Low predictive power of comorbidity indices identified for mortality after acute arthroplasty surgery undertaken for femoral neck fracture.

AIMS: Our aim was to examine the Elixhauser and Charlson comorbidity indices, based on administrative data available before surgery, and to establish their predictive value for mortality for patients who underwent hip arthroplasty in the management of a femoral neck fracture. PATIENTS AND METHODS: We analyzed data from 42 354 patients from the Swedish Hip Arthroplasty Register between 2005 and 2012. Only the first operated hip was included for patients with bilateral arthroplasty. We obtained comorbidity data by linkage from the Swedish National Patient Register, as well as death dates from the national population register. We used univariable Cox regression models to predict mortality based on the comorbidity indices, as well as multivariable regression with age and gender. Predictive power was evaluated by a concordance index, ranging from 0.5 to 1 (with the higher value being the better predictive power). A concordance index less than 0.7 was considered poor. We used bootstrapping for internal validation of the results. RESULTS: The predictive power of mortality was poor for both the Elixhauser and Charlson comorbidity indices (concordance indices less than 0.7). The Charlson Comorbidity Index was superior to Elixhauser, and a model with age and gender was superior to both indices. CONCLUSION: Preoperative comorbidity from administrative data did not predict mortality for patients with a hip fracture treated by arthroplasty. This was true even if association on group level existed.

Multi-state analysis of hemi- and total hip arthroplasty for hip fractures in the Swedish population-Results from a Swedish national database study of 38,912 patients.

INTRODUCTION: Hip fractures are a common problem of the elderly population with significant mortality and morbidity. The choice between total hip arthroplasty (THA) and hemiarthroplasty depends on multiple factors including comorbidity. The Swedish Hip Arthroplasty Register (SHAR) provides a unique opportunity to study mortality and revision rates in this population. Linkage with government databases allow for in-depth research into the factors that influence risk of revision surgery and death in the hip fracture patient. PATIENTS AND METHODS: Data was linked between SHAR, Statistics Sweden and the National Board of Health and Welfare. Data was collected on 38,912 patients who received a fracture-related hip arthroplasty between 2005 and 2012. A multistate analysis was performed and three states were identified: primary hip surgery and alive (state 1), revision after primary hip surgery (state 2) and death (state 3). These were marking points in the longitudinal outcome study. RESULTS: 38,912 patients who received an arthroplasty for an acute hip fracture were included. By the end of the study period 1309 (3.4%) of these patients underwent a revision and 17,365 (45.1%) patients died. Patients with THA had a reduced risk of death from primary operation compared to hemiarthroplasty (HR = 0.49) and a decreased revision risk (HR = 0.69). Female patients had a statistically significant reduced mortality (HR = 0.6) compared to men. There was no statistically significant difference in risk of revision surgery between direct lateral and posterior approach. CONCLUSION: We identified an influence of type of surgery, sex, age and Elixhauser Comorbidity Index (ECI) on risk of revision and mortality. Males, greater comorbidity burden and older patients had higher mortality risks. The posterior approach did not have a significant influence on revision risk. Further research could include all patients who had reoperation(s) to further strengthen our findings. Patients who had a THA had lower revision rate and mortality. The latter is likely due to selection.

Projected increase in total knee arthroplasty in the United States - an alternative projection model.

OBJECTIVE: The purpose of our study was to estimate the future incidence rate (IR) and volume of primary total knee arthroplasty (TKA) in the United States from 2015 to 2050 using a conservative projection model that assumes a maximum IR of procedures. Furthermore, our study compared these projections to a model assuming exponential growth, as done in previous studies, for illustrative purposes. METHODS: A population based epidemiological study was conducted using data from US National Inpatient Sample (NIS) and Census Bureau. Primary TKA procedures performed between 1993 and 2012 were identified. The IR, 95% confidence intervals (CI), or prediction intervals (PI) of TKA per 100,000 US citizens over the age of 40 years were calculated. The estimated IR was used as the outcome of a regression modelling with a logistic regression (i.e., conservative model) and Poisson regression equation (i.e., exponential growth model). RESULTS: Logistic regression modelling suggests the IR of TKA is expected to increase 69% by 2050 compared to 2012, from 429 (95%CI 374-453) procedures/100,000 in 2012 to 725 (95%PI 121-1041) in 2050. This translates into a 143% projected increase in TKA volume. Using the Poisson model, the IR in 2050 was projected to increase 565%, to 2854 (95%CI 2278-4004) procedures/100,000 IR, which is an 855% projected increase in volume compared to 2012. CONCLUSIONS: Even after using a conservative projection approach, the number of TKAs in the US, which already has the highest IR of knee arthroplasty in the world, is expected to increase 143% by 2050.

Lumbar surgery prior to total hip arthroplasty is associated with worse patient-reported outcomes.

AIMS: The aims of this study were to describe the prevalence of previous lumbar surgery in patients who undergo total hip arthroplasty (THA) and to investigate their patient-reported outcomes (PROMs) one year post-operatively. PATIENTS AND METHODS: Data from the Swedish Hip Arthroplasty Register and the Swedish Spine Register gathered between 2002 and 2012 were merged to identify a group of patients who had undergone lumbar surgery before THA (n = 997) and a carefully matched one-to-one control group. We investigated differences in the one-year post-operative PROMs between the groups. Linear regression analyses were used to explore the associations between previous lumbar surgery and these PROMs following THA. The prevalence of prior lumbar surgery was calculated as the ratio of patients identified with previous lumbar surgery between 2002 and 2012, and divided by the total number of patients who underwent a THA in 2012. RESULTS: The prevalence of lumbar surgery prior to THA in 2012 was 3.5% (351 of 10 082). Linear regression analyses showed an association with more pain (B = 4.35, 95% confidence interval (CI) 2.57 to 6.12), worse EuroQol (EQ)-5D index, (B = -0.089, 95% CI -0.112 to -0.066), worse EQ VAS (B = -6.75, 95% CI -8.58 to -4.92), and less satisfaction (B = 6.04, 95% CI 4.05 to 8.02). CONCLUSION: Lumbar spinal surgery prior to THA is associated with less reduction of pain, worse health-related quality of life, and less satisfaction one year after THA. This is useful information to share in the decision-making process and may help establish realistic expectations of the outcomes of THA in patients who also have previously undergone lumbar spinal surgery. Cite this article: Bone Joint J 2017;99-B:759-65.

Improved statistical analysis of pre- and post-treatment patient-reported outcome measures (PROMs): the applicability of piecewise linear regression splines.

PURPOSE: Patient-reported health-related quality-of-life (HRQoL) measures such as the EuroQol 5 dimension (EQ-5D) index are commonplace when assessing healthcare providers or efficiency of medical techniques. HRQoL measures are generally bounded, and the magnitude of possible improvement depends on the pre-treatment HRQoL value. This paper aimed to assess and illustrated the possibility of modelling the relationship between pre- and post-treatment HRQoL measures with piecewise linear splines. METHODS: The method was illustrated using a longitudinal dataset of 36,625 patients with one EQ-5D index before and one a year after total hip arthroplasty. We considered four models: intercept only model, single line regression, and segmented regression with 1 and 2 change points. The post-operative EQ-5D index served as the outcome, while the preoperative EQ-5D index was the predictor. RESULTS: We found that a two-line regression best described the data with the lines meeting at 0.159 on the preoperative EQ-5D index scale. In the low preoperative group (with an initial preoperative index from -0.594 to 0.159), the predicted post-operative scores ranged from 0.368 to 0.765, with post-operative scores increasing 0.528 points for each unit in the preoperative score. In the high preoperative group (initial range from 0.159 to 1), the predicted post-operative scores ranged from 0.765 to 0.855, increasing 0.106 points for each unit in the preoperative score. CONCLUSIONS: Piecewise linear regression is a straightforward approach to analyse baseline and follow-up HRQoL measures such as the EQ-5D index. It can provide a reasonable approximation of the shape of the underlying relationship where the threshold and slopes prove informative and meaningful.

Frequent MYC coamplification and DNA hypomethylation of multiple genes on 8q in 8p11-p12-amplified breast carcinomas.

Genetic and epigenetic (DNA methylation, histone modifications, microRNA expression) crosstalk promotes inactivation of tumor suppressor genes or activation of oncogenes by gene loss/hypermethylation or duplications/hypomethylation, respectively. The 8p11-p12 chromosomal region is a hotspot for genomic aberrations (chromosomal rearrangements, amplifications and deletions) in several cancer forms, including breast carcinoma where amplification has been associated with increased proliferation rates and reduced patient survival. Here, an integrative genomics screen (DNA copy number, transcriptional and DNA methylation profiling) performed in 229 primary invasive breast carcinomas identified substantial coamplification of the 8p11-p12 genomic region and the MYC oncogene (8q24.21), as well as aberrant methylation and transcriptional patterns for several genes spanning the 8q12.1-q24.22 genomic region (ENPP2, FABP5, IMPAD1, NDRG1, PLEKHF2, RRM2B, SQLE, TAF2, TATDN1, TRPS1, VPS13B). Taken together, our findings suggest that MYC activity and aberrant DNA methylation may also have a pivotal role in the aggressive tumor phenotype frequently observed in breast carcinomas harboring 8p11-p12 regional amplification.

Diagnosing antisocial personality disorder among substance abusers: the scid versus the MCMI-II.

There is much controversy among social scientists and clinicians over the proper measurement of antisocial personality disorder (ASPD). The degree to which various diagnostic measures differ in their assessment of ASPD among substance abusers is not known. This study assessed the degree of agreement between a semistructured clinical interview and a self-report inventory on a diagnosis of ASPD among substance abusers. The Structured Clinical Interview for DSM-III-R (SCID-II), a clinically generated instrument, and the Millon Clinical Multiaxial Inventory (MCMI-II), a self-report inventory, were administered to 275 clients randomly assigned to two therapeutic communities (TCs). Based on the limited existing literature, it was hypothesized that there would be minimal agreement between the diagnosis of ASPD by the two scales. This hypothesis was supported. The kappa statistic indicated low agreement between the scales (kappa = 0.27), with the MCMI-II diagnosing ASPD more often than the SCID-II. The low agreement on a diagnosis of ASPD may be due to the different types of information collected by the two scales. The SCID-II emphasizes observable behavioral criteria, while the MCMI-II emphasizes pathological personality traits. The focus of the MCMI-II on pathological personality traits may more accurately diagnose ASPD in substance-abusing populations in which the majority of the clients have extensive criminal histories. Definite conclusions regarding the proper measurement of ASPD in substance-abusing samples is difficult without additional empirical evidence.

Continuous improvement evaluation: a framework for multisite evaluation studies.

This article proposes the use of the continuous improvement evaluation (CIE), a framework for multisite demonstration or evaluation studies. This framework is designed for studying intervention programs that change during the evaluation. The development of family drug courts is provided as an example. CIE relies on outcome data collected over time and benchmarked across similar cases in comparison sites; thus, this study was designed to collect data on effectiveness of intervention programs at multiple sites and over time. A weight is calculated for similarity of any two cases based on features they share. In statistical process control charts, these weights are used to compare outcomes at the site against the average of similar cases in comparison groups. Once data are benchmarked, program staff meet to discuss process changes that have led to improvements in outcomes. To ensure that intervention programs have access to evaluation reports on demand, information technology is used to collect, clean, and pool data. Computers generate study reports, and evaluators review reports after release to clients. Statistical tools can be used to evaluate changing programs. Traditional evaluators may be concerned about some threats to validity associated with CIE. The article concludes with a discussion of typical threats to validity and how these threats are addressed in the CIE framework.

Development of a computerized screening system to identify substance abuse in primary care.

The Drug and Alcohol Problem Assessment for Primary Care (DAPA-PC), developed under a contract from the National Institute on Drug Abuse, is a comprehensive screening system developed for quickly identifying and addressing substance abuse and related problems in a primary care setting. The DAPA-PC system includes a two-level screening instrument, resources for scoring and reporting results, motivational messages, treatment referrals, and informative links, which together address the multifaceted needs of patients dealing with addiction problems and their providers. The need for such a system, preliminary reactions to the instrument, and future course of research are discussed.

Opening the black box. The impact of inpatient treatment services on client outcomes.

This study examined the effects of specific services provided in therapeutic communities (TCs) to treatment outcomes. Findings are compared to prior analyses of treatment outcomes from the District of Columbia Treatment Initiative (DCI) that did not utilize the treatment service information. A subsample of DCI clients randomly assigned to two TC programs, who had remained in inpatient treatment for at least 60 days, were included in the analyses (n = 371). Logistic regression results illustrated that the level of vocational education services received was positively associated with completing treatment, and participation in group services was associated with decreases in postdischarge arrest. In addition, clients who received a greater number of all inpatient services were more likely to complete treatment and were less likely to be arrested after discharge. Findings suggest that TC programs should consider offering more vocational education and group treatment services to enhance prosocial behavior following treatment discharge.

Predictors of treatment outcomes in men and women admitted to a therapeutic community.

This study compared factors that predict treatment outcomes in men and women randomly assigned to two therapeutic communities differing primarily in length of inpatient and outpatient treatment. Based on the prior research literature comparing treatment outcomes of men and women, we formulated the following research question: Do factors that predict drug use at follow-up, postdischarge arrest, and employment at follow-up differ for men and women? Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. Separate regression analyses were conducted for men and women for each of the three outcome variables. The results showed that the predictors of outcome for men and women were similar. Clients who completed the 12-month treatment programs had better outcomes regardless of gender. Men and women who completed treatment were characterized at follow-up by substantial reductions in drug use and arrests and by increased employment. Results further suggested that the longer residential treatment program had a particularly beneficial impact on women. Number of prior arrests was also associated with postdischarge outcomes for women. Women with more arrests at admission were more likely to have a postdischarge arrest and less likely to be employed at follow-up. This finding provides invaluable information about which women may be at greater risk for relapse and in need of additional services. We conclude that completion of treatment is the key predictor of treatment outcomes for both men and women.

[Liver gunshot wounds]. / Plagile hepatice prin arme de foc.

The paper presents the 6 cases of liver shot wounds that were in supervision of the general surgery unit, County Hospital of Baia Mare, between the years 1990-1997. The patients were males, most of them being 20 to 30 years old. In 3 situations hunting rifles were involved, all followed by retention of metal foreign body. The wounds were plurivisceral in 5 of the 6 cases, the most frequently wounded was the right liver lobe. All the patients presented serious traumatic shock and haemorrhagic shock. Livertectomy was used in 40% of the cases being imposed by the dilacerant and transfixiant character of the wounds and also by the retention of foreign bodies in parenchime. We registered 2 demises, both in the first postoperatory hours. The paper proposes a few criteria that allow the application of a conservatory treatment:rapid favourable answer at deshocking therapy; hemodynamic stability; minimal hemoperitoneus (echographical and tomographical); absence of associated visceral wounds or, when they exist, of serious physiopathological consequences; access to performant means of imagistics.

Comparing the impact of standard and abbreviated treatment in a therapeutic community. Findings from the district of Columbia treatment initiative experiment.

This study examines the efficacy of providing Enhanced Abbreviated or Standard Inpatient treatment and Outpatient treatment to drug-abusing clients. The experiment randomly assigned 412 clients to two therapeutic community programs, which differed primarily in planned duration. This study addressed limitations of prior research, as it used random assignment of clients to treatment programs, achieved high follow-up rates and used objective measures of drug use and criminal history. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. Completing the entire 12-month program (inpatient and outpatient) was more important than duration of inpatient program attended. Regardless of program, completers had substantial reductions in posttreatment drug abuse and arrests. A 12-month course of treatment including at least 6 months in a therapeutic community followed by outpatient treatment can produce marked reductions in drug abuse and crime among persons who complete both phases.

Therapeutic community treatment for substance abusers with antisocial personality disorder.

This study compared treatment outcomes of substance abusers with and without antisocial personality disorder (APD) randomly assigned to two therapeutic communities, differing primarily in length of inpatient and outpatient treatment. We hypothesized that APD clients would be less likely to complete treatment, more likely to test positive for drugs and recidivate at follow-up, and that APD clients in the Standard program would have more favorable outcomes than those in the Abbreviated Inpatient program, because of the Standard program's longer inpatient treatment. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. APD clients were as likely to complete treatment as other clients, and they exhibited the same patterns of reduced drug use and recidivism as did non-APD clients. Treatment program attended was unrelated to outcomes. Substance abusers diagnosed with APD can benefit from treatment in a therapeutic community combined with outpatient care.

[Clinico-tomographic correlations in acute pancreatitis]. / Corelatii clinico-tomografice în pancreatita acuta.

In the surgery ward from Baia Mare, in the period 1989-1997 have been operated yearly, on an average, 16-17 acute pancreatitis, out of which 8-9 were necrotic-haemorrhagic acute pancreatitis. The possibility of carrying out the computerized tomography allowed a more precise pre-surgery diagnosis and after surgery was improved observation of evolution of the inflammatory phenomena from the pancreatic zone so that the volume, the structure and the outline of the pancreas, the abdominal or pleural liquid collections and the aspect of the neighboring tissues have been correlated in dynamics, with the clinic aspect of the acute pancreatitis and the prognostic indexes. Even if the computerized tomography allowed a more correct evaluation of the patients suffering of acute pancreatitis, there have been 4-6 decreases due to this affection and its complications, the post-surgery death rate remaining at 17-21%.

The validity of self-reports of drug use at treatment admission and at followup: comparisons with urinalysis and hair assays.

Studies conducted in the 1970s and early 1980s concluded that people will provide valid information about their illicit drug use when research interviews are conducted under appropriate conditions. Recent studies of treated and untreated populations using improved urinalysis techniques as well as hair analysis techniques indicate that the validity of respondents' self-reports of recent drug use may be considerably less than previously reported and may differ according to a number of factors. Results are presented from a study of clients participating in the Washington, DC, Treatment Initiative study who were assessed for drug use by interview, urinalysis, and hair analysis. At intake, almost all clients who tested positive had reported their use of heroin but fewer clients had reported their cocaine use. At posttreatment followup, clients underreported both heroin and cocaine use. Findings from treatment outcome studies that fail to validate and adjust their estimates of self-reported recent drug use should be interpreted with considerable caution.