Despite identifying 60 eligible trials, only one trial compared a combination of manual therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with manual therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials. Further trials of manual therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

Based on low quality evidence, therapeutic ultrasound may have short-term benefits over placebo in people with calcific tendinitis, and LLLT may have short-term benefits over placebo in people with rotator cuff disease. Further high quality placebo-controlled trials are needed to confirm these results. In contrast, based on low quality evidence, PEMF may not provide clinically relevant benefits over placebo, and therapeutic ultrasound, LLLT and PEMF may not provide additional benefits when combined with other physical therapy interventions. We are uncertain whether TENS is superior to placebo, and whether any electrotherapy modality provides benefits over other active interventions (e.g. glucocorticoid injection) because of the very low quality of the evidence. Practitioners should communicate the uncertainty of these effects and consider other approaches or combinations of treatment. Further trials of electrotherapy modalities for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

Objectives To explore the outcome domains and measurement instruments reported in published randomized controlled trials of physical therapy interventions for shoulder pain (rotator cuff disease, adhesive capsulitis, or nonspecific shoulder pain). Study Design and Setting We included trials comparing physical therapy to any other intervention for shoulder pain, indexed up to March 2015 in CENTRAL, MEDLINE, EMBASE, or CINAHL Plus. Two authors independently selected trials for inclusion and extracted information on the domains and measurement instruments reported. Results We included 171 trials. Most trials measured pain (87%), function (72%), and range of movement (67%), whereas adverse events, global assessment of treatment success, strength, and health-related quality of life were measured in 18–27% of trials, and work disability and referral for surgery were measured in less than 5% of trials. Thirty-five different measurement instruments for pain and 29 for function were noted. Measurement of function increased markedly from 1973 to 2014. In rotator cuff disease trials, there was a more frequent measurement of pain and strength and a less frequent measurement of range of movement compared with adhesive capsulitis trials. Conclusions There was wide diversity in the domains and measurement instruments reported. Our results provide the foundation for the development of a core domain and outcome measurement set for use in future shoulder pain trials.

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Lymphoedema of the arm is a potentially serious consequence of any axillary procedure performed during the management of breast cancer. In an attempt to reduce its incidence and severity, patients are instructed to avoid venepunctures and blood pressure measurements on the treated arm. These precautions are not possible in some patients and attempts to adhere to them can cause discomfort, anxiety and stress for both patients and their health-care workers. The strength with which these recommendations are made is in contrast to the level of evidence underpinning them. This paper reviews this evidence regarding the safety, or lack thereof, of blood pressure monitoring and intravenous puncture in women who have had axillary surgery. With this evidence generally being anecdotal in nature, there appears to be no rigorous evidence-based support for the risk-reduction behaviours of avoiding blood pressure monitoring and venepuncture in the affected arm in the prevention of lymphoedema after axillary procedure. A clinical trial was proposed to investigate whether such avoidance measures were valuable, but failed during its inception. There remains a need for research from prospective trials on this controversial topic to determine the most appropriate patient recommendations that should be provided after axillary procedure regarding the risks for development of lymphoedema.

Background: Undifferentiated abdominal pain is a common pediatric presentation to the emergency department (ED).Objectives: The objective of this study was to describe the prevalence of clinically significant abdominal pathology (CSAP) including appendicitis, patterns of imaging and pathology tests, and management and outcomes of children with abdominal pain in ED.Methods: A prospective multicenter observational cohort pilot study of children under the age of 16 years presenting to 4 Australian EDs with abdominal pain was performed for a 1-month period at each site. The primary outcome was to describe the prevalence of CSAP and appendicitis. Age, sex, length of stay, surgery or interventional procedure, investigations, and analgesia use were recorded.Results: There were 555 presentations with abdominal pain during the study period with a median age of 9 years (interquartile range, 6-12 years). Eighty-two patients (14.8%; 95% confidence interval, 11.8-17.7) had CSAP, of which 41 (7.4%, 5.2-9.6) had appendicitis. Three hundred forty-eight (62.7%, 58.7-66.7) were discharged directly from ED, and 207 (37.3%,3) were admitted. Two hundred fifty-five (45.9%, 41.8-50.1) had pathology tests, and 173 (31.2%, 27.3-35.1) had imaging tests in ED. Of those contacted for telephone follow-up, 100 (50.5%, 43.5-57.5) of 198 reported ongoing pain after discharge, and 13.1% (8.4-17.8) had missed over a week of school due to abdominal pain. Conclusions:The prevalence of CSAP and appendicitis in our study was 14.8% (11.8-17.7) and 7.4% (5.2-9.6), respectively. Fewer than half of patients received blood tests, and a third received imaging during their ED attendance. The presentation of abdominal pain conveys a significant health burden on families with time off school and ongoing symptoms of pain.

Objective: Abdominal pain is a common paediatric presentation to the ED. Accurate diagnosis of acute appendicitis is challenging, with the best-performing clinical scoring systems having sensitivities between 72% and 100%. The aim of this study is to assess the diagnostic accuracy of clinician gestalt according to seniority in diagnosing paediatric acute appendicitis in ED.Methods: This is a prospective multicentre observational study of clinician's prediction of appendicitis in children under the age of 16 years presenting to four EDs with abdominal pain over a 1 month period at each site. Clinician-estimated likelihood of acute appendicitis was compared with the final diagnosis determined by histopathology or operative findings and supplemented by telephone follow up for those without an operation. The primary outcome was diagnostic accuracy of clinician gestalt according to clinician seniority in diagnosing appendicitis.Results: There were 381 children enrolled with completed clinician questionnaires, and 224 children had complete follow up or underwent appendicectomy. The median age was 9 years (interquartile range 6-12) and the incidence of appendicitis was 31/224 (13.8%, 95% confidence interval 9.3-18.4). The area under the curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value of clinician gestalt were 0.84 (0.76-0.91), 81% (63-93%), 76% (69-82%), 35% (28-42%) and 96% (92-98%), respectively, giving an overall diagnostic accuracy of 76% (70-82%). AUC stratified by clinician seniority (junior, intermediate and senior) were 0.89 (0.80-0.98), 0.82 (0.69-0.95) and 0.76 (0.56-0.96), respectively. Conclusions: The diagnostic accuracy of ED clinician gestalt in paediatric appendicitis is comparable to current clinical scoring systems irrespective of seniority.

Background Diabetic ketoacidosis (DKA) is a potentially life‐threatening but often preventable acute complication of type 1 diabetes (T1D). Understanding clinical and psychosocial characteristics of people with DKA, particularly those with multiple presentations, may aid the development of prevention strategies. Aims To describe clinical, psychological and demographic factors in adults with DKA and particularly those factors associated with recurrent admissions. Methods A retrospective analysis was performed of all admissions with DKA in people with T1D over a 4‐year period from 1 November 2013 to 31 October 2017 at a metropolitan tertiary hospital in Australia. Potential cases were identified by International Classification of Diseases–10th Revision coding data. Data were then manually extracted by clinicians from the electronic medical record. Results There were 154 clinician‐adjudicated admissions for DKA among 128 people with T1D. Of these, 16 (13%) had multiple DKA admissions. Forty‐one (32%) had a history of depression. The most common factors contributing to presentation included insulin omission (54%), infection (31%), alcohol excess (26%) and new diabetes diagnosis (16%). Compared to people with single admissions, those with recurrent DKA were more likely to smoke (69% vs 27%, P = 0.003), be unemployed (31% vs 11%, P = 0.04) and use illicit substances (44% vs 17%, P = 0.02). Conclusions There is a high prevalence of psychiatric illness, illicit substance use and social disadvantage among people admitted with DKA, particularly those with recurrent presentations. Insulin omission, often due to inappropriate sick day management, was the most common reason for DKA occurrence. Innovative multidisciplinary models of care are required to address these challenges.