervention development guidelines. Technologies for scalable delivery were harnessed and new primary evidence was generated as part of the process.Trial registration number ACTRN12617001595303 (UTN U1111-1197-4809)

ObjectivesMusculoskeletal pain is a leading cause of disability globally. In geographically and socioeconomically diverse countries, such as Australia, care seeking when someone experiences musculoskeletal pain is varied and potentially influenced by their individual characteristics, access to practitioners or perceived trustworthiness of information. This study explored how consumers currently access healthcare, how well it is trusted and if sociodemographic factors influenced healthcare utilisation.DesignAnonymous online observational survey.SettingAustralia.ParticipantsA convenience sample of 831 community-based individuals (18+ years).Outcome measuresDescriptive analyses and generalised estimating equations were used to quantify healthcare-seeking behaviours, sources and trust of health information for (A) first-contact practitioners, (B) medical practitioners, and (C) other sources of information.ResultsOf the 761 respondents, 73% were females, 54% resided in capital cities. 68% of respondents had experienced pain or injury in more than one lower limb joint. Despite this, more than 30% of respondents only sought help when there had not been natural resolution of their pain. Physiotherapists had the highest odds of being seen, asked and trusted for healthcare information. The odds of seeking care from general practitioners were no higher than seeking information from an expert website. Older individuals and women exhibited higher odds of seeking, asking and trusting health information.ConclusionIntelligible and trustworthy information must be available for consumers experiencing lower limb pain. Individuals, particularly younger people, are seeking information from multiple, unregulated sources. This suggests that healthcare professionals may need to invest time and resources into improving the trustworthiness and availability of healthcare information to improve healthcare quality.

IntroductionThis protocol outlines the rationale, design and methods for the process and feasibility evaluations of the primary care management on knee pain and function in patients with knee osteoarthritis (PARTNER) study. PARTNER is a randomised controlled trial to evaluate a new model of service delivery (the PARTNER model) against ‘usual care’. PARTNER is designed to encourage greater uptake of key evidence-based non-surgical treatments for knee osteoarthritis (OA) in primary care. The intervention supports general practitioners (GPs) to gain an understanding of the best management options available through online professional development. Their patients receive telephone advice and support for OA management by a centralised, multidisciplinary ‘Care Support Team’. We will conduct concurrent process and feasibility evaluations to understand the implementation of this new complex health intervention, identify issues for consideration when interpreting the effectiveness outcomes and develop recommendations for future implementation, cost effectiveness and scalability.Methods and analysisThe UK Medical Research Council Framework for undertaking a process evaluation of complex interventions and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks inform the design of these evaluations. We use a mixed-methods approach including analysis of survey data, administrative records, consultation records and semistructured interviews with GPs and their enrolled patients. The analysis will examine fidelity and dose of the intervention, observations of trial setup and implementation and the quality of the care provided. We will also examine details of ‘usual care’. The semistructured interviews will be analysed using thematic and content analysis to draw out themes around implementation and acceptability of the model.Ethics and disseminationThe primary and substudy protocols have been approved by the Human Research Ethics Committee of The University of Sydney (2016/959 and 2019/503). Our findings will be disseminated to national and international partners and stakeholders, who will also assist with wider dissemination of our results across all levels of healthcare. Specific findings will be disseminated via peer-reviewed journals and conferences, and via training for healthcare professionals delivering OA management programmes. This evaluation is crucial to explaining the PARTNER study results, and will be used to determine the feasibility of rolling-out the intervention in an Australian healthcare context.Trial registration numberACTRN12617001595303; Pre-results.

A systematic review of randomised controlled trials. To determine the effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injuries (SCIs). The inclusion criteria contained 22 pairs of key interventions and outcomes. Each intervention and outcome was considered independently such that 22 brief reviews were conducted and summarised in this one paper. The interventions included hand, wheelchair, seated mobility, fitness, strength and gait training, as well as electrical stimulation, passive movements, stretch, cycling, exercise and transcutaneous electrical nerve stimulation (TENS). Interventions were compared with no or sham treatment, usual care or another physiotherapy intervention. The primary outcome for each review was one of the following: seated mobility, wheelchair mobility, hand function, gait, voluntary strength, joint mobility, fitness and pain. Data were extracted to determine mean between-group differences or risk ratios (95% confidence interval). Where possible, results were pooled in meta-analyses and the strength of evidence rated using Grading of Recommendations Assessment, Development and Evaluation. Thirty-eight randomised controlled trials met the inclusion criteria and were relevant to 15 of the brief reviews. The following four interventions were clearly effective: fitness, hand and wheelchair training as well as TENS; however, the strength of evidence was not high for any of these interventions. None of the other interventions were clearly effective. There is initial evidence to support four physiotherapy interventions, but there is still a long way to go to put a strong evidence base to the range of physiotherapy interventions commonly used to manage people with SCI.

The objective of this study was to determine the inter-rater reliability and validity of using a telephone-based version of the spinal cord injury–secondary conditions scale (SCI–SCS). A psychometric study was conducted. The study was conducted in Royal North Shore Hospital, Sydney, Australia. Forty people with a complete or an incomplete spinal cord injury. Inter-rater reliability was tested by comparing the telephone-based version of the SCI–SCS administered on two different days by two different telephone assessors. Validity was tested by comparing the telephone-based version of the SCI–SCS with the paper-based version of the SCI–SCS. The median (interquartile range) age and time since injury were 54 (48–63) years and 28 (14–35) years, respectively. The intraclass correlation coefficient (95% confidence interval) reflecting the agreement between the telephone-based version of the SCI–SCS administered on two different days by two different assessors was 0.96 (0.93–0.98). The corresponding value reflecting agreement between the telephone-based assessment and the paper-based assessment was 0.90 (0.83–0.95). The telephone-based version of the SCI–SCS is a simple and a quick questionnaire to administer that has both inter-rater reliability and validity. It may be useful as a way to screen for secondary health conditions in low- and middle-income countries where it is not always feasible to provide routine face-to-face follow-ups and where literacy may be a problem.

Mixed retrospective-prospective cohort study. To determine 2-year survival following discharge from hospital after spinal cord injury in Bangladesh. Bangladesh. Medical records were used to identify all patients admitted in 2011 with a recent spinal cord injury to the Centre for Rehabilitation of the Paralysed, a large Bangladeshi hospital that specialises in care of people with spinal cord injury. Patients or their families were subsequently visited or contacted by telephone in 2014. Vital status and, where relevant, date and cause of death were determined by verbal autopsy. 350 of 371 people admitted with a recent spinal cord injury in 2011 were discharged alive from hospital. All but eleven were accounted for two years after discharge (97% follow-up). Two-year survival was 87% (95% CI 83% to 90%). Two-year survival of those who were wheelchair-dependent was 81% (95% CI 76% to 86%). The most common cause of death was sepsis due to pressure ulcers. In Bangladesh, approximately one in five people with spinal cord injury who are wheelchair-dependent die within two years of discharge from hospital. Most deaths are due to sepsis from potentially preventable pressure ulcers.

Within-participant randomised controlled trial. To determine whether strength training combined with usual care increases strength in partially paralysed muscles of people with recent spinal cord injury (SCI) more than usual care alone. SCI units in Australia and India. Thirty people with recent SCI undergoing inpatient rehabilitation participated in this 12-week trial. One of the following muscle groups was selected as the target muscle group for each participant: the elbow flexors, elbow extensors, knee flexors or knee extensors. The target muscle on one side of the body was randomly allocated to the experimental group and the same muscle on the other side of the body was allocated to the control group. Strength training was administered to the experimental muscle but not to the control muscle. Participants were assessed at baseline and 12 weeks later. The primary outcome was maximal isometric muscle strength, and the secondary outcomes were spasticity, fatigue and participants’ perception of function and strength. There were no dropouts, and participants received 98% of the training sessions. The mean (95% confidence interval (CI)) between-group difference for isometric strength was 4.3 Nm (1.9–6.8) with a clinically meaningful treatment effect of 2.7 Nm. The mean (95% CI) between-group difference for spasticity was 0.03/5 points (−0.25 to 0.32). Strength training increases strength in partially paralysed muscles of people with recent SCI, although it is not clear whether the size of the treatment effect is clinically meaningful. Strength training has no deleterious effects on spasticity.

A diagnostic accuracy study.The objective was to determine the ability of people with SCI to accurately self-report S4-5 sensory and motor function.Outpatient clinic, Sydney, Australia.A consecutive series of thirty-four people who had sustained a SCI more than 1 year before the study, and who were attending an outpatient medical clinic were recruited. They were assessed on two occasions. On the first occasion, ability to self-report S4-5 sensory and motor function was assessed with four questions. On the second occasion, a rehabilitation physician performed a physical examination to determine participants' S4-5 sensory and motor function. The rehabilitation physician was unaware of the results of participants' self-report. Participants' self-reports were compared with results from the physical examination using likelihood ratios.The likelihood ratios (95% CI) associated with a positive response to the sensory and motor questions were 1.92 (1.0-3.6) and 2.4 (1.2-4.9), respectively. The likelihood ratios associated with a negative response to the sensory and motor questions were 0.1 (0.0-0.6) and 0.4 (0.1-1.2), respectively.People with SCI are reasonably accurate at self-reporting S4-5 sensory and motor function, although there is a high rate of false positives for S4-5 motor in those with motor levels below T10. In some situations it may be appropriate to use self-report rather than a physical examination to determine S4-5 sensory and motor function.

Mixed retrospective-prospective cohort study. To determine psychological and socioeconomic status, complications and quality of life in people with spinal cord injuries (SCI) after discharge from a hospital in Bangladesh. Bangladesh. All patients admitted in 2011 with a recent SCI to a hospital in Bangladesh were identified. Patients were interviewed by telephone in 2014 using translated versions of the SF12, the SCI Secondary Conditions Scale, the Centre for Epidemiologic Studies Depression Scale (CESDS) and the Participation Component of the WHODAS. Questions were also asked about employment, living and financial situation, and opportunities to get out of bed and out of the house. Data were stratified by ability to walk on discharge. A total of 350 people were discharged with a recent SCI in 2011. By 2014, 55 had died. Of those still living, 283 were interviewed (96% follow-up rate). At the time of interview, 47% of participants were employed. One-quarter (26%) of those who were wheelchair-dependent had a pressure ulcer. The mean (s.d.) scores for the Mental and Physical Component of the SF12 were 32.0 points (5.5) and 35.8 points (3.9), respectively. The median (interquartile range) scores for the SCI Secondary Conditions Scale, CESDS and WHODAS for those who were wheelchair-dependent were 15% (10 to 19), 11 points (9 to 18) and 26 points (23 to 26), respectively. Many people with SCI in Bangladesh are house-bound, unemployed, living in poverty and have pressure ulcers. They experience moderate rates of depression and report limited quality of life.

The overall quality and delivery of patient care is becoming increasingly important, especially in those diagnosed with cancer. Multidisciplinary clinics are a valuable adjunct to this, but patients may not fully understand or comprehend all that is said to them. The use of audiotaping consultations has been studied in some settings, but not in head and neck cancer clinics. We report on a series of 50 consecutive head and neck patients to determine their views on the value of this facility. Thirty-nine patients (78 per cent) utilized the opportunity, of which 36 patients (92 per cent) found it beneficial. Over three quarters of the patients who used the facility thought that medical staff could benefit and learn from the tape recording. We recommend that audiotaping becomes a standard part of the multidisciplinary head and neck oncology clinic, helping to improve the overall quality of patient care.

Cross-sectional descriptive study of randomised controlled trials involving physical interventions for people with spinal cord injury (SCI) published between 2003 and 2013. To determine how well randomised controlled trials of physical interventions for people with SCI adhere to the CONSORT (Consolidated Standards of Reporting Trials) guidelines. University of Sydney, Sydney, NSW, Australia. A search was conducted for randomised controlled trials designed to determine the effectiveness of physical interventions for people with SCI published between 2003 and 2013. The CONSORT checklist for the reporting of randomised controlled trials was used to determine how well each trial adhered to the guidelines. Two independent reviewers rated each trial on each of the 37 items on the CONSORT checklist using the following criteria: ‘fully reported’, ‘partially reported’, ‘not reported’, ‘not relevant’ or ‘not reported but unable to determine if relevant/done’. Fifty-three trials were retrieved. None of the trials ‘fully reported’ all items of the CONSORT guidelines. The median (IQR) number of items that was ‘fully reported’ was 11/37 (7–20). The median (IQR) number of items that was either ‘fully reported’ or ‘not relevant’ or ‘not reported but unable to determine if relevant’ was 20/37 items (17–27). The reporting of randomised controlled trials in SCI is only partially adhering to the CONSORT guidelines. Journals can help lift standards by encouraging authors of randomised controlled trials to adhere to the CONSORT guidelines.

Monoclonal antibodies, directed against a 58-kDa Babesia bigemina merozoite antigen that reacted strongly with immune sera from experimentally and naturally infected cattle in Western blots, were used to develop a competitive-inhibition enzyme-linked immunosorbent assay (ELISA). As based on the testing of 70 antibody-positive sera from experimentally infected cattle and 166 antibody-negative sera collected in non-endemic areas of Australia, the sensitivity and specificity of the ELISA were 95.7% and 97.0%, respectively. In sequential sera collected from six calves during the course of experimental B. bigemina infections the ELISA detected seroconversion at about 10 days post-inoculation. The specificity of the ELISA was not affected by the presence of antibodies to B. bovis, Anaplasma marginale or Theileria buffeli. In 42 sera from cattle experimentally infected with B. bovis but negative for B. bigemina the specificity of the ELISA was 95.2%. The use of a competitive-inhibition ELISA format detecting only antibody directed against a single epitope on the 58-kDa antigen appears to have overcome many of the specificity problems that have plagued serological tests for B. bigemina in the past. The test should be useful for epidemiology studies, particularly in areas where B. bovis and B. bigemina have overlapping distributions.

The purpose of this study was to determine the amount and type of equipment prescribed to aid mobility and self-care for patients with spinal cord injuries (SCI) in Australia and to determine how frequently the equipment is used 1 year later and whether patients are satisfied with it.A consecutive series of 61 patients admitted for rehabilitation to two Sydney SCI units were recruited. All mobility and self-care equipment worth more than $AU50 prescribed by therapists before patients' discharge was recorded. This included wheelchairs, commodes, shower chairs, hoists, electric beds, pressure-relieving cushions, bed mattresses, slideboards, walking aids, orthoses, electrical stimulation systems and other pieces of notable exercise equipment. Patients were interviewed 1 year later and asked about each piece of equipment they had been prescribed. Specifically, they were asked about how frequently they had used each piece of equipment and whether they were satisfied with it. Data were analysed using descriptive statistics.Three hundred and fourteen pieces of equipment, including 68 wheelchairs, were prescribed for the 61 patients. Most of the equipment (226/314) was used more than 20 times in the 2 months preceding the 1-year review. Most patients were satisfied or highly satisfied with the majority of equipment prescribed, although patients were very dissatisfied or only partly dissatisfied with 18/314 pieces of equipment.Patients were generally satisfied with the equipment they were prescribed. There was a small amount of equipment prescribed that was not used 1 year later or with which patients were dissatisfied.

Cutaneous sensation deteriorates with age. It is not known if this change is consistent over the entire hand or if sensation is affected by changes in skin mechanics. Cutaneous perceptual thresholds were tested at eight sites in the glabrous skin and two in the hairy skin of both hands in 70 subjects (20–88 years), five male and five female per decade, using calibrated von Frey filaments, two-point discrimination, and texture discrimination. Venous occlusion at the wrist (40 ± 10 mmHg) and moisturizer were used to alter skin mechanics. Cutaneous thresholds increased significantly with age (p

A randomized controlled trial. To determine the effectiveness of electrical stimulation (ES)-evoked muscle contractions superimposed on progressive resistance training (PRT) for increasing voluntary strength in the quadriceps muscles of people with spinal cord injuries (SCI). Sydney, Australia. A total of 20 people with established SCI and neurologically induced weakness of the quadriceps muscles participated in the trial. Participants were randomized between experimental and control groups. Volunteers in the experimental group received ES superimposed on PRT to the quadriceps muscles of one leg thrice weekly for 8 weeks. Participants in the control group received no intervention. Assessments occurred at the beginning and at the end of the 8-week period. The four primary outcomes were voluntary strength (Nm) and endurance (fatigue ratio) as well as the performance and satisfaction items of the Canadian Occupational Performance Measure (COPM; points). The between-group mean differences (95% confidence interval (CI)) for voluntary strength and endurance were 14 Nm (1–27; P=0.034) and 0.1 (−0.1 to 0.3; P=0.221), respectively. The between-group median differences (95% CI) for the performance and satisfaction items of the COPM were 1.7 points (−0.2 to 3.2; P=0.103) and 1.4 points (−0.1 to 4.6; P=0.058), respectively. ES superimposed on PRT improves voluntary strength, although there is uncertainty about whether the size of the treatment effect is clinically important. The relative effectiveness of ES and PRT is yet to be determined.

Assessor-blinded within-subject randomized controlled trial.To determine the effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury.Community, Australia.A total of 20 people with tetraplegia living in the community had one ankle randomized to a control group and the other to an experimental group. Carers administered passive movements to participants' experimental ankles for 10 min, 10 times a week for 6 months. The control ankles were left untreated. The primary outcome was passive ankle dorsiflexion range of motion.Adherence was high (mean adherence rate of 96%). Ankle dorsiflexion range of motion decreased by a mean (s.d.) of 2 degrees (4) in control ankles and increased by 2 degrees (4) in experimental ankles. The mean (95% confidence interval, CI) effect on ankle dorsiflexion range of motion was 4 degrees (95% CI, 2-6 degrees ).Regular passive movements have small effects on ankle joint mobility. It is unclear if these effects are clinically worthwhile.

Introduction In low-income and middle-income countries, people with spinal cord injury (SCI) are vulnerable to life-threatening complications after they are discharged from hospital. The aim of this trial is to determine the effectiveness and cost-effectiveness of an inexpensive and sustainable model of community-based care designed to prevent and manage complications in people with SCI in Bangladesh. Methods and analysis A pragmatic randomised controlled trial will be undertaken. 410 wheelchair-dependent people with recent SCI will be randomised to Intervention and Control groups shortly after discharge from hospital. Participants in the Intervention group will receive regular telephone-based care and three home visits from a health professional over the 2 years after discharge. Participants in the Control group will receive standard care, which does not involve regular contact with health professionals. The primary outcome is all-cause mortality at 2 years. Recruitment started on 12 July 2015 and the trial is expected to take 5 years to complete. Ethics and dissemination Ethical approval was obtained from the Institutional Ethics Committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval, the NHMRC National Statement on Ethical Conduct in Human Research (2007), the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95) and the Bangladesh Guidance on Clinical Trial Inspection (2011). The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. Trial registration numbers ACTRN12615000630516, U1111-1171-1876.

Editorial Note on: Response to the letter of Professor Vafa Rahimi-Movaghar titled ‘Self-report versus sensory-motor examination of anus in spinal cord injured patients’

The posterior cruciate ligament, situated near the center of the knee, functions as the basic stabilizer and is located close to the axis of motion. We diagnosed and repaired thirty-two consecutive acute tears of the posterior cruciate ligament associated with tears of medial or lateral-compartment ligaments, or of both. Of the twenty-nine knees that we could evaluate, twenty-three demonstrated a 2+ to 3+ positive abduction or adduction stress test done in maximum extension and a positive anterior drawer test done in maximum internal rotation, while only nine had a definitely positive posterior drawer test. In all knees we repaired the tears, using the medial meniscus as a graft in nine knees in which the repair of the posterior cruciate ligament did not produce immediate adequate stability at operation. Five to sixteen years after operation, twenty of these twenty-nine knees were available for evaluation. The objective results were good in thirteen, fair in four, and poor in three.

The gross chemical composition of material extracted from yeast cell walls with various solvents or enzymes was studied. Attempts were made to locate these materials in situ by comparing electron micrographs of negatively stained and sectioned cell walls with those of the residues of the extraction procedures. There are at least two chemically distinct species of carbohydrate polymers which can be extracted with strong alkali: one yielding mainly mannose and some amino acid on hydrolysis and the other yielding mannose, glucose and amino acid. The alkali-insoluble material also yielded glucose, mannose and amino acid on hydrolysis but the glucose/mannose ratio was much higher. It was shown that none of these polymers constituted a physically distinct layer in the yeast cell wall. However, there does seem to be a region at the outer surface with distinctive properties. This is not fibrillar in nature and after extraction with ethylene diamine forms a double-layered structure. Materials which react with KMnO4 to produce an electron-dense material are located throughout the wall but tend to be concentrated in the outer and inner regions. Procedures which remove this material also remove up to 80% of the mannose, 40% of the glucose and 35 % of the protein of the original wall material. It was shown that fibres do not constitute a major fraction of the normal cell wall, except possibly in the region of the bud scars but may be produced fairly readily by certain specific treatments. The classical view of the yeast cell wall with the structural integrity being maintained by a fibrous network of β 1–3, 1–6 linked glucose residues is challenged and evidence to support an alternative view is presented.

Uberblick uber die Entwicklung von Sn- und P-Bronze – Entwicklung, Eigenschaften und Verwendung ternarer und quaternarer Sn-Legierungen – Eigenschaften und Verwendbarkeit zinnarmer Lote – Uberblick uber die Verfahren zur elktrolytischen Abscheidung von Uberzugen aus Sn und Sn-Legierungen – Eigenschaften und Verwendung elektrolytisch abgeschiedener Sn-, Sn-Zn-, Sn-Cu-, Sn-Cd-Uberzugen. New developments in tin usage Survey on the development of Sn- and P-bronze, properties and usage of ternary and quaternary Sn-alloys – properties and usage of solders containing less than the usual percentage of tin – survey on latest processes for electrodepositing of coatings of Sn and Sn-alloys – properties and usage of electrodeposited coatings of Sn, Sn, + Zn, Sn + Cu, Sn + Pb and Sn + Cd.