Adolescent and Caregiver-derived Utilities for Traumatic Patella Dislocation Health States.

INTRODUCTION: The treatment of a first-time traumatic patella dislocation in children and adolescents remains controversial. Preference-based health utility assessments can provide health-related quality of life information for orthopaedic conditions and their subsequent treatment. The purpose of this study was to determine utilities for pediatric acute traumatic patella dislocation and subsequent treatment health states from both children with patellar dislocation, and their parents. METHODS: Adolescents with acute first-time patella dislocations and their parents were identified. Six patella dislocation health states were defined: (1) Immediate post injury (Injury), (2) Postdislocation and nonoperative treatment with physical therapy (Rehabilitation), (3) Immediately poststabilization surgery (Postsurgical), (4) Recurrent dislocation after treatment (Recurrent dislocator), (5) Stable knee after initial treatment but unable to participate in sport at previous level (Stable return to lower function), and (6) Stable knee after initial treatment and fully able to participate in sport at previous level (Stable return to same function). Classic feeling thermometer utilities acquisition was performed, with self-report (patient) and proxy-report (parent) interviews performed separately. Patients' physical activity levels were collected using the UCLA Activity Score and the HSS Pedi-FABS. Comparisons between groups were made using Mann-Whitney U test and Wilcoxon signed-rank test. RESULTS: Ninety-five adolescents and 95 parents were included. Median (interquartile range) patient utilities for Injury, Rehabilitation, Postsurgical, Recurrent dislocator, Stable return to lower function, and Stable return to same function health states were: 25 (10 to 45), 50 (35 to 62.5), 30 (15 to 48.5), 20 (10 to 40), 70 (50 to 80), and 100 (100 to 100), respectively. Caregiver-derived utilities for children going through these health states were: 25 (10 to 49.5), 50 (25 to 60), 40 (15 to 60), 20 (5 to 40), 60 (50 to 77.5), and 100 (100 to 100). Stable return to a lower function was assigned a significantly higher utility by adolescents than their caregivers (P=0.03); highly active adolescents assigned a significantly higher utility to achieving a stable return to same function (P=0.02) while assigning significantly lower utility to health states in which they were not fully participating in sport. CONCLUSIONS: Adolescents and their parents felt that successful treatment of an acute patella dislocation was equivalent to perfect health (utility=1); however, adolescents assigned a significantly higher utility to a stable but lower functioning health state compared with their parents. Baseline functional status is an important modifier of health state preference-highly active adolescents assign a significantly greater disutility to health states in which they are not participating in sports at their regular level of play. These findings provide insight into the health-related quality of life impact for acute patella dislocations and their management, and potentially support minimizing time out of play and more aggressive treatment of first time acute patellar dislocations in athletic adolescents. LEVEL OF EVIDENCE: Level III.

Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review.

PURPOSE: The goal of this study was to perform a comparative review to determine whether there is a significant difference in the rate of repeat dislocation and clinical outcome between surgical and conservative management of acute patellar dislocation in children and adolescents. METHODS: A systematic review of the MEDLINE database was performed. English-language clinical outcome studies with a primary outcome/treatment specific to acute patella dislocation in a paediatric population were included. Eleven studies met inclusion criteria; Chi-square analysis, independent t tests and weighted mean pooled cohort statistics were performed where appropriate. RESULTS: A total of 470 conservatively managed and 157 operatively treated knees were included. Conservatively managed patients were on average 17.0 years and had a mean follow-up of 3.9 years; surgically managed patients were on average 16.1 years and had a mean follow-up of 4.7 years. Conservatively managed knees had a 31% rate of recurrent dislocation rate compared to 22% in surgical knees (p = 0.04). Trochlear dysplasia and skeletal immaturity confer greater risk for recurrent instability. Surgical treatment may provide clinically important quality of life and sporting benefit. CONCLUSIONS: Surgical treatment of first time patella dislocation in children and adolescents is associated with a lower risk of recurrent dislocation and higher health-related quality of life and sporting function. There is a paucity of evidence on MPFL reconstruction for first time traumatic patella dislocation in this population. LEVEL OF EVIDENCE: IV.

Utility of Functional Metrics Assessed During Acute Care on Hospital Outcomes: A Systematic Review.

OBJECTIVE: Traditionally, illness severity, social factors, and comorbid conditions have been examined as predictors of hospital outcomes. However, recent research in the rehabilitation setting demonstrated that physical function outperformed comorbidity indices as a predictor of 30-day readmission. The purpose of this study was to review the literature examining the association between acute hospital physical function and various hospital outcomes and health care utilization. TYPE: Systematic review. LITERATURE SURVEY: A review of the MEDLINE database was performed. Search terms included acute functional outcomes and frailty outcomes. Studies up to September 2017 were included if they were in English and examined how functional metrics collected at acute care hospitalization affected hospital outcomes. METHODOLOGY: Cohort characteristics and measures of associations were extracted from the studies. Outcomes include hospital readmission, length of stay, mortality, discharge location, and physical function post acute care. The studies were assessed for potential confounders as well as selection, attrition, and detection bias. SYNTHESIS: A total of 30 studies were identified (hospital readmissions: 6; discharge location: 11; length of stay: 4; mortality: 15; function: 6). Thirteen different metrics assessed function during acute care. Lower function during acute care was associated with statistically significant higher odds of hospital readmission, lower likelihood of discharge to home, longer hospital length of stay, increased mortality, and worse functional recovery when compared to patients with higher function during acute care, when adjusted for age and gender. The Barthel Index may be a useful marker for mortality in the elderly whereas the Functional Independence Measure instrument may be valuable for examining discharge location. CONCLUSIONS: There is increasing evidence that function measured during acute care predicts a broad array of meaningful clinical outcomes. Further research would help direct the use of practical, yet parsimonious functional metrics that effectively screen high-need, high-cost patients to deliver optimal care. LEVEL OF EVIDENCE: I.

Endovascular Thrombectomy in Acute-Onset Ischemic Stroke - beyond the Standard Time Windows: A Case Report and a Review of the Literature.

Endovascular thrombectomy following an acute ischemic stroke can lead to improved functional outcome when performed early. Current guidelines suggest treatment within 6 h after symptom onset. Recent studies including the DEFUSE-3 and DAWN trials demonstrate that some patients may benefit from thrombectomy up to 16 and 24 h after symptom onset, respectively. We present a case of delayed thrombectomy in a 43-year-old man with acute dysarthria, left-sided weakness, and visual neglect. Initial MRI/A demonstrated a small completed stroke and a thrombus in the right middle cerebral artery. Thirty-seven hours after symptom onset, his weakness acutely worsened. A repeat MRI revealed an unchanged core infarct volume and a cerebral angiogram suggested an abrupt occlusion of the right distal M1. Thrombectomy was performed with complete reperfusion and the patient's strength recovered following the procedure. We compared our clinical reasoning with the DEFUSE-3 and DAWN study criteria, and conclude that there is a subset of patients that may safely benefit from thrombectomy in later time windows beyond the trial criteria, especially in the setting of clinical examination of imaging mismatch.

Economic Decision Model for First-Time Traumatic Patellar Dislocations in Adolescents.

BACKGROUND: The surgical management of traumatic patellar dislocations in adolescents is associated with a lower rate of recurrent dislocations compared with nonoperative care. However, the attendant cost of surgery and the quality-of-life benefit of a surgical treatment strategy are unclear. PURPOSE: To compare the cost-utility of 3 management strategies for acute first-time patellar dislocations in adolescents: (1) nonoperative treatment only, (2) initial nonoperative treatment with surgery only for recurrent dislocations, and (3) immediate surgery. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: A 10-year state-transition Markov model was constructed to compare the cost-utility of the 3 index treatment protocols. Utilities used to define health states were derived from a telephone interview of 60 adolescents with a history of acute patellar dislocations. The probability of transition between each health state was informed by the available literature. Direct costs were estimated using a statewide ambulatory surgery database, and indirect costs were estimated based on parental lost productivity. Effectiveness was expressed in quality-adjusted life years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS: In the base case for our model, nonoperative treatment only was the least costly ($7300) but also the least effective (5.30 QALYs); initial nonoperative treatment with delayed surgery cost $10,500 for a 5.93 QALY benefit, while immediate surgical treatment cost $17,100 and provided 6.32 QALY benefits. Compared with nonoperative treatment only, initial nonoperative treatment with delayed surgery was associated with an ICER of $5100 per QALY. When immediate surgery was compared with a strategy of delayed surgery, immediate surgery provided incremental benefits at an ICER of $17,000 per QALY. The model was sensitive to the probability of surgical versus nonoperative treatment to achieve a full return to preinjury activity versus an intermediate lower state. When the probability of achieving a full return to preinjury activity with initial nonoperative treatment exceeds 47.5% (compared with 34.2% in the base case), then initial nonoperative treatment with delayed surgery is preferred to immediate surgery. Similarly, when the probability of achieving a full return to full preinjury activity with surgery falls below 51% (compared with 64% in the base case), then delayed surgery after initial nonoperative treatment is preferred. CONCLUSION: Immediate surgery and delayed surgical treatment are both cost-effective treatment options; however, immediate surgical treatment provides the highest QALY gains within a 10-year time horizon. Our model sensitivity analysis highlights the role of optimizing functional and quality-of-life benefits in the treatment of acute traumatic patellar dislocations. These findings have implications for clinical guidelines and policy decisions relating to adolescent patellar dislocations.

The Early Impact of an Administrative Processing Fee on Manuscript Submissions at The Journal of Bone & Joint Surgery.

BACKGROUND: There was a dramatic increase in the volume of manuscripts submitted to The Journal of Bone & Joint Surgery (JBJS) between 2009 and 2012. This resulted in increased journal administrative costs. To offset this financial burden, in May 2013, JBJS started charging authors an administrative processing fee at the time of submission. The purpose of this study was to assess the impact of the administrative fee on the volume and characteristics of manuscripts submitted to JBJS. METHODS: Our analysis included 866 manuscripts submitted to JBJS between November 2012 and November 2013. We compared manuscripts submitted 6 months prior to fee implementation and prior to the announcement (denoted as the baseline group), in the several months prior to fee implementation but after the fee implementation announcement (denoted as the fee announcement group), and in the 6 months after fee implementation (denoted as the fee implementation group). Manuscripts were reviewed for institutional and author demographic characteristics, as well as for general study characteristics. RESULTS: In the first full calendar year (2014) after the implementation of the fee, the annual volume of submissions to JBJS declined by 33.5% compared with the annual submission volume in 2010 to 2012. In a comparative analysis, the geographical region of origin (p = 0.003), level of evidence (p < 0.0001), funding, and specialty differed between the 3 submission periods. However, subgroup analyses demonstrated that differences were attributable to the fee announcement group and that there were few important differences between the baseline and fee implementation groups. Reporting of funding information improved significantly between the baseline and fee implementation groups; in the post-fee implementation period, studies were more likely to have declared no external funding source (p = 0.001). CONCLUSIONS: The administrative processing fee at JBJS has been associated with a decrease in submission volume, but, overall, there has not been a change in the characteristics of studies submitted. However, decreased overall volume implies a decrease in the absolute number of high-level studies submitted to the journal. Administrative processing fees at high-volume journals may be a financially viable way to offset high administrative costs without substantially changing the characteristics of submitted articles.

Mucoadhesive nanoparticles may disrupt the protective human mucus barrier by altering its microstructure.

Mucus secretions typically protect exposed surfaces of the eyes and respiratory, gastrointestinal and female reproductive tracts from foreign entities, including pathogens and environmental ultrafine particles. We hypothesized that excess exposure to some foreign particles, however, may cause disruption of the mucus barrier. Many synthetic nanoparticles are likely to be mucoadhesive due to hydrophobic, electrostatic or hydrogen bonding interactions. We therefore sought to determine whether mucoadhesive particles (MAP) could alter the mucus microstructure, thereby allowing other foreign particles to more easily penetrate mucus. We engineered muco-inert probe particles 1 µm in diameter, whose diffusion in mucus is limited only by steric obstruction from the mucus mesh, and used them to measure possible MAP-induced changes to the microstructure of fresh human cervicovaginal mucus. We found that a 0.24% w/v concentration of 200 nm MAP in mucus induced a ∼10-fold increase in the average effective diffusivity of the probe particles, and a 2- to 3-fold increase in the fraction capable of penetrating physiologically thick mucus layers. The same concentration of muco-inert particles, and a low concentration (0.0006% w/v) of MAP, had no detectable effect on probe particle penetration rates. Using an obstruction-scaling model, we determined that the higher MAP dose increased the average mesh spacing ("pore" size) of mucus from 380 nm to 470 nm. The bulk viscoelasticity of mucus was unaffected by MAP exposure, suggesting MAP may not directly impair mucus clearance or its function as a lubricant, both of which depend critically on the bulk rheological properties of mucus. Our findings suggest mucoadhesive nanoparticles can substantially alter the microstructure of mucus, highlighting the potential of mucoadhesive environmental or engineered nanoparticles to disrupt mucus barriers and cause greater exposure to foreign particles, including pathogens and other potentially toxic nanomaterials.