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Background To report our recommended methodology for extracting and then confirming research uncertainties – areas where research has failed to answer a research question – derived from previously published literature during a broad scope Priority Setting Partnership (PSP) with the James Lind Alliance (JLA). Methods This process was completed in the UK as part of the PSP for “Common Conditions Affecting the Hand and Wrist”, comprising of health professionals, patients and carers and reports the data (uncertainty) extraction phase of this. The PSP followed the robust methodology dictated by the JLA and sought to identify knowledge gaps, termed “uncertainties” by the JLA. Published Cochrane Systematic Reviews, Guidelines and Protocols, NICE (National Institute for Health and Care Excellence) Guidelines, and SIGN (Scottish Intercollegiate Guidelines Network) Guidelines were screened for documented “uncertainties”. A robust method of screening, internally verifying and then checking uncertainties was adopted. This included independent screening and data extraction by multiple researchers and use of a PRISMA flowchart, alongside steering group consensus processes. Selection of research uncertainties was guided by the scope of the Common Conditions Affecting the Hand and Wrist PSP which focused on “common” hand conditions routinely treated by hand specialists, including hand surgeons and hand therapists limited to identifying questions concerning the results of intervention, and not the basic science or epidemiology behind disease. Results Of the 2358 records identified (after removal of duplicates) which entered the screening process, 186 records were presented to the PSP steering group for eligibility assessment; 79 were deemed within scope and included for the purpose of research uncertainty extraction (45 full Cochrane Reviews, 18 Cochrane Review protocols, 16 Guidelines). These yielded 89 research uncertainties, which were compared to the stakeholder survey, and added to the longlist where necessary; before derived uncertainties were checked against non-Cochrane published systematic reviews. Conclusions In carrying out this work, beyond reporting on output of the Common Conditions Affecting the Hand and Wrist PSP, we detail the methodology and processes we hope can inform and facilitate the work of future PSPs and other evidence reviews, especially those with a broader scope beyond a single disease or condition.

The standards for the management of open fractures of the lower limb published by the British Association of Plastic, Reconstructive and Aesthetic surgeons (BAPRAS) and British Orthopaedic Association (BOA) were introduced to improve the treatment received by patients after open injury to the lower limb. These Standards were released after BAPRAS/BOA published Guidelines for the management of open tibial fractures. We wished to determine the impact of these Standards upon the surgical management of open tibial fractures by comparing patients admitted to an orthoplastic centre in the 45 months concluding December 2009 (the Guidelines era) with those admitted during 2011 (the Standards era). Surgical procedures required during the first 30 days and 12 months after injury were determined. Cases were divided into 'directly admitted patients' (DAP) and 'transferred patients' (TP). Standards-era patients were divided further into those who had surgery exclusively at the orthoplastic centre (orthoplastic patients (OPP)) and those transferred after surgery (TASP). The number of TP trebled in frequency in the Standards era, 25% of whom were transferred before surgery. Significantly fewer surgical procedures were required for DAP and OPP groups compared with TP (and TASP) groups in both eras (Mann-Whitney U-test, p=0.05). DAP and OPP groups during the Standards era underwent the fewest procedures, with the vast majority of cases treated with two or fewer procedures in the first 12 months (88% and 80%, respectively, compared with 61% in the Guidelines era). In the Guidelines era, 44% of TP cases and in the Standards era 39% of TP and 29% of TASP groups underwent two or fewer procedures. Approximately two-thirds of open tibial fractures managed in our orthoplastic centre were patients transferred after surgery. The greatest impact of the Standards was evident for those who underwent surgery exclusively in the orthoplastic centre, reflecting a more deliberate combined strategy. These findings vindicate the Standards as well as mandating reorganisation and resourcing of orthoplastic services to ensure immediate transfer and early combined surgery. By increasing the capacity to deal with time-dependent initial surgery, the surgical burden that the patient must endure, and which the service must provide, are reduced.

COVID-19 has necessitated significant changes to healthcare delivery but little is known regarding patient opinions of risks compared with benefits. This study investigates patient perceptions concerning attendance for planned orthopaedic surgery during the COVID-19 pandemic. A total of 250 adult patients from the elective orthopaedic waiting list at Cardiff and Vale University Health Board were telephoned during lockdown. They were risk stratified for COVID-19 based on British Orthopaedic Association guidance and a discussion was held to determine patient willingness to proceed with surgery. The primary outcome measure was patients' willingness to proceed. Of the total number telephoned, 196 patients were included in the study, with a mean age of 57.4 years; 129 patients were willing to attend for surgery, leaving over one-third wishing to cancel or defer. The most frequent reason given for not wishing to attend was fear of contracting COVID-19. There was a statistically significant difference in the willingness to proceed observed with increasing clinical risk (χ (3) = 50.073,  = .000) with almost double the expected count of unwilling to proceed in the high and very high risk groups, equalled by half the expected count in the low risk group. This study illustrates the variable and personal decisions that patients are making about orthopaedic care because of COVID-19. It highlights the need for change to departmental processes regarding recommencement of planned surgical lists. It also reconfirms the importance of regular communication and shared decision making between a well-informed patient and a holistic orthopaedic team.

The Foley catheter is described in the emergency treatment of penetrating cardiac injuries, and its intra-operative use to control bleeding while definitive measures for intravascular embolization are being made. We present the first reported case of the use of a urinary catheter to control haemorrhage in an extremity stab injury to obtain haemodynamic stability while awaiting definitive surgical treatment. This quick, easy and useful technique can be used for junctional vascular injuries and wounds with a narrow neck, and can be easily removed once in the operating theatre. This life-saving, simple and cost-effective technique ‘internalises’ the externally applied pressure to control massive haemorrhage while awaiting definitive operative intervention. The catheter can be sutured in place if the patient is to be transferred to another department or hospital.

Patients with out-of-hospital respiratory distress who received treatment from emergency medical services personnel with advanced-life-support training had a lower in-hospital mortality than those who received treatment from providers without this training. The difference may be in part attributable to advanced-life-support interventions. Whether the data are sufficient to justify broad implementation of such training is unclear. Patients with out-of-hospital respiratory distress who received treatment from emergency medical services personnel with advanced-life-support training had a lower in-hospital mortality than those who received treatment from providers without this training. Each year, emergency medical services (EMS) personnel in the United States transport 2 million patients with respiratory distress to hospitals by ambulance. Respiratory distress is the second most common symptom of adults transported by ambulance and is associated with a relatively high overall mortality before hospital discharge of 18%. 1 – 3 Among the most common causes of respiratory distress in this setting are congestive heart failure, pneumonia, chronic obstructive pulmonary disease, and asthma. In many cities in the United States and Canada, out-of-hospital care for critically ill and injured patients is provided by paramedics who are trained in advanced-life-support measures. Advanced . . .

ObjectivesThe study aims were to assess the burden of non-traumatic wrist pain in terms of numbers of referrals to secondary care and to characterize how patients present, are diagnosed and are managed in secondary care in the UK National Health Service.MethodsTen consecutive patients presenting with non-traumatic wrist pain were identified retrospectively at each of 16 participating hospitals, and data were extracted for 12 months after the initial referral.ResultsThe 160 patients consisted of 100 females and 60 males with a median age of 49 years, accounting for ∼13% of all new hand/wrist referrals. The dominant wrist was affected in 60% of cases, and the mean symptom duration was 13.3 months. Diagnoses were grouped as follows: OA (31%), tendinopathy (13%), ganglion (14%), ulnar sided pain (17%) and other (25%). The OA group was significantly older than other groups, and other groups contained a predominance of females. The non-surgical interventions, in decreasing frequency of usage, were as follows: CS injections (39%), physiotherapy (32%), splint (31%) and analgesics (12%). Of those who underwent surgery, all patients had previously received non-surgical treatment, but 42% had undergone only one non-surgical intervention.ConclusionsNon-traumatic wrist pain represents a significant burden to secondary care both in terms of new patient referrals and in terms of investigation, follow-up and treatment. Those presenting with OA are more likely to be older and male, whereas those presenting with other diagnoses are more likely to be younger and female.

In considering the influences of microsystems on adolescent substance use, familial and peer contexts have received the most extensive attention in the research literature. School and neighborhood settings, however, are other developmental contexts that may exert specific influences on adolescent substance use. In many instances, school settings are organized to provide educational services to students who share similar educational abilities and behavioral repertoires. The resulting segregation of students into these settings may result in different school norms for substance use. Similarly, neighborhood resources, including models for substance use and drug sales involvement, may play an important role in adolescent substance use. We briefly review literature examining contextual influences on adolescent substance use, and present results from two preliminary studies examining the contribution of school and neighborhood context to adolescent substance use. In the first investigation, we examine the impact of familial, peer, and school contexts on adolescent substance use. Respondents were 283 students (ages 13 to 18) from regular and special education classrooms in six schools. Although peer and parental contexts were important predictors of substance use, school norms for drug use accounted for variance in adolescent use beyond that explained by peer and parental norms. Data from a second study of 114 adolescents (mean age = 15) examines neighborhood contributions to adolescent substance use. In this sample, neighborhood indices did not contribute to our understanding of adolescent substance use. Implications for prevention are presented.