Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use.

PURPOSE: Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use. METHODS: A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use. RESULTS: Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index. CONCLUSIONS: The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Lumbar Spine Sagittal Mismatch Deformity Negatively Affects Total Knee Arthroplasty Outcomes.

There is currently a paucity of data regarding the potential relationships between preexisting spinal deformity and clinical outcomes following total knee arthroplasty (TKA). We sought to expand upon this deficit. We hypothesize that lumbar sagittal mismatch deformity (MD) will correlate with a decrease in functional outcomes after TKA. This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure sagittal parameters of interest: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, and deformity mismatch. Ninety-four TKAs were subsequently available for inclusion and divided into two groups: those with MD as defined by |PI-LL| > 10 degrees and those without MD. The following clinical outcomes were compared between the groups: total postoperative arc of motion (AOM), incidence of flexion contracture, and need for manipulation under anesthesia (MUA). In total, 53 TKAs met the MD criteria, while 41 did not have MD. There were no significant differences in demographics, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with MD were more likely to have MUA (p = 0.026), ROM <0 to 120 (p < 0.001), a decreased AOM by 16 degrees (p < 0.001), and a flexion contracture postoperatively (p = 0.01). Preexisting MD may adversely affect clinical results following TKA. Statistically and clinically significant decreases in postoperative ROM/AOM, increased likelihood of flexion contracture, and increased need for MUA were all noted in those with MD. This is a Level 3 study.

Severity and location of lumbar spine stenosis affects the outcome of total knee arthroplasty.

BACKGROUND: Recent studies have noted that patients with pre-existing lumbar spinal stenosis (LSS) have lower functional outcomes after total knee arthroplasty (TKA). Given that LSS manifests heterogeneously in location and severity, its influence on knee replacement merits a radiographically targeted analysis. We hypothesize that patients with more severe LSS will have diminished knee mobility before and after TKA. METHODS: This retrospective case series assessed all TKAs performed at our institution for primary osteoarthritis from 2017-2020. Preoperative lumbar magnetic resonance image (MRI) with no prior lumbar spine surgery was necessary for inclusion. Stenosis severity was demonstrated by (1) anterior-posterior (AP) diameter of the thecal sac and (2) morphological grade. TKA outcomes in 103 cases (94 patients) were assessed by measuring preoperative and postoperative arc of motion (AOM), postoperative flexion contracture, and need for manipulation under anesthesia. RESULTS: Patients with mild stenosis did significantly better in terms of postoperative knee AOM. As AP diameter decreased at levels L1-2, L2-3, L3-4, and L4-5, there was a significant reduction in preoperative-AOM (p < 0.001 for each), with a 16 degree decrease when using patients' most stenotic level (p < 0.001). The same was noted with respect to increased morphological grade (p < 0.001), with a 5 degree decrease for patients' most stenotic level (p < 0.001). CONCLUSION: Severe LSS, which is readily demonstrated by a reduction in the AP diameter of the thecal sac or increased morphological grade on MRI, correlated with a significant reduction in preoperative AOM that was not improved after TKA. Persistent postoperative reductions in AOM may contribute to reduced patient satisfaction and recovery. LEVEL OF EVIDENCE: Level 4.

Functional roles and foundational characteristics of psychologists in integrated primary care.

Psychologists are presented with unprecedented opportunities to integrate their work in primary care settings. Although some roles of psychologists in primary care overlap with those in traditional psychology practice settings, a number are distinct reflecting the uniqueness of the primary care culture. In this paper, we first describe the integrated primary care setting, with a focus on those settings that have components of patient centered medical home. We then describe functional roles and foundational characteristics of psychologists in integrated primary care. The description of functional roles emphasizes the diversity of roles performed. The foundational characteristics identified are those that we consider the 'primary care ethic,' or core characteristics of psychologists that serve as the basis for the various functional roles in integrated primary care. The 'primary care ethic' includes attitudes, values, knowledge, and abilities that are essential to the psychologist being a valued, effective, and productive primary care team member.

A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia.

BACKGROUND: There remains considerable disagreement regarding the relative efficacy of psychotherapy and medication across types of depression. METHOD: We used random effects meta-analysis to examine the relative efficacy of psychotherapy vis-à-vis medication at post-treatment and follow-up. We also estimated the relative efficacy of continued medication versus discontinued psychotherapy. As twenty-eight studies (39 effects, n=3,381) met inclusion criteria, we were able to conduct an adequately powered test of between-study heterogeneity and examine if the type of depression influenced relative efficacy. RESULTS: Psychotherapy and medication were not significantly different at post-treatment, however effect sizes were not consistent. Although there was no association between severity and relative efficacy, a small but significant advantage for medications in the treatment of dysthymia did emerge. However, psychotherapy showed a significant advantage over medication at follow-up and this advantage was positively associated with length of follow-up. Moreover, discontinued acute phase psychotherapy did not differ from continued medication at follow-up. LIMITATIONS: Limitations included relatively fewer studies of severe and chronic depression, as well as dysthymia. In addition, only a minority of studies reported follow-up data. CONCLUSIONS: Our results indicated that both psychotherapy and medication are viable treatments for unipolar depression and that psychotherapy may offer a prophylactic effect not provided by medication. However, our analyses diverged from previous findings in that effects were not consistent and medication was significantly more efficacious than psychotherapy in the treatment of dysthymia.

Towards a feminist empowerment model of forgiveness psychotherapy.

In recent years Enright and Fitzgibbon's (2000) process model of forgiveness therapy has received substantial theoretical and empirical attention. However, both the process model of forgiveness therapy and the social-cognitive developmental model on which it is based have received criticism from feminist theorists. The current paper considers feminist criticisms of forgiveness therapy and uses a feminist lens to identify potential areas for growth. Specifically, Worell and Remer's (2003) model of synthesizing feminist ideals into existing theory was consulted, areas of bias within the forgiveness model of psychotherapy were identified, and strategies for restructuring areas of potential bias were introduced. Further, the authors consider unique aspects of forgiveness therapy that can potentially strengthen existing models of feminist therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Psychiatrist effects in the psychopharmacological treatment of depression.

BACKGROUND: The National Institutes of Mental Health's (NIMH) 1985 Treatment of Depression Collaborative Research Program (TDCRP) reported that imipramine hydrochloride with clinical management (IMI-CM) was significantly more beneficial than placebo with clinical management (PLA-CM) for individuals undergoing treatment for depression. Unfortunately, in analyzing the NIMH TDCRP data, researchers ignored the potential effect that psychiatrists have on patient outcomes, thereby assuming that psychiatrists are equally effective. However, this assumption has yet to be supported empirically. Therefore, the purpose of the current study is to examine psychiatrist effects in the NIMH TDCRP study and to compare the variation among psychiatrists to the variation between treatments. METHOD: Data from 112 patients [IMI-CM (n = 57, 9 psychiatrists); PLA-CM (n = 55, 9 psychiatrists)] from the NIMH TDCRP study were reanalyzed using a multi-level model. RESULTS: The proportion of variance in the BDI scores due to medication was 3.4% (p < .05), while the proportion of variance in BDI scores due to psychiatrists was 9.1% (p < .05). The proportion of variance in the HAM-D scores due to medication was 5.9% (p < .05), while the proportion of variance in HAM-D scores due to psychiatrist was 6.7% (p = .053). Therefore, the psychiatrist effects were greater than the treatment effects. CONCLUSIONS: In this study, both psychiatrists and treatments contributed to outcomes in the treatment of depression. However, given that psychiatrists were responsible for more of the variance in outcomes it can be concluded that effective treatment psychiatrists can, in fact, augment the effects of the active ingredients of anti-depressant medication as well as placebo.