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Journal articleMahmoud K, Alagha MA, Nowinka Z, et al., 2023, , BMJ Surgery, Interventions, & Health Technologies, Vol: 5, Pages: 1-9, ISSN: 2631-4940
Objectives Knee osteoarthritis is a major cause of physical disability and reduced quality of life, with end-stage disease often treated by total knee replacement (TKR). We set out to develop and externally validate a machine learning model capable of predicting the need for a TKR in 2 and 5 years time using routinely collected health data.Design A prospective study using datasets Osteoarthritis Initiative (OAI) and the Multicentre Osteoarthritis Study (MOST). OAI data were used to train the models while MOST data formed the external test set. The data were preprocessed using feature selection to curate 45 candidate features including demographics, medical history, imaging assessments, history of intervention and outcome.Setting The study was conducted using two multicentre USA-based datasets of participants with or at high risk of knee OA.Participants The study excluded participants with at least one existing TKR. OAI dataset included participants aged 45–79 years of which 3234 were used for training and 809 for internal testing, while MOST involved participants aged 50–79 and 2248 were used for external testing.Main outcome measures The primary outcome of this study was prediction of TKR onset at 2 and 5 years. Performance was evaluated using area under the curve (AUC) and F1-score and key predictors identified.Results For the best performing model (gradient boosting machine), the AUC at 2 years was 0.913 (95% CI 0.876 to 0.951), and at 5 years 0.873 (95% CI 0.839 to 0.907). Radiographic-derived features, questionnaire-based assessments alongside the patient’s educational attainment were key predictors for these models.Conclusions Our approach suggests that routinely collected patient data are sufficient to drive a predictive model with a clinically acceptable level of accuracy (AUC>0.7) and is the first such tool to be externally validated. This level of accuracy is higher than previously published models utilising MRI data, whi
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Journal articleBonicelli A, Tay T, Cobb JP, et al., 2023, , Journal of the Mechanical Behavior of Biomedical Materials, Vol: 138, ISSN: 1751-6161
Measurement of the properties of bone as a material can happen in various length scales in its hierarchical and composite structure. The aim of this study was to test the tissue level properties of clinically-relevant human bone samples which were collected from donors belonging to three groups: ageing donors who suffered no fractures (Control); untreated fracture patients (Fx-Untreated) and patient who experienced hip fracture despite being treated with bisphosphonates (Fx-BisTreated). Tissue level properties were assessed by (a) nanoindentation and (b) synchrotron tensile tests (STT) where strains were measured at the ‘tissue’, ‘fibril’ and ‘mineral’ levels by using simultaneous Wide-angle - (WAXD) and Small angle- X-ray diffraction (SAXD). The composition was analysed by thermogravimetric analysis and material level endo- and exo-thermic reactions by differential scanning calorimetry (TGA/DSC3+). Irrespective of treatment fracture donors exhibited significantly lower tissue, fibril and mineral strain at the micro and nanoscale respectively and had a higher mineral content than controls. In nanoindentation only nanohardness was significantly greater for Controls and Fx-BisTreated versus Fx-Untreated. The other nanoindentation parameters did not vary significantly across the three groups. There was a highly significant positive correlation (p < 0.001) between organic content and tissue level strain behaviour. Overall hip-fractures were associated with lower STT nanostrains and it was behaviour measured by STT which proved to be a more effective approach for predicting fracture risk because evidently it was able to demonstrate the mechanical deficit for the bone tissue of the donors who had experienced fractures.
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Journal articleStanley A, Edwards T, Jaere M, et al., 2023, , Digital Health, Vol: 9, Pages: 1-9, ISSN: 2055-2076
IntroductionKnee pain is caused by various pathologies, making evaluation in primary-care challenging. Subsequently, an over-reliance on imaging, such as radiographs and MRI exists. Electronic-triage tools represent an innovative solution to this problem. The aims of this study were to establish the magnitude of unnecessary knee imaging prior to orthopaedic surgeon referral, and ascertain whether an e-triage tool outperforms existing clinical pathways to recommend correct imaging.MethodsPatients ≥18 years presenting with knee pain treated with arthroscopy or arthroplasty at a single academic hospital between 2015 and 2020 were retrospectively identified. The timing and appropriateness of imaging were assessed according to national guidelines, and classified as ‘necessary’, ‘unnecessary’ or ‘required MRI’. Based on an eDelphi consensus study, a symptom-based e-triage tool was developed and piloted to preliminarily diagnose five common knee pathologies and suggest appropriate imaging.Results1462 patients were identified. 17.2% (n = 132) of arthroplasty patients received an ‘unnecessary MRI’, 27.6% (n = 192) of arthroscopy patients did not have a ‘necessary MRI’, requiring follow-up. Forty-one patients trialled the e-triage pilot (mean age: 58.4 years, 58.5% female). Preliminary diagnoses were available for 33 patients. The e-triage tool correctly identified three of the four knee pathologies (one pathology did not present). 79.2% (n = 19) of participants would use the tool again.ConclusionA substantial number of knee pain patients receive incorrect imaging, incurring delays and unnecessary costs. A symptom-based e-triage tool was developed, with promising performance and user feedback. With refinement using larger datasets, this tool has the potential to improve wait-times, referral quality and reduce cost.
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Journal articleYork T, Raj S, Ashdown T, et al., 2023, , BMC Medical Education, Vol: 23, Pages: 1-10, ISSN: 1472-6920
BackgroundTraumatic musculoskeletal injuries are a common presentation to emergency care, the first-line investigation often being plain radiography. The interpretation of this imaging frequently falls to less experienced clinicians despite well-established challenges in reporting. This study presents novel data of clinicians’ confidence in interpreting trauma radiographs, their perception of AI in healthcare, and their support for the development of systems applied to skeletal radiography.MethodsA novel questionnaire was distributed through a network of collaborators to clinicians across the Southeast of England. Over a three-month period, responses were compiled into a database before undergoing statistical review.ResultsThe responses of 297 participants were included. The mean self-assessed knowledge of AI in healthcare was 3.68 out of ten, with significantly higher knowledge reported by the most senior doctors (Specialty Trainee/Specialty Registrar or above = 4.88). 13.8% of participants reported an awareness of AI in their clinical practice.Overall, participants indicated substantial favourability towards AI in healthcare (7.87) and in AI applied to skeletal radiography (7.75). There was a preference for a hypothetical system indicating positive findings rather than ruling as negative (7.26 vs 6.20).ConclusionsThis study identifies clear support, amongst a cross section of student and qualified doctors, for both the general use of AI technology in healthcare and in its application to skeletal radiography for trauma. The development of systems to address this demand appear well founded and popular. The engagement of a small but reticent minority should be sought, along with improving the wider education of doctors on AI.
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Book chapterHopkins M, McMenemy L, Turner S, et al., 2023, , Blast Injury Science and Engineering A Guide for Clinicians and Researchers Second Edition, Pages: 447-478
Major limb amputation affects millions of people worldwide and became a common procedure in the latter years of the conflicts in Afghanistan and Iraq. Prosthetic devices are commonly introduced to lower-limb amputees to assist with mobility and functionality. Despite vast leaps in the technology of lower-limb prostheses, acceptance of a prosthesis is limited by the quality of interfacing between the residuum and the device. No single design fits all, and production of a socket is a complex task, requiring significant skill and expertise from the prosthetist. The fit and pressure distribution of the socket can significantly impact the health of the soft tissue, leading to conditions such as pressure sores if not properly managed. The residuum-socket interface is further complicated by natural volume fluctuations of the limb, issues with thermoregulation, infections and musculoskeletal pathologies. Researchers, clinicians and industry have attempted to better understand and inform optimal socket fit through computational and hardware methods, and surgical techniques such as direct skeletal fixation have been proposed to bypass the socket altogether. This chapter explores the nature of the prosthetic socket, common issues users present and methods to improve the interface between the residual limb and the prosthesis.
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Book chapterMcGregor AH, 2023, , Blast Injury Science and Engineering A Guide for Clinicians and Researchers Second Edition
This section builds on the journey of blast injury and the success of work to prevent and mitigate injury and the success of our clinical management of blast injuries. This short overview describes some of the factors that are discussed in the following chapters relating to long-term quality of life for survivors of blast injuries.
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Book chapterAnderson KM, McGregor AH, Masouros SD, et al., 2023, , Blast Injury Science and Engineering A Guide for Clinicians and Researchers Second Edition, Pages: 437-446
Continued advances are required to address mobility limitations caused by lower extremity blast injury. Individuals who experience persistent deficits following trauma may benefit from external support and/or offloading provided by ankle foot orthoses (AFOs). Currently available AFOs vary widely in their design and potential benefit. Carbon fibre custom dynamic ankle foot orthoses (CDOs) have been increasingly used to improve mobility after traumatic injury. CDOs are made predominantly from carbon fibre and are intended to restore function across a range of daily and high-energy activities. Patient-reported outcomes, physical performance measures, and biomechanics data from studies focusing on CDO use have demonstrated positive outcomes. CDOs consist of a proximal cuff, posterior carbon fibre strut, and footplate, which can be tuned to meet the needs of the patient. Available literature provides guidance related to key design considerations during the fitting process. Further, intensive training when combined with the CDO has been found to enhance clinical outcomes and facilitate successful return to high-energy activity. A majority of available data related to CDO use following limb trauma is focused on a subset of military personnel, and available civilian data is limited.
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Book chapterSilverman AK, Hendershot BD, McGregor AH, 2023, , Blast Injury Science and Engineering A Guide for Clinicians and Researchers Second Edition, Pages: 489-497
Rehabilitation after blast injury is critical for regaining mobility and functional independence. In addition to immediate rehabilitation goals to facilitate activities of daily living, rehabilitation should address movement patterns and prosthetic interventions that mitigate long-term secondary (musculoskeletal) conditions. For example, after limb loss, which is a common result of blast trauma, people experience disproportionately high rates of osteoarthritis and low back pain relative to the general population. These conditions often develop and/or deteriorate over time and can have detrimental effects on mobility and quality of life. In this chapter, we describe and summarise existing knowledge of these musculoskeletal conditions secondary to blast injuries that include limb loss. Relationships between movement strategies and biomechanical outcomes are also discussed. While many musculoskeletal health conditions are multifactorial in onset and progression, these conditions are strongly related to movement biomechanics, and thus can be mitigated through rehabilitation approaches. Specifically, rehabilitation strategies that balance immediate goals of clinical outcomes and community engagement with long-term goals of healthy joint mechanics are critical for this population. In addition, rehabilitation and prosthetic interventions should be continually monitored and delivered so that they appropriately account for movement adaptations and changing mobility needs of the individual.
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Book chapterKaufmann JJ, McMenemy L, Phillips ATM, et al., 2023, , Blast Injury Science and Engineering A Guide for Clinicians and Researchers Second Edition, Pages: 479-488
Bone mineral density (BMD) loss in lower-limb amputees has in the past been referred to as either osteopenia or osteoporosis. However, evidence and hypotheses in emerging literature are beginning to challenge this, suggesting that the use of these terms could be inappropriate due to key differences in the aetiology and mechanisms underpinning the bone loss in the younger amputee population. Computational and clinical analysis carried out within the Centre for Blast Injury Studies at 51³Ô¹ÏÍø and the ADVANCE Study has provided strong evidence to support this stance. Investigating BMD discordance in the spine and femur of 153 lower-limb amputees and a frequency-matched control population has shown that bone loss in amputees is localised to the amputated limb rather than systemic (as it manifests in age-related osteoporosis). Combined musculoskeletal and finite element modelling goes some way to explaining the cause of this. Weight bearing through a prosthetic socket offloads the distal femur, and consequently large areas of the femoral shaft and neck experience significantly reduced levels of stimulation when compared to weight bearing on a healthy limb. The long-term result of this is a phenomenon that we refer to as unloading osteopenia.
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Journal articleBarrie A, Kent B, Supra Man Collaborative, 2023, , Bone Joint J, Vol: 105-B, Pages: 82-87
AIMS: Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. METHODS: This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap). RESULTS: A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.
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Journal articleNewington L, Alexander C, Kirby P, et al., 2022, , PLoS One, Vol: 17, ISSN: 1932-6203
Objectives:The aims of this study were to explore individuals’ experiences of contributing to health research and to identify the types of impact that are perceived as important by participants or patient and public advisors. Specifically, research led by NMAHPP clinicians (Nursing, Midwifery, Allied health professions, Healthcare science, Psychology and Pharmacy).Methods:Semi-structured one-to-one interviews were conducted with health research participants and patient or public advisors. Interviewees were recruited from five UK sites and via social media. Interview transcripts were analysed using Thematic Analysis to identify key themes and areas of disagreement.Results:Twenty-one interviews were completed, and four main themes were identified. The first, optimising research experiences, included personal reflections and broader recommendations to improve participant experiences. The second, connecting health research with healthcare, described research as key for the continued development of healthcare, but illustrated that communication between research teams, participants, and clinicians could be improved. The third theme explored the personal impacts of contributing to research, with interviewees recalling common positive experiences. The final theme discussed capturing research impacts. Interviewees highlighted potential priorities for different stakeholders, but emphasised that financial impacts should not be the sole factor.Conclusion:Individuals who were involved in NMAHPP health research recalled positive experiences and reported good relationships with their research teams. They felt that their contributions were valued. Suggested strategies to optimise the research experience focused on simplifying documentation, clear signposting of the research activities involved, and feedback on the research findings. Routine sharing of relevant research data with clinicians was also recommended. Personal impacts included a deeper understanding of their health
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Journal articleBottle A, Liddle A, 2022, , BMJ Quality & Safety, Vol: 32, Pages: 244-246, ISSN: 2044-5423
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Journal articlevan Helden JFL, Martinez-Valdes E, Strutton PH, et al., 2022, , Journal of Electromyography and Kinesiology, Vol: 67, ISSN: 1050-6411
PURPOSE: To establish intra- and inter-session reliability of high-density surface electromyography (HDEMG)-derived parameters from the thoracic erector spinae (ES) during static and dynamic goal-directed voluntary movements of the trunk, and during functional reaching tasks. METHODS: Twenty participants performed: 1) static trunk extension, 2) dynamic trunk forward and lateral flexion, and 3) multidirectional functional reaching tasks on two occasions separated by 7.5 ± 1.2 days. Muscle activity was recorded bilaterally from the thoracic ES. Root mean square (RMS), coordinates of the barycentre, mean frequency (MNF), and entropy were derived from the HDEMG signals. Reliability was determined with intraclass correlation coefficient (ICC), coefficient of variation, and standard error of measurement. RESULTS: Good-to-excellent intra-session reliability was found for all parameters and tasks (ICC: 0.79-0.99), whereas inter-session reliability varied across tasks. Static tasks demonstrated higher reliability in most parameters compared to functional and dynamic tasks. Absolute RMS and MNF showed the highest overall reliability across tasks (ICC: 0.66-0.98), while reliability of the barycentre was influenced by the direction of the movements. CONCLUSION: RMS and MNF derived from HDEMG show consistent inter-session reliability in goal-directed voluntary movements of the trunk and reaching tasks, whereas the measures of the barycentre and entropy demonstrate task-dependent reliability.
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Journal articleAllen JE, Clunie G, Ma JK-Y, et al., 2022, , Dysphagia, Vol: 37, Pages: 1586-1598, ISSN: 0179-051X
Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1–13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field.
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Journal articlePanhelleux B, Shalhoub J, Silverman A, et al., 2022, , Vascular, Vol: 30, Pages: 1149-1159, ISSN: 0967-2109
Objectives: Through knee amputation (TKA) is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a TKA approach. This paper seeks to: (1) Determine the number of TKAs performed compared with other major lower limb amputations (MLLA) in England over the past decade; (2) identify the theoretical concepts behind TKA surgical approaches and their potential effect on functional and clinical outcomes; and (3) provide a platform for discussion and research on TKA and surgical outcomes.Methods: National Health Service Hospital Episodes Statistics were used to obtain recent numbers of MLLAs in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on TKA surgery.Results: In the past decade, 4.6% of MLLA in England were TKAs. Twenty-six articles presenting TKA surgical techniques met our criteria. These articles detailed three TKA surgical techniques; the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape; and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur.Conclusions: TKA has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional, and biomechanical outcomes of TKA frequently fail to distinguish between the 3 distinct and differing approaches, making direct comparisons difficult. Future studies that compare TKA approaches to one another and to other amputation levels are needed.
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Journal articleBehforootan S, Thorniley M, Minonzio J-G, et al., 2022, , Journal of the Mechanical Behavior of Biomedical Materials, Vol: 136, ISSN: 1751-6161
The bone quality of patients undergoing hip replacement surgery is poorly predicted by radiographs alone. With better bone quality information available to a surgeon, the operation can be performed more safely. The aim of this study was to investigate whether ultrasound signals of cortical bone at peripheral sites such as the tibia and radius can be used to predict the compressive mechanical properties of cortical bone at the femoral neck.We recruited 19 patients undergoing elective hip arthroplasty and assessed the radius and tibia of these patients with the Azalée guided wave ultrasound to estimate the porosity and thickness of the cortex. Excess bone tissues were collected from the femoral neck and the compressive mechanical properties of the cortex were characterised under a mechanical loading rig to determine stiffness, ultimate strength, and density. The correlations between the ultrasound measurements and mechanical properties were analysed using linear regression, Pearson correlation statistics, and multiple regression analysis.Cortical mechanical properties were weakly to moderately correlated with the ultrasound measurements at various sites (R2 = 0.00–0.36). The significant correlations found were not consistent across all 4 peripheral measurement sites. Additionally, weak to moderate ability of the ultrasound to predict mechanical properties at the neck of femur with multiple regression analysis was found (R2 = 0.00–0.48). Again, this was inconsistent across the different anatomical sites. Overall, the results demonstrate the need for ultrasound scans to be collected directly from clinically relevant sites such as the femoral neck due to the inconsistency of mechanical properties across various sites.
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Journal articleMiles A, McRae J, Clunie G, et al., 2022, , Dysphagia, Vol: 37, Pages: 1349-1374, ISSN: 0179-051X
COVID-19 has had an impact globally with millions infected, high mortality, significant economic ramifications, travel restrictions, national lockdowns, overloaded healthcare systems, effects on healthcare workers’ health and well-being, and large amounts of funding diverted into rapid vaccine development and implementation. Patients with COVID-19, especially those who become severely ill, have frequently developed dysphagia and dysphonia. Health professionals working in the field have needed to learn about this new disease while managing these patients with enhanced personal protective equipment. Emerging research suggests differences in the clinical symptoms and journey to recovery for patients with COVID-19 in comparison to other intensive care populations. New insights from outpatient clinics also suggest distinct presentations of dysphagia and dysphonia in people after COVID-19 who were not hospitalized or severely ill. This international expert panel provides commentary on the impact of the pandemic on speech pathologists and our current understanding of dysphagia and dysphonia in patients with COVID-19, from acute illness to long-term recovery. This narrative review provides a unique, comprehensive critical appraisal of published peer-reviewed primary data as well as emerging previously unpublished, original primary data from across the globe, including clinical symptoms, trajectory, and prognosis. We conclude with our international expert opinion on what we have learnt and where we need to go next as this pandemic continues across the globe.
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Journal articleNewman H, Clunie G, Wallace S, et al., 2022, , Journal of Critical Care, Vol: 72, Pages: 1-16, ISSN: 0883-9441
Purpose: Tracheostomy is a common surgical procedure in ICU. Whilst often life-saving, it can have important impacts on patients. Much of the literature on tracheostomy focuses on timing and technique of insertion, risk factors and complications. More knowledge of patient experience of tracheostomy in ICU is needed to support person-centred care.Materials and Methods: Qualitative systematic review and metasynthesis of the literature on adult experience of tracheostomy in ICU. Comprehensive search of four bibliographic databases and grey literature. Title and abstract screening and full text eligibility was completed independently by two reviewers. Metasynthesis was achieved using thematic synthesis, supported by a conceptual framework of humanised care.Results: 2971 search returns were screened on title and abstract and 127 full texts assessed for eligibility. Thirteen articles were included for analysis. Five descriptive and three analytical themes were revealed. The over-arching theme was ‘To be seen and heard as a whole person’. Patients wanted to be treated as a human, and having a voice made this easier.Conclusions: Voice restoration should be given high priority in the management of adults with a tracheostomy in ICU. Staff training should focus on both technical skills and compassionate care to improve person-centred outcomes.
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Journal articleHall AJ, Clement ND, Ojeda-Thies C, et al., 2022, , SURGEON-JOURNAL OF THE ROYAL COLLEGES OF SURGEONS OF EDINBURGH AND IRELAND, Vol: 20, Pages: E429-E446, ISSN: 1479-666X
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Journal articleRuparell K, Barve R, Tas RN, et al., 2022, , BMJ OPEN, Vol: 12, ISSN: 2044-6055
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