Neuroendocrine neoplasms: Consensus on a patient care pathway.

People with neuroendocrine neoplasms (NENs) face a multitude of challenges, including delayed diagnosis, low awareness of the cancer among healthcare professionals and limited access to multidisciplinary care and expert centres. We have developed the first patient care pathway for people living with NENs in England to guide disease management and help overcome these barriers. The pathway was developed in two phases. First, a pragmatic review of the literature was conducted, which was used to develop a draft patient care pathway. Second, the draft pathway was then updated following semi-structured interviews with carefully selected expert stakeholders. After each phase, the pathway was discussed among a multidisciplinary, expert advisory group (which comprised the authors and the Deputy Chief Operating Officer, West Suffolk NHS Foundation Trust), who reached a consensus on the ideal care pathway. This article presents the outputs of this research. The pathway identified key barriers to care and highlighted how these may be addressed, with many of the findings relevant to the rest of the UK and international audiences. NENs are increasing in incidence and prevalence in England, compounding pre-existing inequities in diagnosis and disease management. Effective integration of this pathway within NHS England will help achieve optimal, equitable care provision for all people with NENs, and should be feasible within the existing expert multidisciplinary teams across the country.

Assessing the policy utility of routine mortality statistics: a global classification of countries.

Objective: To evaluate the utility and quality of death registration data across countries. Methods: We compiled routine death and cause of death statistics data from 2015-2019 from national authorities. We estimated completeness of death registration using the Adair-Lopez empirical method. The quality of cause of death data was assessed by evaluating the assignment of usable causes of death among people younger than 80 years. We grouped data into nine policy utility categories based on data availability, registration completeness and diagnostic precision. Findings: Of an estimated 55 million global deaths in 2019, 70% of deaths were registered across 156 countries, but only 52% had medically certified causes and 42% of deaths were assigned a usable cause. In 54 countries, which are mostly high-income, there is complete and high-quality mortality data. In a further 29 countries, located across different regions, death registration is complete, but cause of death data quality remains suboptimal. Additionally, 37 countries possess functional death registration systems with cause of death data of poor to moderate quality. In 30 countries, death registration ranges from limited to nascent completeness, accompanied by poor or unavailable cause of death data. Furthermore, 38 countries lack accessible data altogether. Conclusion: By implementing more proactive death notification processes, expanding the use of digitized data collection platforms, streamlining data compilation procedures and improving data quality assessment, governments could enhance the policy utility of mortality data. Encouraging the routine application of automated verbal autopsy methods is crucial for accurately determining the causes of deaths occurring at home.

Comparative performance of national civil registration and vital statistics systems: a global assessment.

Objective: To assess the current state of the world's civil registration and vital statistics systems based on publicly available data and to propose strategic development pathways, including priority interventions, for countries at different levels of civil registration and vital statistics performance. Methods: We applied a performance assessment framework to publicly available data, using a composite indicator highly correlated with civil registration and vital statistics performance which we then adjusted for data incomparability and missing values. Findings: Globally, civil registration and vital statistics systems score on average 0.70 (0-1 scale), with substantial variations across countries and regions. Scores ranged from less than 0.50 in emerging systems to nearly 1.00 in the most developed systems. Approximately one fifth of the world's population live in the 43 countries with low system performance (< 0.477). Irrespective of system development, health sector indicators consistently scored lower than other determinants of civil registration and vital statistics performance. Conclusion: From our assessment, we provide three main recommendations for how the health sector can contribute to improving civil registration and vital statistics systems: (i) enhanced health sector engagement in birth and death notification; (ii) a more systematic approach to training cause of death diagnostics; and (iii) leadership in the implementation of verbal autopsy methods. Four different civil registration and vital statistics improvement pathways for countries at different levels of system development are proposed, that can constitute a blueprint for regional civil registration and vital statistics strengthening activities that countries can adapt and refine to suit their capabilities, resources, and particular challenges.

Global analysis of birth statistics from civil registration and vital statistics systems.

Objective: To assess civil registration and vital statistics completeness for births in World Health Organization's Member States and identify data completeness gaps. Methods: For the 194 Member States, we sourced birth registration data from the United Nations Children's Fund database of national surveys, and, where available, vital registration reports. We acquired publicly available vital statistics compiled by national authorities. We determined civil registration completeness as the percentage of living children younger than five years whose births have been reported as registered. We evaluated vital statistics completeness against the United Nations World Population Prospects' live birth estimates, and grouped countries into seven categories based on their civil registration and vital statistics completeness. Findings: Globally, civil registration completeness for births was 77%, exceeding vital statistics completeness for births at 63%. Twenty countries had limited civil registration (25% to 74% completeness) and had nascent or no vital statistics data (completeness < 25%) for births. Five countries had nascent or no civil registration and vital statistics for births. Twenty countries had functional civil registration (75% to 94% completeness) but nascent or no available vital statistics. Approximately half (96) of the countries had complete civil registration and vital statistics for births, but contributed to only 22% of global births. Conclusion: The gap in completeness between civil registration data and vital statistics for births is most pronounced in countries with lower civil registration completeness. Enhancing data transfer processes for birth registration, along with targeted investments to elevate registration rates, is crucial for yielding comprehensive fertility statistics for governmental planning.

Articulating vs Static Spacers for Native Knee Infection in the Setting of Degenerative Joint Disease.

BACKGROUND: Patients with advanced knee arthritis who develop a septic joint are not adequately treated with irrigation and debridement and intravenous antibiotics because of antecedent cartilage damage. The gold standard treatment has been a 2-stage approach. The periprosthetic joint infection literature has demonstrated the superiority of articulating spacers, and metal-on-poly (MOP) spacers are being used with increasing frequency. The purpose of this study was to compare the postoperative outcomes of patients with infected, arthritic knees treated by a 2-stage approach to those of patients who received single-stage treatment with a MOP spacer. METHODS: Sixteen patients with native knee septic arthritis treated with an antibiotic spacer between 1998 and 2019 were reviewed. Demographic data, clinical data, knee motion, Knee Society score, Timed-Up-and-Go, and pain scores were collected. Survivorship of final implants was compared. RESULTS: Six of 16 knees (38%) received single-stage treatment, and 10 received 2-stage treatment (62%). Five of 6 MOP spacers (83%) were retained at a mean follow-up of 3 ± 1.2 years. Nine of 10 (90%) receiving static spacers had subsequent reconstruction, with 9 (100%) surviving at mean follow-up of 7 ± 3.2 years. The patients who received MOP spacers trended toward greater terminal flexion, higher Knee Society score, and faster Timed-Up-and-Go at final follow-up. CONCLUSION: Infection in a native, arthritic knee may be effectively treated using single-stage MOP spacer. Postoperative outcomes of single-stage MOP spacers compare favorably to staged static spacers and with those undergoing revision surgery for other indications. Longer follow-up is needed to evaluate durability of MOP spacers.

The Role of the Hindfoot in Total Knee Arthroplasty Alignment.

Limb alignment is a critically important factor to consider in the management of the patient with knee arthritis. Abnormal alignment is associated with the accelerated progression of osteoarthritis and, if not addressed at the time of surgery, may contribute to early failure of knee replacement implants. The contribution of the hindfoot to overall limb alignment has received limited attention in the context of deformity correction in total knee arthroplasty (TKA). In this review, we present evidence supporting the inclusion of the hindfoot in the consideration of overall limb alignment for TKA and propose a management algorithm.

Ninety-day Postoperative Narcotic Use After Hospitalization for Orthopaedic Trauma.

BACKGROUND: The purpose of this study was to compare narcotic use in the 90-day postoperative period across orthopaedic trauma, spine, and adult reconstruction patients and examine whether patient-reported pain scores at discharge correlate with narcotic use during the 90-day postoperative period. METHODS: Electronic medical record query was done between 2012 and 2015 using diagnosis-related groups for spine, adult reconstruction, and trauma procedures. Demographics, length of stay (LOS), visual analog scale pain scores during hospitalization, and narcotics prescribed in the 90-day postoperative period were collected. Multivariate analysis and linear regression were done. RESULTS: Five thousand thirty patients were analyzed. Spine patients had the longest LOS, highest mean pain during LOS, and were prescribed the most morphine in the 90-day postoperative period. Linear regression revealed that pain scores at discharge markedly influence the quantity of narcotics prescribed in the 90-day postoperative period. DISCUSSION: Patient-reported pain at hospital discharge was associated with increased narcotic use in the 90-day postoperative period.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents' performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge. METHODS: Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores. RESULTS: There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009). CONCLUSIONS: VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum. LEVEL OF EVIDENCE: Level 1.

Periacetabular osteotomy using an imageless computer-assisted navigation system: a new surgical technique.

Periacetabular osteotomy (PAO) is an effective surgical treatment for hip dysplasia. The goal of PAO is to reorient the acetabulum to improve joint stability, lessen contact stresses and slow the development of hip arthrosis. During PAO, the acetabulum is repositioned to adequately cover the femoral head. PAO preserves the weight-bearing posterior column of the pelvis, maintains the acetabular blood supply and retains the hip abductor musculature. The surgical technique needed to perform PAO is technically demanding, with correct repositioning of the acetabulum the most important-and challenging-aspect of the procedure. Imageless navigation has proven useful in other technically challenging surgeries, although its use in PAO has not yet been investigated. We have modified the standard technique for PAO to include the use of an imageless navigation system to confirm acetabular fragment position following osteotomy. Here, we describe the surgical technique and discuss the potential of this modified technique to improve patient-related outcomes.

Low rates of renal injury in total joint arthroplasty patients without pre-existing renal disease.

Acute kidney injury is a reported complication of total joint arthroplasty (TJA), with potentially severe long-term complications. Our study aimed to identify the rate of perioperative renal injury in patients without pre-existing renal dysfunction who undergo TJA. Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified a mean annual rate of perioperative renal injury of 0.172% between 2009 and 2015. Factors most strongly associated with perioperative renal injury are age of 70 years or older, current smoking, history of diabetes mellitus, history of hypertension, and American Society of Anesthesiologists class of 3 or greater. There was no significant increase in the rate of renal injury from year to year. In patients without pre-existing renal disease, perioperative rates of acute kidney injury remain low in patients undergoing TJA.

The Role of Bariatric Surgery in the Obese Total Joint Arthroplasty Patient.

Although bariatric surgery is a proven means of weight loss and treatment of obesity-related comorbidities in morbidly obese patients, it is not yet clear how it affects outcomes after total joint arthroplasty in this high-risk patient population. This article explores the effects of obesity and bariatric surgery on osteoarthritis and total joint arthroplasty, and also discusses the financial and ethical implications of use of bariatric surgery for risk reduction before total joint arthroplasty.

Biomechanical Implications of an Oblique Knee Joint Line.

Surgical correction of multiapical deformities of the lower limb requires careful preoperative planning. Surgeons must account for the potential creation of secondary deformity, such as knee joint line obliquity, and the risks associated with accepting these changes in limb alignment. In this study, we evaluate the effect of knee joint obliquity on tibial plateau contact pressures and knee instability. Three cadaveric knees were dissected and put through biomechanical testing to simulate loading of an oblique knee joint. We observed < 1 mm femoral displacement (proxy measure of instability) between 15 degrees of varus tilt and 10 degrees of valgus tilt, and greater increases in tibial plateau contact pressures with valgus tilt than with varus tilt. Our results suggest that, if the creation of a secondary coronal plane deformity at the knee joint cannot be avoided, up to 15 degrees of varus or 10 degrees of valgus alignment can be tolerated by an otherwise structurally normal knee.

Bariatric Surgery and Time to Total Joint Arthroplasty: Does It Affect Readmission and Complication Rates?

BACKGROUND: Bariatric surgery is frequently recommended prior to total joint arthroplasty (TJA) for morbidly obese patients with end-stage arthropathy. Current published data on the efficacy of bariatric surgery for preoperative medical optimization has yielded mixed results, and the effect of time from bariatric surgery to TJA on the preoperative risk profile is not well defined. Our study evaluated the effect of time from bariatric surgery to TJA on 90-day complication and readmission rates. METHODS: We utilized the Healthcare Cost and Utilization Project (HCUP) California State Inpatient Database (SID) to identify patients who underwent TJA following bariatric surgery between 2007 and 2011. Primary endpoints were 90-day complication rates and all-cause 90-day readmission rates following TJA. RESULTS: We identified 330 cases of bariatric surgery followed by total hip arthroplasty (THA) and 1017 cases followed by total knee arthroplasty (TKA). There were no significant demographic differences among patients who underwent TJA greater than or less than 6 months after bariatric surgery. Patients undergoing THA more than 6 months after bariatric surgery were significantly less likely to be readmitted within 90 days for any cause. There was no association between time from bariatric surgery to THA or TKA and 90-day complications. DISCUSSION: Delaying THA at least 6 months after bariatric surgery may help reduce the rate of 90-day readmissions in this high-risk patient population. Arthroplasty surgeons recommending bariatric surgery as preoperative risk modification should consider the patient's overall nutritional status, medical comorbidities, and overall response to surgery prior to booking for TJA.

Outpatient Total Joint Arthroplasty.

PURPOSE OF REVIEW: Outpatient total joint arthroplasty (OTJA) allows for a safe, cost effective pathway for appropriately selected patients. With current pressures on arthroplasty surgeons and their associated institutions to reduce costs per episode of care, it is important to define the steps and challenges associated with establishing an outpatient arthroplasty program. RECENT FINDINGS: Several studies have outlined techniques of selecting patients suitable for this type of postoperative pathway. With emerging concerns about patients who undergo outpatient arthroplasty being at increased risk of medical complications, which may lessen projected cost savings, it is important to identify value-based strategies to optimize patient recovery after OTJA. This article reviews digital techniques for patient selection and data collection, operating room efficiency systems, and provides a summary of methods to build and maintain value in outpatient total joint replacement within the framework of bundled payment reimbursement.