Drivers of inpatient hospitalization costs, joint-specific patient-reported outcomes, and health-related quality of life in shoulder arthroplasty for cuff tear arthropathy.

BACKGROUND: Cuff tear arthropathy (CTA) can be successfully treated with various types of shoulder arthroplasty. While reverse total shoulder arthroplasty (RSA) is commonly used to treat CTA, CTA hemiarthroplasty (CTA-H, hemiarthroplasty with an extended humeral articular surface) can also be effective in patients with preserved glenohumeral elevation and an intact coracoacromial (CA) arch. As the value of arthroplasty is being increasingly scrutinized, cost containment has become a priority. The objective of this study was to assess hospitalization costs and improvements in joint-specific measures and health-related quality of life for these two types of shoulder arthroplasty in the management of CTA. METHODS: Seventy-two patients (39 CTA-H and 33 RSA) were treated during the study time period using different selection criteria for each of the two procedures: CTA-H was selected in patients with retained active elevation, an intact CA arch, and an intact subscapularis, while RSA was selected in patients with pseudoparalysis or glenohumeral instability. The Simple Shoulder Test (SST) was used as a joint-specific patient-reported outcome measure. Improvement in quality-adjusted life years was measured using the Short Form 36. Costs associated with inpatient care were collected from hospital financial records. Univariate and multivariate analyses focused on determining predictors of hospitalization costs and improvements in patient-reported outcomes. RESULTS: Significant improvements in SST and Short Form 36 physical component scores were seen in both groups. Inpatient hospitalization costs were significantly higher in the RSA group than that in the CTA-H group ($15,074 ± $1614 vs. $10,389 ± $1948, P < .001), driven primarily by supplies including the cost of the prosthesis ($9005 ± $2521 vs. $4715 ± $2091, P < .001). The diagnosis of diabetes was an independent predictor of higher inpatient hospitalization costs for both groups. There were no independent predictors for quality-adjusted life year improvements. SST improvement in the CTA-H group was significantly higher in patients with lower preoperative SST scores. CONCLUSION: Using a standard algorithm of CTA-H for shoulders with retained active elevation and an intact CA arch and RSA for poor active elevation or glenohumeral instability, both procedures led to significant improvements in health-related quality of life and joint-specific measures. Costs were significantly lower for patients meeting the selection criteria for CTA-H. Further value analytics are needed to compare the relative cost effectiveness of RSA and CTA-H for patients with CTA having retained active elevation, intact CA arch, and intact subscapularis.

Drivers of lower inpatient hospital costs and greater improvements in health-related quality of life for patients undergoing total shoulder and ream-and-run arthroplasty.

BACKGROUND: With increasing emphasis on value-based care and the heavy demands on the US health care budget, surgeons must be cognizant of factors that drive cost and quality of patient care. Our objective was to determine patient-level drivers of lower costs and improved health-related quality of life (HRQoL) in 2 anatomic shoulder arthroplasty procedures: total shoulder arthroplasty (TSA) and ream-and-run arthroplasty. METHODS: This study included 222 TSAs and 211 ream-and-run arthroplasties. Simple Shoulder Test, Single Assessment Numeric Evaluation, and Short Form 36 scores were collected preoperatively and 2 years postoperatively. Quality-adjusted life-years (QALYs) were calculated as a measure of HRQoL. Univariate and multivariate analyses determined factors significantly associated with decreased hospitalization costs and improved HRQoL. RESULTS: In the TSA group, female sex, lower American Society of Anesthesiologists class, diagnosis other than capsulorrhaphy arthropathy, lower pain score, and higher Single Assessment Numeric Evaluation score were associated with decreased total hospitalization costs; in addition, female sex was an independent predictor of lower total costs. Insurance other than workers' compensation, a diagnosis of chondrolysis, and higher optimism led to greater QALY gains, but a diagnosis of capsulorrhaphy arthropathy was the only independent predictor of greater QALY gains. In the ream-and-run arthroplasty group, older age, lower body mass index (BMI), lower American Society of Anesthesiologists class, insurance other than Medicaid, diagnosis other than capsulorrhaphy arthropathy, no history of surgery, higher preoperative Simple Shoulder Test score, and higher preoperative Short Form 36 Physical Component Summary score were associated with lower total costs; moreover, lower BMI was an independent predictor of lower costs. Higher preoperative optimism was an independent predictor of greater QALY gains. CONCLUSIONS: Identifying factors associated with decreased costs and increased quality is becoming increasingly important in value-based care. This study identified fixed (sex and diagnosis) and modifiable (BMI) factors that drive decreased hospitalization costs and increased HRQoL improvements in shoulder arthroplasty patients. Higher preoperative patient optimism is a consistent predictor of improved HRQoL for both TSA patients and ream-and-run arthroplasty patients, and further study on optimizing the influence of patient expectations and optimism may be warranted.

Arthroscopic management of glenohumeral arthritis in the young patient does not negatively impact the outcome of subsequent anatomic shoulder arthroplasty.

PURPOSE: The objective of this study was to determine the impact of prior arthroscopic management of glenohumeral arthritis in the young patient on results of subsequent anatomic shoulder arthroplasty. METHODS: Forty-three patients that had a total shoulder or ream-and-run arthroplasty with a history of arthroscopic management were matched to 86 patients without prior surgery. Each case was matched to two cases without prior arthroscopic surgery with similar age, sex, Walch classification, and type of arthroplasty. RESULTS: Forty-three patients with a history of arthroscopic management were matched to 86 patients without prior surgery. The mean two year SST scores (10.3 vs. 9.9, p = 0.334), % MPI (75.4 vs. 73.0%, p = 0.687), two year SANE scores (79.6 vs. 79.8, p = 0.953), and % of patients to exceed SST score MCID (89 vs. 91%, p = 0.860) and SANE score MCID (86 vs. 75%, p = 0.180) were statistically similar in patients with prior arthroscopic debridement compared with those without prior arthroscopic debridement. The rate of MUA (9 vs. 6%, p = 0.480) and open revision (9 vs. 8%, p = 1.000) were statistically similar between groups. CONCLUSION: Arthroscopic management of glenohumeral arthritis in patients aged 65 years and younger prior to anatomic shoulder arthroplasty was not associated with inferior outcomes for either total shoulder arthroplasty or ream-and-run arthroplasty.

Electricity and generator availability in LMIC hospitals: improving access to safe surgery.

BACKGROUND: Access to reliable energy has been identified as a global priority and codified within United Nations Sustainable Goal 7 and the Electrify Africa Act of 2015. Reliable hospital access to electricity is necessary to provide safe surgical care. The current state of electrical availability in hospitals in low- and middle-income countries (LMICs) throughout the world is not well known. This study aimed to review the surgical capacity literature and document the availability of electricity and generators. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search for surgical capacity assessments in LMICs in MEDLINE, PubMed, and World Health Organization Global Health Library was performed. Data regarding electricity and generator availability were extracted. Estimated percentages for individual countries were calculated. RESULTS: Of 76 articles identified, 21 reported electricity availability, totaling 528 hospitals. Continuous electricity availability at hospitals providing surgical care was 312/528 (59.1%). Generator availability was 309/427 (72.4%). Estimated continuous electricity availability ranged from 0% (Sierra Leone and Malawi) to 100% (Iran); estimated generator availability was 14% (Somalia) to 97.6% (Iran). CONCLUSIONS: Less than two-thirds of hospitals providing surgical care in 21 LMICs have a continuous electricity source or have an available generator. Efforts are needed to improve electricity infrastructure at hospitals to assure safe surgical care. Future research should look at the effect of energy availability on surgical care and patient outcomes and novel methods of powering surgical equipment.

Water availability at hospitals in low- and middle-income countries: implications for improving access to safe surgical care.

INTRODUCTION: Although two billion people now have access to clean water, many hospitals in low- and middle-income countries (LMICs) do not. Lack of water availability at hospitals hinders safe surgical care. We aimed to review the surgical capacity literature and document the availability of water at health facilities and develop a predictive model of water availability at health facilities globally to inform targeted capacity improvements. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search for surgical capacity assessments in LMICs in MEDLINE, PubMed, and World Health Organization Global Health Library was performed. Data regarding water availability were extracted. Data from these assessments and national indicator data from the World Bank (e.g., gross domestic product, total health expenditure, and percent of population with improved access to water) were used to create a predictive model for water availability in LMICs globally. RESULTS: Of the 72 records identified, 19 reported water availability representing 430 hospitals. A total of 66% of hospitals assessed had water availability (283 of 430 hospitals). Using these data, estimated percent of water availability in LMICs more broadly ranged from under 20% (Liberia) to over 90% (Bangladesh, Ghana). CONCLUSIONS: Less than two-thirds of hospitals providing surgical care in 19 LMICs had a reliable water source. Governments and nongovernmental organizations should increase efforts to improve water infrastructure at hospitals, which might aid in the provision of safe essential surgical care. Future research is needed to measure the effect of water availability on surgical care and patient outcomes.

Anesthesia Care Capacity at Health Facilities in 22 Low- and Middle-Income Countries.

BACKGROUND: Globally, an estimated 2 billion people lack access to surgical and anesthesia care. We sought to pool results of anesthesia care capacity assessments in low- and middle-income countries (LMICs) to identify patterns of deficits and provide useful targets for advocacy and intervention. METHODS: A systematic review of PubMed, Cochrane Database of Systematic Reviews, and Google Scholar identified reports that documented anesthesia care capacity from LMICs. When multiple assessments from one country were identified, only the study with the most facilities assessed was included. Patterns of availability or deficit were described. RESULTS: We identified 22 LMICs (15 low- and 8 middle-income countries) with anesthesia care capacity assessments (614 facilities assessed). Anesthesia care resources were often unavailable, including relatively low-cost ones (e.g., oxygen and airway supplies). Capacity varied markedly between and within countries, regardless of the national income. The availability of fundamental resources for safe anesthesia, such as airway supplies and functional pulse oximeters, was often not reported (72 and 36 % of hospitals assessed, respectively). Anesthesia machines and the capability to perform general anesthesia were unavailable in 43 % (132/307 hospitals) and 56 % (202/361) of hospitals, respectively. CONCLUSION: We identified a pattern of critical deficiencies in anesthesia care capacity in LMICs, including some low-cost, high-value added resources. The global health community should advocate for improvements in anesthesia care capacity and the potential benefits of doing so to health system planners. In addition, better quality data on anesthesia care capacity can improve advocacy, as well as the monitoring and evaluation of changes over time and the impact of capacity improvement interventions.

Clinical course and prognosis of non-secretory multiple myeloma.

OBJECTIVE: To determine the prognosis of patients with non-secretory myeloma. METHODS: We studied 124 patients diagnosed with multiple myeloma who had no monoclonal protein detected on serum and urine immunofixation at diagnosis and on all subsequent follow-up testing (non-secretory myeloma). The overall survival (OS) of patients with non-secretory myeloma was compared with 6953 patients with typical myeloma seen during the same time period in whom a monoclonal protein was detected at the time of diagnosis. RESULTS: One hundred and twenty-four patients met criteria for non-secretory multiple myeloma. The median follow-up was 102 months (range, 1-204 months). The median progression-free survival with initial therapy was 28.6 months, and the median OS was 49.3 months. There was a significant improvement in OS since 2001; median survival 43.8 months (prior to 2001) vs. 99.2 months (2001-2012), P < 0.001. OS was superior in patients with a normal baseline FLC ratio (n = 10) compared to patients with an abnormal ratio (n = 19), medians not reached in both groups. Prior to 2001, OS was similar in non-secretory myeloma (n = 86) and secretory myeloma (n = 4011), median 3.6 vs. 3.5 yr, respectively, P = 0.63. However, among patients diagnosed between 2001 and 2012, OS was superior in non-secretory myeloma (n = 36) compared to secretory myeloma (n = 2942), median 8.3 vs. 5.4 yr, respectively, P = 0.03. CONCLUSIONS: Non-secretory myeloma is an uncommon subtype of multiple myeloma. In the last decade, there has been an improvement in the survival of non-secretory myeloma and appears superior to secretory myeloma.

Clinical Course and Prognosis of Non-Secretory Multiple Myeloma.

OBJECTIVE: To determine the prognosis of patients with non-secretory myeloma. Methods: We studied 124 patients diagnosed with multiple myeloma who had no monoclonal protein detected on serum and urine immunofixation at diagnosis and on all subsequent follow up testing (non-secretory myeloma). The overall survival (OS) of patients with non-secretory myeloma was compared with 7075 patients with typical myeloma seen during the same time period in whom a monoclonal protein was detected at the time of diagnosis. RESULTS: One hundred and twenty four patients met criteria for non-secretory multiple myeloma. The median follow-up was 102 months (range, 1-204 months). The median progression free survival with initial therapy was 28.6 months, and the median OS was 49.3 months. There was a significant improvement in OS since 2001; median survival 99.2 versus 43.8 months (prior to 2001) versus 99.2 months (2001-2012), P<0.001. OS was superior in patients with a normal baseline FLC ratio (n=10) compared to patients with an abnormal ratio (n=19), medians not reached in both groups. Prior to 2001, OS was similar in non-secretory myeloma (n=86) and secretory myeloma (n=4011), median 3.6 versus 3.5 years, respectively, P=0.63. However, among patients diagnosed between 2001-2012, OS was superior in non-secretory myeloma (n=36) compared to secretory myeloma (n=2942), median 8.3 versus 5.4 years, respectively, P=0.03. CONCLUSIONS: Non-secretory myeloma is an uncommon subtype of multiple myeloma. In the last decade, there has been an improvement in the survival of non-secretory myeloma, and appears superior to secretory myeloma. This article is protected by copyright. All rights reserved.

Association Between Metabolic Syndrome and Hearing Impairment: a Study on 200 Subjects.

The metabolic syndrome (MS) is a cluster of conditions that occur. togehther, increase risk of heart disease, storke, type 2 diabetes mellitus and hypertension as a possible outcome. The previous research has shown a link between hearing loss and being overweight, diabetic, or suffering from heart disease. However, research on the possible link between hearing loss and metabolic syndrome is limited. Hearing loss due to metabolic syndrome was evaluated in the present investigation. Two hundred individuals with metabolic syndrome were included. All the patients were evaluated on three types of audiometry (pure tone, impedence, and DPOAE).Anthropometric data, blood pressure, blood sugar, and lipid profiles, were all collected from each patient. We also asked about their smoking and drinking habits in the past. SPSS v. 22.0 was used to conduct the statistical analysis. Overall, SNHL affected 58.5% of patients. Patients having moderate hearing loss were the largest demographic group (40%), followed by those with mild hearing loss (15% ). Severe hearing loss only occurred in 3.5% of patients. Hearing loss was shown to be more prevalent in patients with more than three components of metabolic syndrome. Significant associations were found between hearing impairment and metabolic risk factors as waist circumference, fasting blood sugar, serum high-density lipoprotein, serum triglycerides, and systolic and diastolic blood pressure. Hearing loss was only marginally connected to smoking and excessive drinking.

Pantalar Arthrodesis.

A triple arthrodesis is comprised of subtalar, talonavicular, and calcaneocuboid joints arthrodesis. A pantalar arthrodesis is triple arthrodesis combined with tibiotalar arthrodesis. The goal of the procedure is to obtain a correction of deformity and achieve a plantigrade, functional, painless, stable, weightbearing foot that can be used to ambulate. This is done by creating an osseous continuity across the ankle, subtalar, and talonavicular, and calcaneocuboid joints. There are several approaches and fixation strategies that result in successful clinical union and should be chosen to match the clinical situation. Modern techniques result in high rates of union and pain relief.

Functional and Radiographic Disease Progression in Nonoperatively Managed Kienböck Disease.

BACKGROUND: The purpose of this study was to describe the natural history of Kienböck disease among patients who elected to proceed with nonoperative treatment. METHODS: The authors performed a retrospective study of all patients treated nonoperatively for Kienböck disease within their institution from January 1, 1999, to December 31, 2014. Inclusion criteria included follow-up greater than 1 year, serial posteroanterior and lateral wrist radiographs, and clinical examination. Posteroanterior/lateral radiographs were independently reviewed at initial presentation and at final follow-up, including Lichtman stage, carpal index, Stahl index, ulnar variance, and intercarpal angles. RESULTS: Twenty-five patients with 25 wrists were included (mean age, 50.2 years), with an average length of clinical follow-up of 3.9 years and a mean length of radiographic follow-up of 5.2 years. There was no significant difference in range of motion; however, patient-reported pain was significantly decreased, and modified Mayo wrist scores and grip strength were increased. Lichtman stage, scapholunate angle, and radioscaphoid angle were increased; and carpal index, posteroanterior lunate ratio, and Stahl index were decreased across the study period. The mean progression in Lichtman stage was 0.5 stage/year with a range of 0 to 1.6 stages/year throughout the study period. There was no significant difference in Lichtman stage progression based on stage at presentation. A history of smoking was associated with increased radiographic disease progression. CONCLUSION: The present study demonstrates that among patients with Kienböck disease managed nonoperatively, the majority of patients significantly improve over time with respect to pain, grip strength, and Mayo wrist score, despite radiographic progression of disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Fresh Precut Osteochondral Allograft Core Transplantation for the Treatment of Capitellum Osteochondritis Dissecans.

Osteochondritis dissecans (OCD) of the elbow is a disease of unclear etiology that affects young children and adolescents, particularly overhead athletes and gymnasts. Common surgical options include fixation, debridement, loose body removal, and marrow stimulation (microfracture/drilling). For large, deep, and/or uncontained defects, osteochondral autograft transplantation (OAT) has been advocated. However, there are some drawbacks to OAT, particularly related to donor-site morbidity. Fresh osteochondral allograft (OCA) transplantation avoids the donor-site morbidity associated with OAT and has been shown to be effective for treating capitellar OCD. This Technical Note details a surgical technique of OCA transplantation of the capitellum in an adolescent patient using a fresh precut OCA core. This procedure addresses the cartilage defect and loss of subchondral bone associated with OCD without the drawbacks associated with harvesting an autograft. Furthermore, as the graft is readily available, it avoids delays related to the donor-recipient matching process.

Safe Distraction Technique for Hip Arthroscopy in a Polytraumatized Patient with Pelvic, Acetabular, and Ankle Fractures: A Case Report.

CASE: A healthy 41-year-old man presented after a motorcycle collision resulting in polytrauma and underwent hip arthroscopy for removal of loose bodies after initial stabilization of pelvic, acetabular, and ipsilateral ankle fractures. Given these injuries, a novel hip distraction technique with a combination of postless traction and skeletal traction was used. CONCLUSION: Specific considerations for hip arthroscopy with concomitant acetabular fracture include alternate techniques for joint distraction, maintenance of low pump pressures, and technical pearls for clearing hemarthrosis. Orthopaedic surgeons familiar with hip arthroscopy can use these methods.

Place, poverty and prescriptions: a cross-sectional study using Area Deprivation Index to assess opioid use and drug-poisoning mortality in the USA from 2012 to 2017.

OBJECTIVE: To identify the relationships between county-level area deprivation and patterns of both opioid prescriptions and drug-poisoning mortality. DESIGN, SETTING AND PARTICIPANTS: For this retrospective cross-sectional study, we used the IQVIA Xponent data to capture opioid prescriptions and Centres for Disease Control and Prevention National Vital Statistics System to assess drug-poisoning mortality. The Area Deprivation Index (ADI) is a composite measure of social determinants of health comprised of 17 US census indicators, spanning four socioeconomic domains. For all US counties with available opioid prescription (2712 counties) and drug-poisoning mortality (3133 counties) data between 2012 and 2017, we used negative binomial regression to examine the association between quintiles of county-level ADI and the rates of opioid prescriptions and drug-poisoning mortality adjusted for year, age, race and sex. PRIMARY OUTCOME MEASURES: County-level opioid prescription fills and drug-poisoning mortality. RESULTS: Between 2012 and 2017, overall rates of opioid prescriptions decreased from 96.6 to 72.2 per 100 people, while the rates of drug-poisoning mortality increased from 14.3 to 22.8 per 100 000 people. Opioid prescription and drug-poisoning mortality rates were consistently higher with greater levels of deprivation. The risk of filling an opioid prescription was 72% higher, and the risk of drug-poisoning mortality was 36% higher, for most deprived compared with the least deprived counties (both p<0.001). DISCUSSION: Counties with greater area-level deprivation have higher rates of filled opioid prescriptions and drug-poisoning mortality. Although opioid prescription rates declined across all ADI quintiles, the rates of drug-poisoning mortality continued to rise proportionately in each ADI quintile. This underscores the need for individualised and targeted interventions that consider the deprivation of communities where people live.

Association of Neighborhood Measures of Social Determinants of Health With Breast, Cervical, and Colorectal Cancer Screening Rates in the US Midwest.

Importance: Despite advances in cancer treatment and cancer-related outcomes, disparities in cancer mortality remain. Lower rates of cancer prevention screening and consequent delays in diagnosis may exacerbate these disparities. Better understanding of the association between area-level social determinants of health and cancer screening may be helpful to increase screening rates. Objective: To examine the association between area deprivation, rurality, and screening for breast, cervical, and colorectal cancer in patients from an integrated health care delivery system in 3 US Midwest states (Minnesota, Iowa, and Wisconsin). Design, Setting, and Participants: In this cross-sectional study of adults receiving primary care at 75 primary care practices in Minnesota, Iowa, and Wisconsin, rates of recommended breast, cervical, and colorectal cancer screening completion were ascertained using electronic health records between July 1, 2016, and June 30, 2017. The area deprivation index (ADI) is a composite measure of social determinants of health composed of 17 US Census indicators and was calculated for all census block groups in Minnesota, Iowa, and Wisconsin (11 230 census block groups). Rurality was defined at the zip code level. Using multivariable logistic regression, this study examined the association between the ADI, rurality, and completion of cancer screening after adjusting for age, Charlson Comorbidity Index, race, and sex (for colorectal cancer only). Main Outcomes and Measures: Completion of recommended breast, cervical, and colorectal cancer screening. Results: The study cohorts were composed of 78 302 patients eligible for breast cancer screening (mean [SD] age, 61.8 [7.1] years), 126 731 patients eligible for cervical cancer screening (mean [SD] age, 42.6 [13.2] years), and 145 550 patients eligible for colorectal cancer screening (mean [SD] age, 62.4 [7.0] years; 52.9% [77 048 of 145 550] female). The odds of completing recommended screening were decreased for individuals living in the most deprived (highest ADI) census block group quintile compared with the least deprived (lowest ADI) quintile: the odds ratios were 0.51 (95% CI, 0.46-0.57) for breast cancer, 0.58 (95% CI, 0.54-0.62) for cervical cancer, and 0.57 (95% CI, 0.53-0.61) for colorectal cancer. Individuals living in rural areas compared with urban areas also had lower rates of cancer screening: the odds ratios were 0.76 (95% CI, 0.72-0.79) for breast cancer, 0.81 (95% CI, 0.79-0.83) for cervical cancer, and 0.93 (95% CI, 0.91-0.96) for colorectal cancer. Conclusions and Relevance: Individuals living in areas of greater deprivation and rurality had lower rates of recommended cancer screening, signaling the need for effective intervention strategies that may include improved community partnerships and patient engagement to enhance access to screening in highest-risk populations.

Basilar Thumb Arthritis: The Utility of Suture-Button Suspensionplasty.

BACKGROUND: We sought to compare the functional outcomes, radiographic outcomes, and complications of trapeziectomy and flexor carpi radialis (FCR) to abductor pollicis longus (APL) side-to-side tendon transfer with or without suture-button suspensionplasty for thumb basilar joint arthritis. METHODS: Patients treated with and without suture-button suspensionplasty were compared over a 6-year period. Data were reviewed for complications and functional outcomes, including grip and pinch strength, range of motion, and visual analog scale (VAS) pain scores. Plain radiographs were independently reviewed at initial presentation and at final follow-up, including proximal phalanx length, trapezial space height, and trapezial height ratio. RESULTS: Seventy thumb arthroplasties were performed in 70 patients. Trapeziectomy with FCR-APL side-to-side tendon transfer was performed in 39 patients, and trapeziectomy with FCR-APL side-to-side tendon transfer with suture-button suspensionplasty was performed in 31 patients. Mean length of follow-up was 28.4 ± 3.9 and 23.8 ± 2.6 months, respectively. Postoperative grip, oppositional and appositional pinch strength, and VAS pain scores improved compared with preoperative values, but were not significantly different based on suture-button suspensionplasty. Percentage decline in trapezial space ratio was significantly different between groups at 36.7% and 20.4% for procedures with and without suture-button suspensionplasty, respectively indicating that the trapezial space was better maintained within the suture suspension cohort. The incidence of postoperative complications, including surgical site infection, paresthesias, reoperation, complex regional pain syndrome, and symptomatic subsidence, was not significantly different between groups. CONCLUSIONS: Trapeziectomy with FCR to APL side-to-side tendon transfer with and without suture-button suspensionplasty results in comparable improvement in pain, grip strength, and functional parameters. Suture-button suspensionplasty results in significantly greater preservation of trapezial space.

Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis.

Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I2) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I2 = 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I2 = 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I2 = NA; IRR = 0.88, 95% CI 0.64, 1.20, I2 = 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I2 = 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.

Musculoskeletal disease in Nepal: A countrywide cross-sectional survey on burden and surgical access.

INTRODUCTION: Musculoskeletal disease (MSD) is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in low and middle-income countries (LMICs) are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure incidence and prevalence of surgically treatable conditions, including MSD, in patients in LMICs. METHODS: A countrywide survey was done in Nepal using SOSAS in May-June 2014. Clusters were chosen based on population weighted random sampling. Chi squared tests and multivariate logistic regression assessed associations between demographic variables and MSD. RESULTS: Self-reported MSDs were seen in 14.8% of survey respondents with an unmet need of 60%. The majority of MSDs (73.9%) occurred between 1 and 12 months prior to the survey. Female sex (OR = 0.6; p < 0.000), access to motorized transport (for secondary facility, OR = 0.714; p < 0.012), and access to a tertiary health facility (OR = 0.512; p < 0.008) were associated with lower odds of MSD. DISCUSSION: Based on this study, there are approximately 2.35 million people living with MSDs in Nepal. As the study identified non-availability, lack of money, and fear and/or lack of trust as the major barriers to orthopedic care in Nepal, future work should consider interventions to address these barriers. CONCLUSION: There is a need to increase surgical capacity in LMICs; in particular, there is a need to bolster trauma and orthopedic care. Previous studies have suggested ways to allocate resources to build capacity. We recommend targeting the alleviation of these identified barriers in parallel with capacity building.