STUDY DESIGN: Meta-analysis.OBJECTIVES: To define the accuracy of clinical tests for assessing anterior cruciate ligament (ACL) ruptures.BACKGROUND: The cruciate ligaments, and especially the ACL, are among the most commonly injured structures of the knee. Given the increasing injury prevalence, there is undoubtedly a growing need for clinical decision making of health care providers. We reviewed the literature to analyze the diagnostic accuracy of the clinical examination for assessing ACL ruptures.METHODS AND MEASURES: MEDLINE (1966 to April 2005), EMBASE (1989 to April 2005), and CINAHL (1982 to April 2005) searches were performed. Also reference lists of the included studies were reviewed. Studies selected for data extraction were those that addressed the accuracy of at least 1 physical diagnostic test for ACL rupture and compared the performance of the clinical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or MRI. Searching was limited to English, German, and Dutch languages.RESULTS: Twenty-eight studies that assessed the accuracy of clinical tests for diagnosing ACL ruptures met the inclusion criteria. Study results were, however, heterogeneous. The Lachman test is the most valid test to determine ACL tears, showing a pooled sensitivity of 85% (95% confidence interval [CI], 83-87) and a pooled specificity of 94% (95% CI, 92-95). The pivot shift test is very specific, namely 98% (95% CI, 96-99), but has a poor sensitivity of 24% (95% CI, 21-27). The anterior drawer test shows good sensitivity and specificity in chronic conditions, respectively 92% (95% CI, 88-95) and 91% (95% CI, 87-94), but not in acute conditions.CONCLUSION: In case of suspected ACL injury it is recommended to perform the Lachman test. Because the pivot shift test is very specific both in acute as well as in chronic conditions, it is recommended to perform the pivot shift test as well.
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Objective Primary to provide an overview of diagnostic accuracy for clinical tests for common elbow (sport) injuries, secondary accompanied by reproducible instructions to perform these tests. Design A systematic literature review according to the PRISMA statement. Data sources A comprehensive literature search was performed in MEDLINE via PubMed and EMBASE. Eligibility criteria We included studies reporting diagnostic accuracy and a description on the performance for elbow tests, targeting the following conditions: distal biceps rupture, triceps rupture, posteromedial impingement, medial collateral ligament (MCL) insufficiency, posterolateral rotatory instability (PLRI), lateral epicondylitis and medial epicondylitis. After identifying the articles, the methodological quality was assessed using the QUADAS-2 checklist. Results Our primary literature search yielded 1144 hits. After assessment 10 articles were included: six for distal biceps rupture, one for MCL insufficiency, two for PLRI and one for lateral epicondylitis. No articles were selected for triceps rupture, posteromedial impingement and medial epicondylitis. Quality assessment showed high or unclear risk of bias in nine studies. We described 24 test procedures of which 14 tests contained data on diagnostic accuracy. Conclusions Numerous clinical tests for the elbow were described in literature, seldom accompanied with data on diagnostic accuracy. None of the described tests can provide adequate certainty to rule in or rule out a disease based on sufficient diagnostic accuracy.
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In this review article, the authors contextualize the contemporary practice of medical tourism in terms of the concept of worldmaking, which was introduced (in this journal) with two articles a year or two ago by Hollinshead. Here, the authors first contextualize medical tourism in terms of "worldmaking" per medium of the observations of the corporeal realms identified by Alexis de Tocqueville almost 200 years ago. In 1835, de Tocqueville wrote with enthusiasm tinged with nostalgic regret about the new world of American democracy that he then saw as the world of the future. A serious rupture in history took place of which he became a most relevant critic. But there have been (according to Mainil, Platenkamp, and Meulemans) many ruptures since then: that is, there have been short periods of "in-between worlds" that became ever more anchored in the timeline of Western history. Today, they argue that tourism as a field of expertise, practice, and knowledge is intertwined with several other networks of expertise. It is responsible (itself) for many small "ruptures" in these modern times. Mass tourism can be seen as such a shift. Sustainable tourism and the attention paid to climate change would be another such shift. And the authors of this review argue that an interesting and deep-seated case in this regard is medical tourism. They argue here that medical tourism has a great deal of worldmaking capacity, especially by means of the Internet and international marketing tools. It arises in the interstices of the interacting networks of a global world. It crosses borders in line with emerging power structures in a global network, but it also meets local resistance or regional obstacles that are related to other networks. In between these worlds of human experience, various interactions of perspectives on the concept of health itself come to the surface. Within the field of medical tourism different stakeholders play a role in a worldmaking process. Our reviewers from the Low Countries thereby argue that medical tourism itself is responsible for a Tocquevillean rupture within and across our global network society. In their view, medical tourism also constitutes a new hybrid-that is, as a hybrid medical paradigm that seems to be appearing within the performative and productive world of tourism.
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Background Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics. Methods In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations. Findings Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin. Conclusions Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.
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Non-discursive practices such as the economy and political constellations have always caused shifts in history. However, in the network society of today, these shifts have become omnipresent. Globalization of health and medical tourism have created a shift or rupture in the history of healthcare provision and into the lives of different stakeholders. The purpose of this paper is to detect and assess the rupture caused by global health care or medical tourism within the field of the written media, in order to define the reality of medical tourism as a trans-historical field. The methodology of this study comprised an extensive discourse analysis of written and new media performed over a time frame of more than a decade. Market, medical, ethical and patient discourses were detected along scientific sources, international and local newspapers. Results indicate that a change in the market discourse has caused a shift in the attitude towards medical tourism, where ethical voices are seen as submissive to the market logic. In the current time perspective, medical tourism has become more mature with the development of non-ethical counterparts such as organ tourism and reproductive tourism as a consequence. The research framework shows that the general public receives a normative message from the medical tourism sector.
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Background: Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries. Methods: OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women. Results: The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. Conclusions: Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances.
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A damage estimation exercise has been carried out using the building stock inventory and population database of the Istanbul Metropolitan Municipality and selected European earthquake loss estimation packages: KOERILOSS, SELENA, ESCENARIS, SIGE, and DBELA. The input ground-motions, common to all models, correspond to a “credible worst case scenario” involving the rupture of the four segments of the Main Marmara Fault closest to Istanbul in a Mw 7.5 earthquake. The aim of the exercise is to assess the applicability of the selected software packages to earthquake loss estimation in the context of rapid post-earthquake response in European urban centers. The results in terms of predicted building damage and social losses are critically compared amongst each other, as well as with the results of previous scenario-based earthquake loss assessments carried out for the study area. The key methodological aspects and data needs for European rapid post-earthquake loss estimation are thus identified.
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Background: The most common reason for caesarean section (CS) is repeat CS following previous CS. Vaginal birth after caesarean section (VBAC) rates vary widely in different healthcare settings and countries. Obtaining deeper knowledge of clinicians’ views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Interview studies with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of ‘OptiBIRTH’, an ongoing research project. The study reported here is based on interviews in high VBAC countries. The aim of the study was to investigate the views of clinicians working in countries with high VBAC rates on factors of importance for improving VBAC rates. Methods: Individual (face-to-face or telephone) interviews and focus group interviews with clinicians (in different maternity care settings) in three countries with high VBAC rates were conducted during 2012–2013. In total, 44 clinicians participated: 26 midwives and 18 obstetricians. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country. Results: The findings are presented in four main categories with subcategories. First, a common approach is needed, including: feeling confident with VBAC, considering VBAC as the first alternative, communicating well, working in a team, working in accordance with a model and making agreements with the woman. Second, obstetricians need to make the final decision on the mode of delivery while involving women in counselling towards VBAC. Third, a woman who has a previous CS has a similar need for support as other labouring women, but with some extra precautions and additional recommendations for her care. Finally, clinicians should help strengthen women’s trust in VBAC, including building their trust in giving birth vaginally, recognising that giving birth naturally is an empowering experience for women, alleviating fear and offering extra visits to discuss the previous CS, and joining with the woman in a dialogue while leaving the decision about the mode of birth open. Conclusions: This study shows that, according to midwives and obstetricians from countries with high VBAC rates, the important factors for improving the VBAC rate are related to the structure of the maternity care system in the country, to the cooperation between midwives and obstetricians, and to the care offered during pregnancy and birth. More research on clinicians’ perspectives is needed from countries with low, as well as high, VBAC rates.
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The improvement of passive fire protection of storage vessels is a key factor to enhance safety among the LPG distribution chain. A thermal and mechanical model based on finite elements simulations was developed to assess the behaviour of full size tanks used for LPG storage and transportation in fire engulfment scenarios. The model was validated by experimental results. A specific analysis of the performance of four different reference coating materials was then carried out, also defining specific key performance indicators (KPIs) to assess design safety margins in near-miss simulations. The results confirmed the wide influence of coating application on the expected vessel time to failure due to fire engulfment. Aquite different performance of the alternative coating materialswas evidenced. General correlationswere developed among the vessel time to failure and the effective coating thickness in full engulfment scenarios, providing a preliminary assessment of the coating thickness required to prevent tank rupture for a given time lapse. The KPIs defined allowed the assessment of the available safety margins in the reference scenarios analyzed and of the robustness of thermal protection design.
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