Pulmonary rehabilitation (PR) for people with COPD leads to clinically significant improvements in quality of life and exercise capacity [1]. In England and Wales, UK, in 2013-2014, only 15% of eligible patients were referred (51% from primary care), of whom 31% did not attend assessment [2]. We aimed to generate a theory-informed understanding of enablers and barriers to PR referral and uptake from primary care.This mixed-methods study [3] used normalisation process theory (NPT) [4] to understand how PR referral becomes embedded in clinical practice via NPT constructs of coherence (how clinicians understand and value PR), cognitive participation (how PR referral is sustained in practice), collective action (how PR referral is operationalised) and reflexive monitoring (how clinicians judge whether PR referral is worthwhile). Burden of treatment theory (BoT) [5] informed understanding of the patient experience via parallel constructs relating to how patients make sense of their condition and treatment, how they organise self-care work, what taking up PR involves for patients and how patients judge if PR is worthwhile.Online surveys (dichotomous, multiple response, Likert scales and free-text items) were sent to all PR providers in the East of England (EoE), to other PR providers in England and Wales who contributed to the national COPD audit, and to all primary care practices in the EoE. Purposive sampling was used to recruit for semistructured interviews and focus groups, targeting all EoE PR providers and, in EoE areas with higher and lower PR utilisation rates, general practitioners (GPs), practice nurses, commissioners and patients (white British and South Asian) who had accepted a PR offer, declined PR or were not referred. Survey, interview and focus group questions were mapped to NPT constructs. Qualitative data and free-text survey responses were analysed following a framework approach [6] informed by NPT constructs. Qualitative data collection and concurrent analysis continued until saturation was achieved, i.e. deductive codes were adequately represented and no new codes identified [7]. Quantitative data were analysed descriptively. GP and nurse survey responses were compared using Chi-squared analysis. Research questions and interview/focus group guides were reviewed by the patient and participant involvement group.Informed consent was obtained from all participants. The study was approved by Cambridge Central Research Ethics Committee (ref. 17/EE/0136).EoE primary care practices (107 out of 415, 25.8%), EoE PR services (14 out of 20, 70%), and other England and Wales PR services (46 out of 179, 25.7%) completed the surveys. 32 clinicians, six commissioners and 42 COPD patients took part in interviews and focus groups. 28 patients had accepted a PR offer, seven had declined, seven were not referred and seven were of South Asian heritage (table 1).From the survey and qualitative research, we identified enablers and barriers across six domains (figure 1). @ERSpublications Healthcare service and patient ba...
Background Despite advancements in primary correction of hallux valgus (HV), significant rates of reoperation remain across common techniques, with complications following primary correction up to 50% according to some studies.1 This study explored different methods of surgery currently used in treating HV recurrence specifically (for which literature on the subject has been limited), evaluating open and adapted minimally invasive surgical (MIS) primary techniques used for revision. Methods In December 2020, literature search for both open and MIS surgical techniques in HV revision was conducted using PubMed, EMBASE, and MEDLINE library databases. Results and Conclusion Of initial 143 publications, 10 were finally included for data synthesis including 273 patients and 301 feet. Out of 301 feet, 80 (26.6%) underwent revision with MIS techniques (involving distal metatarsal osteotomies). Those undergoing grouped MIS revisions had an average improvement of 38.3 in their American Orthopaedic Foot and Ankle Society score, compared to 26.8 in those using open techniques. Revision approaches using grouped MIS techniques showed a postoperative reduction in intermetatarsal angle and HV angle of 5.6 and 18.4 degrees, respectively, compared to 15.5 and 4.4 degrees, respectively, for open techniques. There are, however, limitations in the current literature on MIS techniques in revision HV surgery specifically. MIS techniques grouped did not show worse outcomes or safety concerns compared to open techniques.
Introduction Numerous minimally invasive techniques have been developed for Hallux Valgus in recent years. Third-generation Minimally Invasive Chevron Akin (MICA) osteotomy has shown promising early results, but longer-term follow-up is required to assess whether patient clinical and radiological improvement is sustained. This cohort study presents three-year follow-up outcomes for patients of a single surgeon case series. Methods Thirty-three patients underwent third-generation MICA surgery between 2017 and 2018. Patient clinical-reported outcome measures included American Orthopaedic Foot & Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ) scores, and Coughlin satisfaction. Radiographic outcomes were evaluated after a period of three years using hallux valgus angle (HVA) and inter-metatarsal angle (IMA), and compared to pre- and early post-operative outcomes. Results At 36 months, mean AOFAS scores improved from 48.2 to 95.6, mean MOXFQ scores improved from 57.6 to 6.7. Using the Coughlin scale, 81.8% of patients rated their outcome as ‘Excellent’ and 18.2% as ‘Good’. Radiographic outcomes showed HVA and mean IMA decreased from 34.6 degrees to 16.0 degrees and from 13.1 to 6.1, respectively at 36 months. Conclusion Third-generation MICA demonstrates promising patient satisfaction scores post-operatively, and we have shown these improvements are sustained over a minimum three-year follow-up period. Level of Evidence Level IV, case series.
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