Correlations between a dedicated orthopaedic complications grading system and early adverse outcomes in joint arthroplasty.

BACKGROUND: Reliable classification of postoperative complications is important for quality improvement efforts. In 2014, The Knee Society proposed a grading system for complications after TKA, but to our knowledge, a relationship between complication grades and surgical outcomes has not yet been established. QUESTIONS/PURPOSES: We attempted to determine (1) whether an association exists between complication grade and early adverse outcomes after TKA and THA, and (2) what proportion of the variability in complications could be associated with the classification grade (a metric of potential predictive value of the grading schema). METHODS: A total of 210 primary THAs and TKAs in 201 patients performed at one center from January 1, 2011 to December 31, 2011 were reviewed; of those, 188 patients (94%; 197 procedures) had complete 90-day postoperative data and were evaluated retrospectively for postoperative complications. We defined and graded complications according to the classification system proposed by Iorio et al. and The Knee Society. Early adverse outcomes assessed included length of hospital stay and unplanned readmissions or reoperations. A total of 254 complications were documented in 135 patients (137 procedures); 53 patients (60 procedures) had no complications. Bivariate analyses were conducted to identify associations between complication grade and early adverse outcomes and patient variables; analyses considered patient variables including age, sex, status as a state prisoner (yes or no), American Society of Anesthesiologists score, BMI, and procedure (TKA or THA). Multiple regression and logistic regression analyses were conducted to determine the association between complication grade and early adverse outcomes (length of stay [LOS] and unplanned readmission or reoperations) adjusted for confounding patient variables. Alpha was set at 0.05 for two-sided tests. RESULTS: Maximum complication grade (range, from 0-4) was associated with a longer LOS (for each point increase of maximum grade, LOS increased 0.105 ± 0.024 days, p < 0.001) and more readmissions or reoperations (odds ratio [OR], 3.79; 95% CI, 1.91-7.54; p < 0.001). Total grade (range, 0-22) also was associated with increased LOS (for each point increase of total grade, LOS increased 0.032 ± 0.006 days, p < 0.001) and increased readmissions or reoperations (OR, 1.34; 95% CI, 1.18-1.53; p < 0.001). Total grade could account for 38% of the variation in LOS and readmissions or reoperations (C-statistic = 0.94; 95% CI, 0.90-0.98); whereas maximum complication grade could account for 35% of the variation in LOS and readmissions or reoperations (C-statistic = 0.35; 95% CI, 0.88-0.96). Thus, we found total grade to be a slightly better predictor of LOS and readmissions or reoperations than maximum grade. CONCLUSIONS: We found that the proposed grading system is applicable to TKA and THA in terms of documentation of complication severity and as an indicator of increased LOS and increased unplanned readmissions or reoperation rates. That total complication grade was a better predictor of LOS than maximum grade suggests that multiple complications of a lesser grade can be just as important as a single higher grade complication in terms of effect on outcomes.

Challenges to screening and evaluation of memory impairment among Hispanic elders in a primary care safety net facility.

OBJECTIVE: Implement a memory impairment screening procedure for elderly Hispanic primary care patients, and analyze its yield and challenges to further triage and diagnostic evaluation. METHODS: Three hundred twenty nine Hispanic patients aged ≥60 years or proxy informants were enrolled from outpatient primary care clinics at an urban safety-net medical center. Patients were screened for memory impairment using the WHO-UCLA AVLT; for those without consent capacity, proxies were given the IQCODE. Bilingual research assistants conducted in-person or telephone screening. Age, gender, education, comorbidities, acculturation, overall health, access to care, and memory concerns were assessed as potential predictors of memory impairment. Based on identified implementation challenges, a multi-disciplinary stakeholder committee proposed revised approaches to increase diagnostic evaluation and sustainability. RESULTS: Of 677 eligible patients approached, 329 (49%) were screened, and 77 (23%) met criteria for memory impairment using the WHO-UCLA AVLT (N=60) or the IQCODE (N=17). Only male gender and higher comorbidity uniquely predicted memory impairment (ps<0.05). Few screen-positive patients declined further triage and evaluation, but a substantial proportion could not be subsequently contacted. Challenges to implementing a memory screening program included staff time and adequate clinic space for in-person screening; challenges to follow-up of positive screening results included inability to contact patients and lack of primary care continuity to facilitate further triage and referral. CONCLUSIONS: Nearly one-fourth of primary care Hispanic elders screened as memory-impaired, but few factors predicted positive screening. Stakeholder-guided adaptations are needed-particularly in resource-constrained settings-to overcome challenges to further diagnostic evaluation and referral.

Patient-on-Staff Assaults: Perspectives of Mental Health Staff at an Acute Inpatient Psychiatric Teaching Hospital in the United States.

INTRODUCTION: Physical assaults perpetrated by patients in psychiatric hospitals against mental health staff (MHS) is a serious concern facing psychiatric hospitals. Assaulted staff reports physical and psychological trauma that affects their personal and professional lives. There is a dearth of literature exploring this phenomenon. PURPOSE: To explore MHS perspectives of assault by psychiatric patients. METHODS: A transcendental phenomenological qualitative design was used to explore and analyze the perspectives of a purposeful sample of 120 MHS perspectives at an acute inpatient psychiatric hospital. Participants' age ranged from 22 to 63 years (mean age = 32.4). Moustakas' theoretical underpinnings guided the study. RESULTS: Two patterns, 8 themes, and 19 subthemes were identified: (a) Psychological impacts revealed four themes-increase of anxiety/fear level, helplessness and hopelessness, flashbacks/burnout, and doubting own competency. (b) Physiosocial impacts revealed four themes-unsupportive superiors, stigmatization of staff victim, failure to report the incident, and environmental safety. DISCUSSION: Participants verbalized that assaults by patients have instilled fear and trauma in them. Most of the assaults occurred when staff were performing their routine job functions and setting limits to patient's behavior. CONCLUSION: The study allowed MHS opportunities to narrate their lived experiences of being assaulted by patients and provided validation of their perspectives. Findings illuminated the phenomenon and may help to support policy changes in psychiatric hospitals.

Modulation of topoisomerase IIalpha expression by a DNA sequence-specific polyamide.

Topoisomerase IIalpha (topo IIalpha) is an important target for several chemotherapeutic agents, including etoposide and doxorubicin. Confluent cells express low levels of topo IIalpha and are resistant to etoposide treatment. Repression of transcription in confluent cells is mediated by binding of the transcription factor NF-Y to inverted CCAAT motifs within the topo IIalpha promoter. To block the repressive binding of NF-Y, a polyamide (JH-37) was designed to bind to the flanking regions of selected CCAAT sites within the topo IIalpha promoter. Electrophoretic mobility shift assays and DNase I footprinting assays showed occupancy of the inverted CCAAT sites by JH-37. Chromatin immunoprecipitation assays confirmed in vivo inhibition of NF-Y binding to the topo IIalpha promoter. Following incubation of confluent NIH3T3 cells with JH-37, increased expression of topo IIalpha mRNA and protein was detectable. This correlated both with increased DNA double-strand breaks as shown by comet assay and decreased cell viability following exposure to etoposide. Polyamides can modulate gene expression and chemosensitivity of cancer cells.

Repeated three-dimensional magnetic resonance imaging of atherosclerosis development in innominate arteries of low-density lipoprotein receptor-knockout mice.

BACKGROUND: In vivo methods to evaluate the size and composition of atherosclerotic lesions in animal models of atherosclerosis would assist in the testing of antiatherosclerotic drugs. We have developed an MRI method of detecting atherosclerotic plaque in the major vessels at the base of the heart in low-density lipoprotein (LDL) receptor-knockout (LDLR(-/-)) mice on a high-fat diet. METHODS AND RESULTS: Three-dimensional fast spin-echo magnetic resonance images were acquired at 7 T by use of cardiac and respiratory triggering, with approximately 140- micro m isotropic resolution, over 30 minutes. Comparison of normal and fat-suppressed images from female LDLR(-/-) mice 1 week before and 8 and 12 weeks after the transfer to a high-fat diet allowed visualization and quantification of plaque development in the innominate artery in vivo. Plaque mean cross-sectional area was significantly greater at week 12 in the LDLR(-/-) mice (0.14+/-0.086 mm2 [mean+/-SD]) than in wild-type control mice on a normal diet (0.017+/-0.031 mm2, P<0.01). In the LDLR(-/-) mice, but not control mice, increase in plaque burden at week 12 relative to week 1 was also highly significant (P=0.001). Lumen cross section was not significantly different between time points or groups. MRI and histological assessments of plaque size were closely correlated (R=0.8). The lumen of proximal coronary arteries could also be visualized. CONCLUSIONS: This is the first report of in vivo detection of aortic arch atherosclerosis in any animal model. The method could significantly assist rapid evaluation of experimental antiatherosclerotic therapies.

Variability in Fluoroscopic Image Acquisition During Operative Fixation of Ankle Fractures.

The goal of this study was to determine whether injury, level of surgeon training, and patient factors are associated with increased use of fluoroscopy during open reduction and internal fixation of ankle fractures. These relationships are not well defined. The study was a retrospective chart review of patients treated at an academic institution with primary open reduction and internal fixation of an ankle. Patient demographics, including sex, age, and body mass index, were collected, as was surgeon year of training (residency and fellowship). Image acquisition data included total number of images, total imaging time, and cumulative dose. Ankle fractures were classified according to the Weber and Lauge-Hansen classifications and the number of fixation points. Bivariate analysis and multiple regression models were used to predict increasing fluoroscopic image acquisition. Alpha was set at 0.05. Of 158 patients identified, 58 were excluded. After bivariate analysis, fracture complexity and year of training showed a significant correlation with increasing image acquisition. After multiple regression analysis, fracture complexity and year of training remained clinically significant and were independent predictors of increased image acquisition. Increasing fracture complexity resulted in 20 additional images, 16 additional seconds, and an increase in radiation of 0.7 mGy. Increasing year of training resulted in an additional 6 images and an increase of 0.35 mGy in cumulative dose. The findings suggest that protocols to educate trainee surgeons in minimizing the use of fluoroscopy would be beneficial at all levels of training and should target multiple fracture patterns.

Primary care providers' views of challenges and rewards of dementia care relative to other conditions.

OBJECTIVES: To compare primary care providers' (PCPs') perceptions about dementia and its care within their healthcare organization with perceptions of other common chronic conditions and to explore factors associated with differences. DESIGN: Cross-sectional survey. SETTING: Three California healthcare organizations. PARTICIPANTS: One hundred sixty-four PCPs. MEASUREMENTS: PCPs' views about primary care for dementia were analyzed and compared with views about care for heart disease, diabetes mellitus, and selected other conditions. Differences in views about conditions according to PCP type (internists, family physicians) were assessed. Multivariate analysis examined relationships between provider and practice characteristics and views about dementia care. RESULTS: More PCPs strongly agreed that older patients with dementia are difficult to manage (23.8%) than for heart disease (5.0%) or diabetes mellitus (6.3%); PCPs can improve quality of life for heart disease (58.9%) and diabetes mellitus (61.6%) than for dementia (30.9%); older patients should be routinely screened for heart disease (63.8%) and diabetes mellitus (67.7%) than dementia (55.5%); and their organizations have expertise/referral resources to manage diabetes mellitus (49.4%) and heart disease (51.8%) than dementia (21.1%). More PCPs reported almost effortless organizational care coordination for heart disease (13.0%) or diabetes mellitus (13.7%) than for dementia (5.6%), and a great deal or many opportunities for improvement in their ability to manage dementia (50.6%) than incontinence, depression, or hypertension (7.4-34.0%; all P<.05). Internists' views regarding dementia care were less optimistic than those of family physicians, but PCP type was unrelated to views on diabetes mellitus or heart disease. CONCLUSION: Improving primary care management of dementia should directly address PCP concerns about expertise and referral resources, difficulty of care provision, and PCP views about prospects for patient improvement.