Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: Smoking Cessation Disparities.

Currently, 13.7% of the adult American population smokes cigarettes. Although rates of cigarette smoking have decreased over time, those of e-cigarette usage have increased. Smoking rates are highest in American Indians/Alaskan Natives and adults whose highest education level is a General Educational Development certificate, who live in rural American areas, and who have an annual household income of less than $35,000. After arthroplasty, smoking is linked to impaired wound healing, superficial and deep wound infections, and aseptic loosening. Patients who smoke should be strongly encouraged to stop and be supported with smoking cessation programs. Monitoring smoking cessation with cotinine levels may be inaccurate because variations have been noted in race, ethnicity, and sex. Confirmation of cessation as a hard stop to surgery could increase existing healthcare disparities. The role of the surgeon in encouraging patients to stop smoking, at least temporarily, before total joint arthroplasty cannot be overemphasized.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Dental Health Disparities.

Poor oral health is common in the United States; however, it is much more common in African Americans, Hispanics, and other racial/ethnic minorities. Almost one in five low-income adults states that their mouth and teeth are in poor condition. Twenty-nine percent of Americans have no dental insurance. Patients who have active infections are at greater risk for prosthetic joint infection. Optimization in these vulnerable groups should focus on treating active infections, with a prioritization of free clinics, academic clinics, and websites, such as "The Neighborhood Navigator," and easily accessible surgical consults.

Perception of Risk: A Poll of American Association of Hip and Knee Surgeons Members.

BACKGROUND: Providers of total hip and knee replacements are being judged regarding quality/cost by payers using competition-based performance measures with poor medical and no socioeconomic risk adjustment. Providers might assume that other providers shed risk and the perception of added risk can influence practice. A poll was collected to examine such perceptions. METHODS: In 2019 a poll was sent to the 2800 surgeon members of the American Association of Hip and Knee Surgeons using Survey Monkey while protecting respondent anonymity/confidentiality. The questions asked whether the perception of poorly risk-adjusted medical comorbidities and socioeconomic risk factors influence surgeons to selectively offer surgery. RESULTS: There were 474 surgeon responses. Prior to elective total hip arthroplasty/total knee arthroplasty, 95% address modifiable risk factors; 52% require a body mass index <40, 64% smoking cessation, 96% an adequate hemoglobin A1C; 82% check nutrition; and 63% expect control of alcohol 2. Due to lack of socioeconomic risk adjustment, 83% reported feeling pressure to avoid/restrict access to patients with limited social support, specifically the following: Medicaid/underinsured, 81%; African Americans, 29%; Hispanics/ethnicities, 27%; and low socioeconomic status, 73%. Of the respondents, 93% predicted increased access to care with more appropriate risk adjustment. CONCLUSION: Competition-based quality/cost performance measures influence surgeons to focus on medical risk factors in offering lower extremity arthroplasty. The lack of socioeconomic risk adjustment leads to perceptions of added risk from such factors as well. This leads to marginal loss of access for patients within certain medical and socioeconomic classes, contributing to existing healthcare disparities. This represents an unintended consequence of competition-based performance measures.

Quality of life and caregiver burden in familial frontotemporal lobar degeneration: Analyses of symptomatic and asymptomatic individuals within the LEFFTDS cohort.

OBJECTIVE: The Longitudinal Evaluation of Familial Frontotemporal Dementia Subjects evaluates familial frontotemporal lobar degeneration (FTLD) kindreds with MAPT, GRN, or C9orf72 mutations. Objectives were to examine whether health-related quality of life (HRQoL) correlates with clinical symptoms and caregiver burden, and whether self-rated and informant-rated HRQoL would correlate with each other. METHODS: Individuals were classified using the Clinical Dementia Rating (CDR® ) Scale plus National Alzheimer's Coordinating Center (NACC) FTLD. HRQoL was measured with DEMQOL and DEMQOL-proxy; caregiver burden with the Zarit Burden Interview (ZBI). For analysis, Pearson correlations and weighted kappa statistics were calculated. RESULTS: The cohort of 312 individuals included symptomatic and asymptomatic individuals. CDR® plus NACC FTLD was negatively correlated with DEMQOL (r = -0.20, P = .001), as were ZBI and DEMQOL (r = -0.22, P = .0009). There was fair agreement between subject and informant DEMQOL (κ = 0.36, P <.0001). CONCLUSION: Lower HRQoL was associated with higher cognitive/behavior impairment and higher caregiver burden. These findings demonstrate the negative impact of FTLD on individuals and caregivers.

Assessment of executive function declines in presymptomatic and mildly symptomatic familial frontotemporal dementia: NIH-EXAMINER as a potential clinical trial endpoint.

INTRODUCTION: Identifying clinical measures that track disease in the earliest stages of frontotemporal lobar degeneration (FTLD) is important for clinical trials. Familial FTLD provides a unique paradigm to study early FTLD. Executive dysfunction is a clinically relevant hallmark of FTLD and may be a marker of disease progression. METHODS: Ninety-three mutation carriers with no symptoms or minimal/questionable symptoms (MAPT, n = 31; GRN, n = 28; C9orf72, n = 34; Clinical Dementia Rating scale plus NACC FTLD Module < 1) and 78 noncarriers enrolled through Advancing Research and Treatment in Frontotemporal Lobar Degeneration/Longitudinal Evaluation of Familial Frontotemporal Dementia Subjects studies completed the Executive Abilities: Measures and Instruments for Neurobehavioral Evaluation and Research (NIH-EXAMINER) and the UDS neuropsychological battery. Linear mixed-effects models were used to identify group differences in cognition at baseline and longitudinally. We examined associations between cognition, clinical functioning, and magnetic resonance imaging volumes. RESULTS: NIH-EXAMINER scores detected baseline and differences in slopes between carriers and noncarriers, even in carriers with a baseline Clinical Dementia Rating scale plus NACC FTLD Module = 0. NIH-EXAMINER declines were associated with worsening clinical symptoms and brain volume loss. DISCUSSION: The NIH-EXAMINER is sensitive to cognitive changes in presymptomatic familial FTLD and is a promising surrogate endpoint.

Potential Role of Cost and Quality of Life in Treatment Decisions for Arthritis-Related Knee Pain in African American and Latina Women.

OBJECTIVE: The present study was undertaken to investigate whether Latina and African American women with arthritis-related knee pain and primary care providers who treat them believe their treatment decisions would benefit from having more information about the impact of treatment on their quality of life, medical care costs, and work productivity. METHODS: We conducted 4 focus groups of Latina and African American women over age 45 years who had knee pain. We also conducted 2 focus groups with primary care providers who treated Latina and African American women for knee pain. The participants were recruited from the community. They were asked their opinions about a decision tool that presented information on a range of treatment options and their impacts on quality of life, medical care costs, and work productivity. They were asked whether providing this information would help them make better treatment decisions. We analyzed the focus group transcripts using ATLAS.ti. RESULTS: We found that minority women and primary care providers endorsed the use of a decision-making tool that provided information of the impact of treatment on quality of life, medical care costs, and work productivity. Providers felt that patients would benefit from having the additional information but were concerned about its complexity and some patients' ability to comprehend the information. CONCLUSION: Latina and African American women could make more informed treatment decisions for their knee pain using a decision-making tool that provides them with significant information about how various treatment options may impact their quality of life, medical care costs, and workforce productivity.

Musculoskeletal health disparities: health literacy, cultural competency, informed consent, and shared decision making.

The factors that contribute to musculoskeletal healthcare disparities may influence the results of studies regarding the long-term outcome of orthopaedic implants. Patient decisions regarding their healthcare and their subsequent outcomes are influenced by health literacy. Providing patients with the information that they need to consent to treatment must be provided in a culturally competent manner. The influence of the physician or healthcare provider on the treatment choice varies depending on the type of decision-making process: patient-based, physician-based, or shared decision making. Respecting the patient's autonomy while acknowledging the knowledge and experience of the physician, we advocate for shared decision making. This may require modification of existing regulations regarding informed consent. Furthermore, federal and state directives have been put into place to address healthcare disparities, especially with respect to culturally competent care and access to proper healthcare.

Musculoskeletal healthcare disparities: influence of patient sex, race, and ethnicity on utilization of total joint arthroplasty.

Total joint arthroplasty is an effective treatment of musculoskeletal diseases including osteoarthritis, rheumatoid arthritis, trauma, and other diseases of the major joints. Based on data obtained from the National Inpatient Survey from 2000 through 2010, substantial differences in the rates of utilization of total hip, knee, and shoulder arthroplasty were detected with respect to race, ethnicity, and gender/sex. The results of this study support the likelihood that it is the interaction between multiple factors (patient, physician, and system/institutional) that contributes to musculoskeletal health disparities. Our study shows that disparities in the utilization of total joint arthroplasty that were evident in 2000 continue to exist. Additional studies evaluating innovative approaches to reducing musculoskeletal disparities relating to total joint arthroplasty are needed.

Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors.

Children and adolescents who are forcibly displaced represent almost half the world's internally displaced and refugee populations. We undertook a two-part systematic search and review of the evidence-base for individual, family, community, and societal risk and protective factors for the mental health outcomes of children and adolescents. Here we review data for displacement to low-income and middle-income settings. We draw together the main findings from reports to identify important issues and establish recommendations for future work. We draw attention to exposure to violence as a well established risk factor for poor mental health. We note the paucity of research into predictor variables other than those in the individual domain and the neglect of other variables for the assessment of causal associations, including potential mediators and moderators identifiable in longitudinal work. We conclude with research and policy recommendations to guide the development and assessment of effective interventions.

Challenges in designing an All-Wales professional development programme to empower ward sisters and charge nurses.

AIM: To discuss the challenges of designing a professional development programme for ward managers working in in-patient facilities in Wales. BACKGROUND: In 2008, the Minister of Health launched the Free to Lead, Free to Care initiative to empower ward managers. One work-stream involved the creation of a universal professional development programme to ensure they had the skills and knowledge to function effectively in their roles in the newly restructured NHS in Wales. METHODS: A collaborative, staged approach, involving multiple stakeholders, resulted in the design of a programme founded in principles of action and work-based learning tailored to the needs of the individual in attaining accredited competencies. KEY ISSUES: Achieving buy-in and ownership from stakeholders are essential to ensure standardization and consistency of implementation of a universal programme. Shared responsibility and acceptance of key principles underpinning an individualized, work-based programme are fundamental to ensuring equity of outcome achievement. IMPLICATIONS FOR MANAGEMENT: Managerially facilitated cultural change is needed to embed individual work-based professional development programmes in the clinical environment, with practitioners supported through a variety of learning strategies appropriate to their learning needs.

Severe mental disorders in complex emergencies.

People with severe mental disorders are a neglected and vulnerable group in complex emergencies. Here, we describe field experiences in establishing mental health services in five humanitarian settings. We show data to quantify the issue, and suggest reasons for this neglect. We then outline the actions needed to establish services in these settings, including the provision of practical training, medication, psychosocial supports, and, when appropriate, work with traditional healers. We have identified some persisting problems locally, nationally, and internationally, and suggest some solutions. Protection and care of people with severe mental disorders in complex emergencies is a humanitarian responsibility.

Responding to the needs of children in crisis.

This paper explores the issues confronting service providers setting up child and family mental health programmes in conflict, post conflict and disaster areas. Drawing on clinical experience and research in humanitarian settings, it calls for greater attention to the child's perspective, their individuality and the cultural, social and political context in which they live. It argues that those concerned with the psychopathology of children in crises should widen their frame of reference beyond narrowly defined traumatic reactions to include other mental health and psychosocial issues, including the current problems of daily life and the needs of children with pre-existing psychiatric disorders. It recommends culturally valid means of assessment, the creation of age-appropriate services and training for primary healthcare workers. Children's mental health needs in crises are varied, complex and intimately connected with their needs for security, food, shelter, education and family connection. This requires holistic, rights-based approaches that can access resources to address basic needs, advocate for security and protection, and recognize and address the needs of the more vulnerable children. This is the approach recommended by the Inter Agency Standing Committee Guidelines for Mental health and Psychosocial Support in Emergency Settings.

Relationships, partnerships and politics in the lives of the urban poor in AIDS-afflicted Swaziland.

This paper seeks to better understand how poor urban families caring for children are able to access help from beyond the kinship group in a setting where HIV prevalence has risen to over 40%. The fieldwork shows that livelihoods were affected by multiple shocks and families were struggling to provide education, health care, clothing and food for all children in their care. Orphan status or gender did not appear to affect children's access to education. Families turned to neighbours, churches and the work place for assistance. Neighbours varied in their response and were rarely able to give material assistance. Churches were seen solely as sources of emotional and spiritual support. Work-place relationships provided material as well as emotional support. Government and NGO assistance was limited and poorly coordinated at the beginning of the fieldwork and criteria for selection was unclear to many respondents. Some respondents felt marginalised from community structures. Using respondents' experiences when trying to access education and health care, the author illustrates the importance of the quality of relationships and partnerships at all levels (international, national and local) as well as the need for more synergy between top-down and bottom-up approaches. A much stronger coordinating role for government officials and the development of public welfare support are seen as critical to alleviate the poverty in which AIDS thrives.

Childcare in poor urban settlements in Swaziland in an era of HIV/AIDS.

This paper explores the role of the family in caring for orphans and other children in poor urban communities having some of the highest levels of HIV/AIDS prevalence in the world. A range of family forms in Swaziland was found to be caring for orphans. Child-headed households and lone-elderly carers were not the most common; maternal kin played a more important role in orphan care than did paternal kin, indicating both stresses due to AIDS and the dynamic nature of the family. Women of all ages were bearing the brunt of the extra care responsibilities caused by the epidemic. There was limited involvement in children's well-being by agencies of any kind and orphan care remained largely situated within kin structures. The AIDS epidemic was impacting on families in a variety of ways, with a corresponding increase in poverty and vulnerability. Carers did not perceive orphans as a separate category of children requiring assistance over and above any other vulnerable child. Families require assistance at the household, community and national level. Meanwhile, community-based initiatives were poorly developed. Welfare sector policies should strengthen the family model of childcare by increasing support to the poorest families rather than treating orphans as a separate category of vulnerable children and thereby excluding other needy children.

MicroPET assessment of androgenic control of glucose and acetate uptake in the rat prostate and a prostate cancer tumor model.

PET has been used to monitor changes in tumor metabolism in breast cancer following hormonal therapy. This study was undertaken to determine whether PET imaging could evaluate early metabolic changes in prostate tumor following androgen ablation therapy. Studies were performed comparing two positron-emitting tracers, 18F-FDG and 11C-acetate, in Sprague-Dawley male rats to monitor metabolic changes in normal prostate tissue. Additional studies were performed in nude mice bearing the CWR22 androgen-dependent human prostate tumor to evaluate metabolic changes in prostate tumor. In rats, for the androgen ablation pretreatment, 1 mg diethylstilbestrol (DES) was injected subcutaneously 3 and 24 hours before tracer injection. For androgen pretreatment, 500 microg dihydrotestosterone (DHT) was injected intraperitoneally 2 and 6 hours before tracer injection. The rats were divided into three groups, Group A (no-DES, no-DHT, n = 18), Group B (DES, no-DHT, n = 18) and Group C (DES, DHT, n = 18). In each group, 10 animals received 18F-FDG, whereas the remaining eight animals were administered 11C-acetate. Rats were sacrificed at 120 min post-injection of 18F-FDG or 30 min post-injection of 11C-acetate. Pretreatment of the mouse model using DHT (200 microg of DHT in 0.1 mL of sunflower seed oil) or DES (200 microg of DES in 0.1 mL of sunflower seed oil) was conducted every 2 days for one week. Mice were imaged with both tracers in the microPET scanner (Concorde Microsystems Inc.). DES treatment caused a decrease in acetate and glucose metabolism in the rat prostate. Co-treatment with DHT maintained the glucose metabolism levels at baseline values. In the tumor bearing mice, similar effects were seen in 18F-FDG study, while there was no significant difference in 11C-acetate uptake. These results indicate that changes in serum testosterone levels influence 18F-FDG uptake in the prostate gland, which is closely tied to glucose metabolism, within 24 hours of treatment and in the prostate tumor within 1 week. These early metabolic changes could enable monitoring metabolic changes in prostate tumor following treatment by imaging using 18F-FDG PET. Further studies are needed to clarify the reason for the insensitivity of 11C-acetate for measuring metabolic change in prostate tumor.

Is coding of diagnoses, comorbidities, and complications in total knee arthroplasty accurate?

Coding of diagnoses, comorbidities, and complications is important for health care delivery, not only for appropriate hospital and physician reimbursement, but also for a correct assessment of complication rates. The purpose of this study was to determine the agreement of coding of diagnoses, comorbidities, and complications for total knee arthroplasty between 2 groups of coders. Between January 1, 1997, and November 18, 1997, 100 consecutive primary total knee arthroplasties were done by 2 orthopaedic surgeons. Diagnoses, comorbidities, and complications were coded by professional hospital coders according to the Healthcare Finance Administration guidelines, then recoded by a second team with orthopaedic experience. Although the hospital coders matched diagnoses with the orthopaedic team 96.5% of the time, they determined a complication rate of 1.4 per patient and a comorbidity rate of 2.9 per patient, whereas the orthopaedic team coded for 0.7 complications per patient and 3.7 comorbidities. Based on these results, there should be interaction and communication between hospital coders and health care professionals to check that coding is accurate and reproducible.