A Provider Perspective of Psychosocial Predictors of Upper-Extremity Vascularized Composite Allotransplantation Success.

PURPOSE: We performed a qualitative study to understand the psychosocial factors associated with success in upper-extremity vascularized composite allotransplantation from the perspective of transplant providers. METHODS: We recruited 13 providers actively involved in upper-extremity vascularized composite allotransplantation. Participants included physicians, nurses, social workers, occupational therapists, and research administrators. We conducted semistructured face-to-face focus group interviews using a guide that explored providers' perceptions of qualities contributing to transplant outcome. Topics included social support networks and their influence on recovery, barriers to treatment compliance and successful posttransplant rehabilitation, and the process of setting patients' expectations. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS: The analysis identified numerous factors that contribute to transplant success: (1) recipients' prior experiences modify their ability to cope and adapt after transplantation, (2) behaviors and characteristics such as positivity influence candidacy and may be predictive of successful outcomes, and (3) social support is essential for improved function and compliance. The provider care team cited difficulty in predicting recipient compliance and in setting realistic expectations. CONCLUSIONS: Motivated recipients with developed coping and resiliency, a positive attitude, and stable, physically-able caregivers are perceived by providers to have greater success after transplantation. CLINICAL RELEVANCE: Findings from this work may help providers determine optimal candidates for upper-extremity vascularized composite allotransplantation.

Perceived Success in Upper-Extremity Vascularized Composite Allotransplantation: A Qualitative Study.

PURPOSE: We performed a qualitative study to understand psychosocial factors associated with perceived success of upper-extremity vascularized composite allotransplantation (VCA). We interviewed transplant recipients and their primary caregivers. METHODS: We recruited 4 upper-extremity VCA recipients and primary caregivers for 3 of them. We conducted semistructured face-to-face interviews using a guide that explored participants' transplantation experiences. Topics included comparison of pretransplant and posttransplant expectations, reflections on factors contributing to the success of the transplant experience, and posttransplant rehabilitation and functioning. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS: Participants described several factors as contributing to the success of the transplant experience, including developing realistic expectations about posttransplant function and lifelong immunosuppression, support from one's community and particularly the primary caregiver, and framing the experience in a positive light. Social, aesthetic, and other values unique to the hands, as opposed to prosthetics, motivated recipients to undergo VCA despite its inherent risk and uncertainties. CONCLUSIONS: Despite inherent challenges, undergoing VCA was viewed as worthwhile to regain benefits unique to hands. Participants met the challenges of the transplant process through setting realistic expectations, strong social support, and a positive perspective. CLINICAL RELEVANCE: Findings from this work may help clinicians and prospective patients to prepare for and set appropriate expectations of VCA.

Global Health Education Revamped: Implementation of a Cross-Cultural Virtual Elective Through Continuous Improvement Methods.

Introduction: Virtual platforms can increase access to global health (GH) education and cross-cultural communication. The Cleveland-Cusco Connection (CCC) is a virtual GH elective between medical schools in the USA and Peru. This elective was held annually from 2020 to 2023, with monthly virtual sessions held in English and Spanish to facilitate bidirectional learning about healthcare systems, culture, and barriers to care in both nations. Using student surveys throughout the electives, we report the outcomes, barriers, and changes of the CCC over 3 years. Methods: We administered pre- and post-elective surveys to students in the elective in their native languages. We evaluated self-reported non-native language skills, health systems, GH knowledge, and cultural sensitivity. We also surveyed students about course efficacy in achieving learning objectives and areas for improvement. We performed non-parametric statistical analyses to evaluate trends in survey responses. Results: Over three academic years, 92 students participated in CCC. Students from the US had statistically significant increases in their self-reported understanding of the Peruvian healthcare and medical education systems (p = 0.013). US students also saw an increase in cultural sensitivity scores, with statistically significant increases in the knowledge (p = 0.035) and motivation components (p = 0.031). The most frequently reported challenges encountered throughout the course included: competing coursework assignments, scheduling conflicts, and language barriers. Discussion: Cross-cultural virtual electives demonstrate effectiveness in teaching trainees about international healthcare systems and can improve cultural sensitivity. Strategies to improve the elective include reducing workload, improving engagement for partner countries, and teaching bilingually. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01941-6.

Factors Influencing Physician Recommendation for Intraarticular Therapies in Osteoarthritis: Results From a Qualitative Study.

OBJECTIVE: Several current and many emerging osteoarthritis (OA) treatments are intraarticular (IA) injections; however, little is known about physicians' perceptions and beliefs regarding IA injections or their considerations when deciding whether to recommend them to patients. We aimed to investigate physician-perceived benefits and drawbacks of offering IA injections. METHODS: We conducted individual interviews with orthopedic surgeons, rheumatologists, and physiatrists who treat patients with knee OA. We conducted a thematic analysis to identify factors that physicians weigh when making IA injection recommendations. RESULTS: We interviewed 18 physicians from academic and community practices. We identified the following 4 categories of themes that influenced providers' recommendations to their patients regarding injections: 1) the physician's knowledge, beliefs, and concerns, including their propensity to rely on guidelines versus clinical experience, and understanding of the efficacy and risks associated with injectables, such as possible cartilage damage; 2) the characteristics of the injectable product, such as ease or number of administrations needed; 3) the individual patient-specific factors, including OA severity, comorbidities, and patient preference for and expectations of specific IA injections; and 4) the financial and administrative factors, including insurance coverage and out-of-pocket costs. CONCLUSION: Physicians factor the uncertain efficacy of injectable treatments and the need to manage patient expectations into their decision to offer IA therapies. Some providers relied on evidence and guidelines while others were swayed more by clinical experience. High out-of-pocket costs were seen as a barrier to use. These findings may help in the delivery of IA injections for OA and in the development of injectable products.

Patient Perspectives Surrounding Intraarticular Injections for Knee Osteoarthritis: A Qualitative Study.

OBJECTIVE: Intraarticular (IA) injections are used frequently for knee osteoarthritis (OA), but little is known about patients' attitudes toward these therapies. We aimed to better understand patients' perceptions of the facilitators of and barriers to IA injections for knee OA. METHODS: We conducted a qualitative, descriptive, exploratory study and held focus groups and individual interviews with participants with knee OA, including some who had and some who had not received IA injections. We conducted a thematic analysis to identify themes describing the factors that participants found influential when deciding whether to try an IA injection. RESULTS: We held 3 focus groups with 12 participants and conducted 3 individual interviews (15 participants total). We identified the following 4 themes that shaped participants' decisions to receive a specific injection: 1) the impact of OA on participants' lives; 2) participants' attitudes and concerns, including desire to avoid surgery, willingness to accept uncertain outcomes, and concerns about side effects and dependence; 3) the way participants gathered and processed information from physicians, peers, and the internet; and 4) the availability of injectable products. Participants weighed the desire to regain function and delay surgery with concerns about side effects, uncertain efficacy, and costs. CONCLUSION: Participants were concerned about the effectiveness, toxicity, availability, and cost of injectable products. They balanced disparate sources of information, uncertain outcomes, limited product availability, and other injection-related concerns with a desire to decrease pain. These findings can provide clinicians, investigators, and public health professionals with insights into challenges that patients face when making injection decisions.

Establishing a Virtual Global Health Education Partnership: The Cleveland-Cusco Connection.

Introduction: The Cleveland-Cusco Connection (CCC) elective was created during the COVID-19 pandemic to continue global health (GH) education for Case Western Reserve University (CWRU) and Universidad Nacional de San Antonio Abad del Cusco (UNSAAC) medical students. The CCC elective was held over Zoom and aimed to promote international collaboration, knowledge about health systems, and perspectives in GH with synchronous and asynchronous learning. Methods: Peruvian and US medical students participated in six monthly sessions consisting of student presentations and large and small group discussions. The elective was led collaboratively by CWRU and UNSAAC students. We evaluated students' experience using pre- and post-course surveys. Results: Nineteen students (76%) completed the post-course survey. The median rating for meeting each course objective was "somewhat effective" on a 5-point scale ranging from "very ineffective" to "very effective." All respondents would recommend the course to a friend. Common barriers included language challenges, fatigue from other coursework, and technology issues. Seven students' pre- and post-course surveys could be linked. The number of students who agreed with the statements assessing course objectives increased for all questions between the pre- and post-test, with only the number agreeing that they understood the Peruvian healthcare system increasing significantly (p < 0.05). Discussion: The CCC elective provides a valuable GH educational opportunity via a virtual platform. Students reported that learning from their peers was effective and enjoyable. Conclusion: Virtual GH electives like the CCC may offer benefits in terms of cost, equity, and flexibility and merit further investigation. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01626-6.

Does Screening for Depressive Symptoms Help Optimize Duloxetine Use in Knee Osteoarthritis Patients With Moderate Pain? A Cost-Effectiveness Analysis.

OBJECTIVE: Duloxetine is a treatment approved by the US Food and Drug Administration for both osteoarthritis (OA) pain and depression, though uptake of duloxetine in knee OA management varies. We examined the cost-effectiveness of adding duloxetine to knee OA care in the absence or presence of depression screening. METHODS: We used the Osteoarthritis Policy Model, a validated computer microsimulation of knee OA, to examine the value of duloxetine for patients with knee OA who have moderate pain by comparing 3 strategies: 1) usual care, 2) usual care plus duloxetine for patients who screen positive for depression on the Patient Health Questionnaire 9 (PHQ-9), and 3) usual care plus universal duloxetine. Outcome measures included quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. Model inputs, drawn from the published literature and national databases, included annual cost of duloxetine ($721-937); average pain reduction for duloxetine (17.5 points on the Western Ontario and McMaster Universities Osteoarthritis Index pain scale [0-100]), and likelihood of depression remission with duloxetine (27.4%). We considered 2 willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY. We varied parameters related to the PHQ-9 and the cost of duloxetine, efficacy, and toxicities to address uncertainty in model inputs. RESULTS: The screening strategy led to an additional 17 QALYs per 1,000 subjects and increased costs by $289/subject (ICER = $17,000/QALY). Universal duloxetine led to an additional 31 QALYs per 1,000 subjects and $1,205 per subject (ICER = $39,300/QALY). Under the majority of sensitivity analyses, universal duloxetine was cost-effective at the $100,000/QALY threshold. CONCLUSION: The addition of duloxetine to usual care for knee OA patients with moderate pain, regardless of depressive symptoms, is cost-effective at frequently used WTP thresholds.

Virtual global health in graduate medical education: a systematic review.

Objectives: To synthesize recent virtual global health education activities for graduate medical trainees, document gaps in the literature, suggest future study, and inform best practice recommendations for global health educators. Methods: We systematically reviewed articles published on virtual global health education activities from 2012-2021 by searching MEDLINE, EMBASE, Cochrane Library, ERIC, Scopus, Web of Science, and ProQuest Dissertations & Theses A&I. We performed bibliography review and search of conference and organization websites. We included articles about primarily virtual activities targeting for health professional trainees. We collected and qualitatively analyzed descriptive data about activity type, evaluation, audience, and drivers or barriers. Heterogeneity of included articles did not lend to formal quality evaluation. Results: Forty articles describing 69 virtual activities met inclusion criteria. 55% of countries hosting activities were high-income countries. Most activities targeted students (57%), with the majority (53%) targeting trainees in both low- to middle- and high-income settings. Common activity drivers were course content, organization, peer interactions, and online flexibility. Common challenges included student engagement, technology, the internet, time zones, and scheduling. Articles reported unanticipated benefits of activities, including wide reach; real-world impact; improved partnerships; and identification of global health practice gaps. Conclusions: This is the first review to synthesize virtual global health education activities for graduate medical trainees. Our review identified important drivers and challenges to these activities, the need for future study on activity preferences, and considerations for learners and educators in low- to middle-income countries. These findings may guide global health educators in their planning and implementation of virtual activities.

Factors associated with use of antibiotic prophylaxis following dental procedures in total joint replacement recipients.

Background: Total joint replacement recipients (TJR) are at risk for prosthetic joint infection (PJI), particularly those with comorbidities such as diabetes mellitus (DM) and rheumatoid arthritis (RA). Methods: We mailed surveys to 1078 subjects undergoing primary TJR between 2011 and 2016 â€‹at an academic center. The survey asked about medical, dental, and orthopedic history and use of antibiotics prior to dental appointments. We generated adjusted relative risks (aRR) for using antibiotic prophylaxis less than always using Poisson regression, adjusting for demographic, clinical, and behavioral factors. Results: We received surveys from 639 subjects; 597 were eligible and formed the analytical sample. 66 â€‹% reported always using antibiotic prophylaxis. DM and RA were not associated with prophylaxis use. Factors associated with less frequent use included: BMI ≥30 (aRR â€‹= â€‹1.27, 95 â€‹% CI [1.01, 1.60]), dental cleanings <2 times/year (aRR â€‹= â€‹1.95, 95 â€‹% CI [1.56, 2.43]), and expressing little concern (compared to neutral) about getting PJI (aRR â€‹= â€‹1.23, 95 â€‹% CI [0.97, 1.55]), though this association was not statistically significant. Greater antibiotic use was reported in subjects who had ≥3 TJRs, (aRR â€‹= â€‹0.48, 95 â€‹% CI [0.29, 0.80]), underwent more invasive dental procedures (aRR â€‹= â€‹0.74, 95 â€‹% CI [0.59, 0.93]), and were concerned (vs. neutral) about PJI (aRR â€‹= â€‹0.53, 95 â€‹%CI [0.33, 0.84]). Conclusions: Two-thirds of TJR recipients in an academic center reported always using antibiotic prophylaxis prior to dental visits. Usage rates varied by demographics, BMI, number of TJRs, type of dental procedure, and behavioral factors -- but not by comorbidities associated with higher PJI risk.