Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.

AIMS: To conduct a concept analysis of clinical practice contexts (work environments) in health care. BACKGROUND: Context is increasingly recognized as important to the development, delivery, and understanding of implementation strategies; however, conceptual clarity about what comprises context is lacking. DESIGN: Modified Walker and Avant concept analysis comprised of five steps: (1) concept selection; (2) determination of aims; (3) identification of uses of context; (4) determination of its defining attributes; and (5) definition of its empirical referents. METHODS: A wide range of databases were systematically searched from inception to August 2014. Empirical articles were included if a definition and/or attributes of context were reported. Theoretical articles were included if they reported a model, theory, or framework of context or where context was a component. Double independent screening and data extraction were conducted. Analysis was iterative, involving organizing and reorganizing until a framework of domains, attributes. and features of context emerged. RESULT: We identified 15,972 references, of which 70 satisfied our inclusion criteria. In total, 201 unique features of context were identified, of these 89 were shared (reported in two or more studies). The 89 shared features were grouped into 21 attributes of context which were further categorized into six domains of context. CONCLUSION: This study resulted in a framework of domains, attributes and features of context. These attributes and features, if assessed and used to tailor implementation activities, hold promise for improved research implementation in clinical practice.

BACKGROUND: To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff. AIM: To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system. DESIGN: A structured content analysis of a national guideline and local policies using a behaviour specification framework. METHODS: Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist. RESULTS: There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%). CONCLUSION: Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability. RELEVANCE TO CLINICAL PRACTICE: Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff.

AIM: To develop a theory-based complex intervention (targeting nursing staff), to enhance enablers and overcome barriers to enact expected behaviour when monitoring patients and responding to abnormal vital signs that signal deterioration. DESIGN: A mixed method design including structured observations on hospital wards, field notes, brief, unrecorded interviews and semi-structured interviews to inform the development of an intervention to enhance practice. METHODS: Semi-structured interviews will be conducted with nursing staff using a topic guide informed by the Theoretical Domains Framework. Semi-structured interviews will be transcribed verbatim and coded deductively into the 14 Theoretical Domains Framework domains and then inductively into "belief statements". Priority domains will be identified and mapped to appropriate behaviour change techniques. Intervention content and mode of delivery (how behaviour change techniques are operationalized) will be developed using nominal groups, during which participants (clinicians) will rank behaviour change techniques/mode of delivery combinations according to acceptability and feasibility. Findings will be synthesised to develop an intervention manual. DISCUSSION: Despite being a priority for clinicians, researchers and policymakers for two decades, "sub-optimal care" of the deteriorating ward patient persists. Existing interventions have been largely educational (i.e. targeting assumed knowledge deficits) with limited evidence that they change staff behaviour. Staff behaviour when monitoring and responding to abnormal vital signs is likely influenced by a range of mediators that includes barriers and enablers. IMPACT: Systematically applying theory and evidence-based methods, will result in the specification of an intervention which is more likely to result in behaviour change and can be tested empirically in future research.

AIMS: To systematically review the evidence for the effect of pelvic organ prolapse (POP) and/or continence surgery on pelvic floor muscle (PFM) morphometry and function in women, and to investigate whether a relationship exists between PFM measures and clinician-reported objective pelvic floor outcomes postoperatively. METHODS: Six electronic databases were searched until March 2018. Studies were included if they examined the effect of POP and/or continence surgery on the PFM in women, and reported pre- and postoperative data. Methodological quality was assessed using a modified Downs and Black checklist. Three meta-analyses were planned based on postoperative follow-up time. RESULTS: Twenty-one studies met the inclusion criteria. Varied surgical interventions and 33 different PFM measures were represented. The methodological quality of included studies varied considerably. The 0 to 6 weeks postoperative meta-analysis showed no statistically significant change in PFM function (SMD = 0.04; 95% confidence interval [CI] = -0.26 to 0.33). This was consistent at 3 and 6 or more months (SMD = 1.13; 0.35 95% CI = -0.34 to 2.60, - 0.42 to 1.12 respectively). None of the included studies investigated the relationship between PFM measures and clinician-reported objective outcomes postoperatively. CONCLUSIONS: This review did not show a clear effect of POP and/or continence surgery on PFM morphometry or function in women and was unable to show a relationship with outcomes such as objective prolapse score and urodynamic findings. This could be because surgery does not measurably impact on the PFM or due to the poor quality and heterogeneity of studies. Future well-designed research is needed to specifically investigate change in the PFM following surgery.

BACKGROUND: Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life; nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes. METHODS: A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48 h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C); (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SS score of less than 48/60. RESULTS: The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650) kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000 kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.4-3.3, P = 0.001] and malnutrition (OR = 1.9, 95% CI = 1.1-3.2, P = 0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3 kg; 95% CI = -2.4 to -0.2, P = 0.02) and physical function scores (-0.6 points; 95% CI = -0.9 to -0.3, P = 0.001). CONCLUSIONS: Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.

OBJECTIVE: To explore if there is a relationship between allied health professionals' confidence to perform a range of evidence-based practice (EBP) activities and the time since they graduated from their entry-level degree and the presence of postgraduate qualifications. DESIGN: Cross-sectional survey. SETTING: Allied health professionals from two Australian public metropolitan health services, including acute, subacute, and community settings. PARTICIPANTS: Sample of 288 (n = 288) allied health professionals from the disciplines of physiotherapy, occupational therapy, speech pathology, social work, dietetics/nutrition, and other. MAIN OUTCOME MEASURE: Cross-sectional survey including 12 questions measuring respondents' confidence to conduct a range of EBP activities. RESULTS: Allied health professionals begin to lose confidence related to EBP activities within the first 5 years of clinical practice, particularly for those activities involving critical analysis of published studies. Respondents with postgraduate qualifications were more likely to report greater confidence with EBP activities, suggesting that higher level qualifications protect against the effect of degradation of EBP skills and confidence over time. CONCLUSIONS: Allied health professionals' confidence to perform EBP activities degrades over time, particularly for those individuals with no postgraduate qualifications. Registration and accreditation bodies along with allied health professional employers should explore potential strategies to preserve and enhance EBP skills, confidence, and behaviours.

OBJECTIVE: To explore patient experiences of, and preferences for, physical activity after a lung cancer diagnosis. METHODS: This was a qualitative study involving seven patients who had been treated for lung cancer within the previous 2 years. Participants attended a focus group interview. Conventional content analysis methodology was used to analyse the text by two independent researchers. RESULTS: Eight major themes emerged from the data. These were as follows: the influence of past lifestyle and chronic disease; the perceived benefits of physical activity; using physical activity to facilitate return to activities of daily living; the impact of symptoms, capacity and motivation; family and peer support; access to services; health professionals; and enjoyment of different types of physical activity. Patients suggested several factors that could improve their healthcare experience. These include access to exercise professionals particularly after cancer treatment; access to information about physical activity in different formats; supervision from health professionals and peer support; and use of behaviour change strategies to achieve sustainable increases in physical activity. CONCLUSION: Our results should be considered in the improvement of lung cancer care pathways as we strive to implement physical activity services into routine clinical care.

KEY POINTS: Shift work is highly prevalent and is associated with significant adverse health impacts. There is substantial inter-individual variability in the way the circadian clock responds to changing shift cycles. The mechanisms underlying this variability are not well understood. We tested the hypothesis that light-dark exposure is a significant contributor to this variability; when combined with diurnal preference, the relative timing of light exposure accounted for 71% of individual variability in circadian phase response to night shift work. These results will drive development of personalised approaches to manage circadian disruption among shift workers and other vulnerable populations to potentially reduce the increased risk of disease in these populations. ABSTRACT: Night shift workers show highly variable rates of circadian adaptation. This study examined the relationship between light exposure patterns and the magnitude of circadian phase resetting in response to night shift work. In 21 participants (nursing and medical staff in an intensive care unit) circadian phase was measured using 6-sulphatoxymelatonin at baseline (day/evening shifts or days off) and after 3-4 consecutive night shifts. Daily light exposure was examined relative to individual circadian phase to quantify light intensity in the phase delay and phase advance portions of the light phase response curve (PRC). There was substantial inter-individual variability in the direction and magnitude of phase shift after three or four consecutive night shifts (mean phase delay -1:08 ± 1:31 h; range -3:43 h delay to +3:07 h phase advance). The relative difference in the distribution of light relative to the PRC combined with diurnal preference accounted for 71% of the variability in phase shift. Regression analysis incorporating these factors estimated phase shift to within ±60 min in 85% of participants. No participants met criteria for partial adaptation to night work after three or four consecutive night shifts. Our findings provide evidence that the phase resetting that does occur is based on individual light exposure patterns relative to an individual's baseline circadian phase. Thus, a 'one size fits all' approach to promoting adaptation to shift work using light therapy, implemented without knowledge of circadian phase, may not be efficacious for all individuals.

AIMS: to assess pelvic floor muscle maximum voluntary contraction (MVC) before and after surgical treatment for pelvic organ prolapse (POP). METHODS: This was a prospective observational study with women scheduled for surgical correction of POP. Assessments occurred 15 days before and 40 days after surgery. The primary outcome was pelvic floor muscle (PFM) MVC measured using the manometer Peritron™. The average strength of PFM contraction was also measured. Secondary outcomes were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) score. The Student paired t-test was used for quantitative data. For the pre and postsurgery comparisons of PFM strength in relation to POP-Q value we used the nonparametric Kruskal-Wallis test for dependent variables. The level of significance adopted was P < 0.05. RESULTS: Sixty-seven women were recruited, 65 (97%) completed the study. The mean age of participants was 62 ± 10.2. There was no difference (1.9 cm H2 O ± 12.9; P = 0.22) between MVC before (27.1 cm H2 O ± 17.0) and after surgery (29 cm H2 O ± 17.8). The average contraction was higher after surgery (2.3 cmH2 O ± 8.6; P = 0.03). The higher the severity of pre and postsurgery POP, the worse the MVC. CONCLUSION: There was no difference in MVC pre and postsurgery, however we found an improvement in PFM average contraction strength postsurgery.