Explore the vast range of titles available.

Background To explore the health beliefs, experiences, treatment and expectations of people with chronic knee pain, and investigate if, how and why these change after taking part on an integrated exercise-based rehabilitation programme - Enabling Self-management and Coping with Arthritis knee Pain through Exercise, ESCAPE-knee pain . Methods Semi-structured interviews were conducted with people with chronic knee pain, before (n = 29) and after (n = 23) participation on the programme. Thematic analysis was used to document people's baseline health beliefs, attitudes and cognitions, and to see if how and why these changed after completing the programme. Results Initially people had poor understanding and negative, fatalistic beliefs about the management or prognosis for knee pain. Following the programme the majority of participants had positive experiences describing improvement in pain, physical and psychosocial functioning, greater knowledge and understanding of their condition and treatment options, and in their ability to use exercise to control symptoms. Beliefs about the causation and prognosis of knee pain were unchanged, but their concerns about possible dangers of exercise had decreased, they appreciated how exercise could reduce symptoms (treatment beliefs) and their confidence in their ability to use exercise to effect improvements (exercise self-efficacy) increased. These improvements were attributed to the content and structure of the programme, and the care and guidance of the physiotherapist. Several expressed a need for on-going support. Conclusions ESCAPE-knee pain appears to achieve improvements by increasing people's treatment belief in safety and the utility of exercise to control symptoms, rather than alteration in their beliefs about causation or prognosis. Trial Registration Current Controlled Trials ISRCTN94658828

Background Scaling-up and sustaining effective healthcare interventions is essential for improving healthcare; however, relatively little is known about these processes. In addition to quantitative experimental designs, we need approaches that use embedded, observational studies on practice-led, naturally occurring scale-up processes. There are also tensions between having adequately rigorous systems to monitor and evaluate scale-up well that are proportionate and pragmatic in practice. The study investigated the scale-up of an evidence-based complex intervention for knee and hip osteoarthritis (ESCAPE-pain) within ‘real-world’ settings by England’s 15 Academic Health Science Networks (AHSNs). Methods A pragmatic evaluation of the scale-up of ESCAPE-pain using the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance. The evaluation used routine monitoring data collected from April 2014 to December 2018 as part of a national scale-up programme. Results Between 2014 and 2018, ESCAPE-pain was adopted by over 110 clinical and non-clinical sites reaching over 9000 people with osteoarthritis. The programme showed sustained clinical effectiveness (pain, function and quality of life) and high levels of adherence (78.5% completing 75% of the programme) within a range of real-world settings. Seven hundred seventy people (physiotherapists and exercise professionals) have been trained to deliver ESCAPE-pain, and 84.1% of sites have continued to deliver the programme post-implementation. Conclusions ESCAPE-pain successfully moved from being an efficacious “research intervention” into an effective intervention within ‘real-world’ clinical and non-clinical community settings. However, scale-up has been a gradual process requiring on-going, dedicated resources over 5 years by a national network of Academic Health Science Networks (AHSNs). Whilst the collection of monitoring and evaluation data is critical in understanding implementation and scale-up, there remain significant challenges in developing systems sufficiently rigorous, proportionate and locally acceptable.

BackgroundThere is virtually no limit to the number of innovations being developed, tested and piloted at any one time to improve the quality and safety of care. The perennial problem is spreading innovations that are proven to be effective on a smaller scale or under controlled conditions. Much of the literature on spread refers to the important role played by external agencies in supporting the spread of innovations.Academic Health Science Networks and the spread of innovationExternal agencies can provide additional capacity and capabilities to adopter organisations, such as technical expertise, resources and tools to assist with operational issues. In England, the National Health Service (NHS) established 15 Academic Health Science Networks (AHSNs) to help accelerate the spread and adoption of innovation in healthcare. However, formal clinical-academic networks (such as AHSNs) themselves will not deliver positive, tangible outcomes on the ground (ie, evidence-based innovations embedded at scale across a system). This begs the question of how do AHSNs practically go about achieving this change successfully? We provide an AHSN’s perspective on how we conceptualise and undertake our work in leading implementation of innovation at scale.An AHSN\"s perspectiveOur approach is a collaborative process of widening understanding of the innovation and its implementation. At its core, the implementation and spread of innovation into practice is a collective social process. Healthcare comprises complex adaptive systems, where contexts need to be negotiated for implementation to be successful. As AHSNs, we aim to lead this negotiation through facilitating knowledge exchange and production across the system to mobilise the resources and collective action necessary for achieving spread.

OBJECTIVE Muscles are essential components of our sensorimotor system that help maintain balance and perform a smooth gait, but it is unclear whether arthritic damage adversely affects muscle sensorimotor function. Quadriceps sensorimotor function in patients with knee osteoarthritis (OA) was investigated, and whether these changes were associated with impairment of functional performance. METHODS Quadriceps strength, voluntary activation, and proprioceptive acuity (joint position sense acuity) were assessed in 103 patients with knee OA and compared with 25 healthy control subjects. In addition, their postural stability, objective functional performance (the aggregate time for four activities of daily living), and disabilities (Lequesne index) were also investigated. RESULTS Compared with the control subjects, the patients with knee OA had weaker quadriceps (differences between group mean 100N, CI 136, 63N), poorer voluntary activation (20% CI 13, 25%) that was associated with quadriceps weakness, and impaired acuity of knee joint position sense (1.28°, CI 0.84, 1.73°). As a group the patients were more unstable (p=0.0017), disabled (10, CI 7, 11), and had poorer functional performance (19.6 seconds, CI 14.3, 24.9 seconds). The most important predictors of disability were objective functional performance and quadriceps strength. CONCLUSIONS In patients with knee OA, articular damage may reduce quadriceps motoneurone excitability, which decreases voluntary quadriceps activation thus contributing to quadriceps weakness, and diminishes proprioceptive acuity. The arthrogenic impairment in quadriceps sensorimotor function and decreased postural stability was associated with reduced functional performance of the patients.

IntroductionKnee and hip osteoarthritis (OA) is a leading cause of disability worldwide. Therapeutic exercise is a recommended core treatment for people with knee and hip OA, however, the observed effect sizes for reducing pain and improving physical function are small to moderate. This may be due to insufficient targeting of exercise to subgroups of people who are most likely to respond and/or suboptimal content of exercise programmes. This study aims to identify: (1) subgroups of people with knee and hip OA that do/do not respond to therapeutic exercise and to different types of exercise and (2) mediators of the effect of therapeutic exercise for reducing pain and improving physical function. This will enable optimal targeting and refining the content of future exercise interventions.Methods and analysis Systematic review and individual participant data meta-analyses. A previous comprehensive systematic review will be updated to identify randomised controlled trials that compare the effects of therapeutic exercise for people with knee and hip OA on pain and physical function to a non-exercise control. Lead authors of eligible trials will be invited to share individual participant data. Trial-level and participant-level characteristics (for baseline variables and outcomes) of included studies will be summarised. Meta-analyses will use a two-stage approach, where effect estimates are obtained for each trial and then synthesised using a random effects model (to account for heterogeneity). All analyses will be on an intention-to-treat principle and all summary meta-analysis estimates will be reported as standardised mean differences with 95% CI.Ethics and disseminationResearch ethical or governance approval is exempt as no new data are being collected and no identifiable participant information will be shared. Findings will be disseminated via national and international conferences, publication in peer-reviewed journals and summaries posted on websites accessed by the public and clinicians.PROSPERO registration numberCRD42017054049.

Wildlife–vehicle collisions have important ecological, economic, and social effects. In North America and across northern Europe, moose (Alces alces) are one of the largest ungulates hit by motor vehicles. The force and increasing frequency of these collisions has resulted in a commitment by wildlife and transportation agencies to limit or reduce causal factors. In an effort to improve these mitigation strategies, we used the most readily available source of knowledge of collision factors, expert opinion, to develop a series of models that explained and predicted location of moose–vehicle collisions (MVC). We developed expert-based models using the Analytical Hierarchy Process (AHP) and we used a structured survey approach where experts could assess criteria relevancy, weight criteria, and review weights for consistency. We hypothesized that collisions were the product of habitat- or driver-related factors and we formulated the survey accordingly. We used the receiver operating characteristic to validate the resulting models and the Kappa index of agreement to quantify differences among spatial predictions originating from the experts. Local and nonlocal experts weighted the moose habitat classification as the most important criterion for identifying MVC. Among driver-related criteria, speed limit was weighted as the most important factor. Overall, habitat-based models were more proficient than driver-based models in predicting MVC within Mount Revelstoke and Glacier National Parks, Canada. Both local and nonlocal expert models were excellent predictors of MVC, with local experts slightly outperforming nonlocal experts. Considering that habitat-related criteria were more powerful for predicting MVC, and that habitat can vary considerably across study areas, we suggest that local experts be used when possible. The AHP is a valuable tool for wildlife, highway, and park managers to better understand why and where wildlife–vehicle collisions occur. Adopting this process, our data suggested that MVC were most strongly correlated with highway attractants associated with habitat. Vegetation management or alternative routing could minimize spatial juxtaposition of moose and motor vehicles.

The Global Burden of Disease study identified musculoskeletal (MSK) disorders as the largest cause of years lived with disability and the third largest cause of disability-adjusted life years. A major contributor to MSK disorders is chronic knee and hip pain, usually labelled osteoarthritis (OA). OA affects eight and a half million people in the United Kingdom, of whom six million are in constant pain. Reduced mobility and activity attributable to joint pain increases the risk of developing comorbidity such as diabetes, cardiac and respiratory disorders, depression, obesity and mortality - more people with pain die than those in the pain-free population. All these problems are increasing as sedentary lifestyles, obesity and the number of people living longer increases. Exercise programmes can improve muscle function and pain. Therefore, muscle function is a modifiable risk factor for OA; maintaining well-conditioned muscles might prevent primary or secondary joint damage.

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society, American Society of Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health-care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. = hemoglobin A1c; = American Association of Clinical Endocrinologists; = adiposity-based chronic disease; = American College of Endocrinology; = American Diabetes Association; = Apnea-Hypopnea Index; = American Society of Anesthesiologists; = American Society of Metabolic and Bariatric Surgery; = body mass index; = biliopancreatic diversion; = biliopancreatic diversion with duodenal switch; = confidence interval; = continuous positive airway pressure; = clinical practice guideline; = C-reactive protein; = computed tomography; = cardiovascular disease; = dysglycemia-based chronic disease; = duodenal switch; = deep venous thrombosis; = dual-energy X-ray absorptiometry; = essential fatty acid; = evidence level; = enteral nutrition; = enhanced recovery after bariatric surgery; = U.S. Food and Drug Administration; = Guidelines for Guidelines; = gastroesophageal reflux disease; = gastrointestinal; = health-care professional(s); = hypertension; = intensive care unit; = intragastric balloon(s); = intravenous; = laparoscopic adjustable gastric band; = laparoscopic adjustable gastric banded plication; = laparoscopic greater curvature (gastric) plication; = laparoscopic Roux-en-Y gastric bypass; = laparoscopic sleeve gastrectomy; = metabolic syndrome; = nonalcoholic fatty liver disease; = nonalcoholic steatohepatitis; = nonsteroidal anti-inflammatory drug; = osteoarthritis; = one-anastomosis gastric bypass; = Obesity Medicine Association; = odds ratio; = obesity-related complication(s); = obstructive sleep apnea; = pulmonary embolism; = parenteral nutrition; = pulmonary recruitment maneuver; = randomized controlled trial; = registered dietician; = recommended daily allowance; = Roux-en-Y gastric bypass; = sleeve gastrectomy; = small intestinal bacterial overgrowth; = The Obesity Society; = thyroid-stimulating hormone; = type 1 diabetes; = type 2 diabetes; = venous thromboembolism; = Wernicke encephalopathy; = World Health Organization.