Patient Perspectives on Transitions from Acute to Community-Based Physiotherapy Care Following Total Knee Replacement Surgery Within the Context of a Bundled Care Model.

Purpose: Research on fiscal implications of the bundled care (BC) model exist; however, patient-perceived experiences are less well known. As BC expands in Ontario, this study aims to examine these experiences with physiotherapy care within the total knee replacement (TKR) BC programme. Methods: Qualitative cross-sectional study design. Semi-structured one-on-one telephone interviews were conducted with eight patients four to six weeks post-TKR. Thematic analysis was used. Results: This exploratory study identified three themes across the care journey that patients perceived as influencing their physiotherapy experiences: timely access to physiotherapy care, quality of physiotherapy care, and patient outcomes. Communication, clinical support, and social support were sub-themes. Conclusions: Patients' overall experiences with BC physiotherapy were positive. Areas for improvement included coordination of postoperative physiotherapy and return-to-work support. Patients valued group settings and were interested in meeting previous TKR patients. Health system planners are advised to consider incorporating patient experiences when evaluating and developing BC programmes to achieve patient-centred outcomes.

Objectif : il existe des recherches sur les conséquences budgétaires du modèle des faisceaux de soins (FS), mais les expériences perçues par les patients sont moins connues. Puisque le FS se généralise en Ontario, la présente étude vise à examiner ces expériences dans le contexte des soins physiothérapiques au sein du programme de FS de l'arthroplastie totale du genou (ATG). Méthodologie : étude transversale qualitative. Les chercheurs ont effectué des entrevues téléphoniques individuelles semi-structurées auprès de huit patients, de quatre à six semaines après une ATG. Ils ont utilisé une analyse thématique. Résultats : cette étude exploratoire a permis de faire ressortir trois thèmes dans le parcours des soins que les patients perçoivent comme influents sur leurs expériences de la physiothérapie : l'accès rapide aux soins de physiothérapie, la qualité de ces soins et l'issue des patients. Les sous-thèmes de la communication, du soutien clinique et du soutien social ont également été dégagés. Conclusions : les expériences globales des patients à l'égard de la physiothérapie des FS étaient positives. Les secteurs à améliorer incluaient la coordination de la physiothérapie postopératoire et le soutien au retour au travail. Les patients aimaient les contextes de groupe et s'intéressaient à rencontrer des patients qui avaient déjà subi une ATG. Les planificateurs du système de santé sont invités à envisager d'intégrer les expériences des patients lorsqu'ils évaluent et développent des programmes de FS pour obtenir des résultats axés sur les patients.

Metastasis to the Bladder: A Rare Site of Recurrence of Renal Cell Carcinoma.

Renal cell carcinoma (RCC) is considered to be the deadliest urologic cancer with high rates of metastasis and recurrence after nephrectomy. RCC can metastasize to nearly any organ but most commonly metastasizes to the liver, lung, brain, and bone. To date, there are only about 40 reported cases of RCC with solitary bladder metastasis. The following report contributes to this limited data set of patients with RCC who develop solitary metastasis to the bladder. A 69-year-old male presented with occasional gross hematuria and was found to have a left renal mass infiltrating the collecting system. Ureteroscopic biopsy revealed clear cell RCC, and the patient subsequently underwent radical left nephrectomy. Eight months after nephrectomy, the patient presented to the clinic with gross hematuria. In-office cystoscopy demonstrated a nodular lesion in the bladder arising from the left ureteral orifice. The patient underwent transurethral resection of the bladder mass and pathology demonstrated clear cell RCC. Subsequent imaging showed no evidence of metastatic disease. Five months after transurethral resection, the patient was found to have a left distal ureteral mass and underwent left ureterectomy with partial cystectomy. Pathology again demonstrated clear cell RCC. RCC with solitary metastasis to the bladder is rare, and there are no targeted guideline recommendations for management. Per standard of care, patients with painless hematuria and risk factors for malignancy should undergo cystoscopy. In patients with a history of RCC, metastasis to the bladder should be considered in the differential diagnosis. Patients with metastatic RCC to the bladder should undergo a thorough work-up for additional sites of metastasis. In patients with RCC who develop solitary bladder metastasis amenable to resection following nephrectomy, there is a lack of evidence to guide therapy and a multidisciplinary discussion is warranted. However, if the tumor is amenable to resection, metastasectomy is a reasonable therapeutic approach and offers the patient an improved quality of life and an opportunity for remission.

Identification of Risk Factors for Testing of Hepatitis C in Non-Birth Cohort Patients: Is Universal Screening Necessary?

OBJECTIVES: CDC reported that 45% of Hepatitis C (HCV) infected people denied known risk factors. Electronic health record RF-based, non-Birth Cohort (born outside of years 1945-1965) screening is challenging as risk factors are often input as nonsearchable data. Testing non-Birth Cohort patients solely based on risk factors has the potential to miss a substantial number of HCV infected patients. The aim was to determine the HCV antibody positive prevalence who would have been missed had providers only followed risk factor based screening recommendations. METHODS: A 1:3 case-control retrospective nested chart review was conducted. HCV risk factors and opioid prescriptions were manually abstracted from the Electronic Health Record; other variables were collected using Explorys. In July 2015 HCV screening data was collected on non-Birth Cohort patients who were HCV tested across MedStar Health, as a presumptive marker for high risk. Univariate and multivariate logistic regression models were utilized to determine HCV antibody positive predictors. RESULTS: Eighteen (23%) HCV antibody positive and 123 (49%) HCV antibody negative had no identified risk factors; 6 (33%) HCV antibody positive reported risk factors only after a positive test result. There was a significant interaction between age over 40 and opioid prescription use; these groups were 11× more likely to be HCV antibody positive (CI95 1.6-74.8). CONCLUSIONS: HCV testing solely based on presence of risk factors in non-Birth Cohort patients has the potential to miss a significant number of HCV antibody positive patients. Given patient- and provider-level barriers in elucidating risk factors, universal HCV antibody screening may be warranted.

Regional differences for pancreaticoduodenectomy in Florida: Location matters.

INTRODUCTION: Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS: Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS: Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS: There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.

Menthol Enhances the Desensitization of Human α3ß4 Nicotinic Acetylcholine Receptors.

The α3ß4 nicotinic acetylcholine receptor (nAChR) subtype is widely expressed in the peripheral and central nervous systems, including in airway sensory nerves. The nAChR subtype transduces the irritant effects of nicotine in tobacco smoke and, in certain brain areas, may be involved in nicotine addiction and/or withdrawal. Menthol, a widely used additive in cigarettes, is a potential analgesic and/or counterirritant at sensory nerves and may also influence nicotine's actions in the brain. We examined menthol's effects on recombinant human α3ß4 nAChRs and native nAChRs in mouse sensory neurons. Menthol markedly decreased nAChR activity as assessed by Ca(2+) imaging, (86)Rb(+) efflux, and voltage-clamp measurements. Coapplication of menthol with acetylcholine or nicotine increased desensitization, demonstrated by an increase in the rate and magnitude of the current decay and a reduction of the current integral. These effects increased with agonist concentration. Pretreatment with menthol followed by its washout did not affect agonist-induced desensitization, suggesting that menthol must be present during the application of agonist to augment desensitization. Notably, menthol acted in a voltage-independent manner and reduced the mean open time of single channels without affecting their conductance, arguing against a simple channel-blocking effect. Further, menthol slowed or prevented the recovery of nAChRs from desensitization, indicating that it probably stabilizes a desensitized state. Moreover, menthol at concentrations up to 1 mM did not compete for the orthosteric nAChR binding site labeled by [(3)H]epibatidine. Taken together, these data indicate that menthol promotes desensitization of α3ß4 nAChRs by an allosteric action.